Final Report on the Fynes Public Interest Hearing (MPCC 2011‑004) - Volume 2

VOLUME 2 OF 3

National Defence Act - Part IV
Section 250.53

Final Report

Following a Public Interest Hearing
Pursuant to Subsection 250.38(1) of the National Defence Act
With Respect to a Complaint

Concerning the Conduct of
Sergeant David Mitchell; Petty Officer, 2^nd Class Eric McLaughlin;
Sergeant Matthew Ritco; Sergeant Scott Shannon;
Warrant Officer Jon Bigelow; Warrant Officer (Retired) Sean Bonneteau;
Warrant Officer Blair Hart; Master Warrant Officer Ross Tourout;
Chief Warrant Officer (Retired) Barry Watson; Major Daniel Dandurand;
Lieutenant-Colonel Brian Frei; Lieutenant-Colonel (Retired) Bud Garrick; and
Lieutenant-Colonel Gilles Sansterre

File: MPCC-2011-004
Ottawa, March 10, 2015

Mr. Glenn M. Stannard, O.O.M.
Chairperson

Overview
The Hearing Process
Narrative
The Investigations
Findings
Recommendations
The Military Police Response
1. 7.0 The Military Police Response
2. 7.1 The Notice of Action | PDF version (390 KB) – as released March 10, 2015

Appendices
1. Glossary of Terms / Acronyms used throughout this Report
2. Decision to Conduct a Public Interest Investigation – April 29, 2011
3. Decision to Hold a Public Interest Hearing – September 6, 2011
4. Decision to Recommend Funding for Legal Representation for the Complainants – October 26, 2011
5. Publication Ban Order – May 17, 2012
6. Ruling on Motion by Complainants to Issue Summons to Appear – June 14, 2012
7. Decision to Recommend Funding for Legal Counsel for the Complainants to Prepare Closing Submissions – October 30, 2012
8. Ruling on Request to Comment on the Interim Report – November 29, 2012
9. Notice of Action and related correspondence | PDF version (22 MB) – as released March 10, 2015

IV. The Investigations

4.0 The Subjects of the Complaint: Role, Involvement and Background

The 2008 Sudden Death Investigation

Master Corporal Matthew Ritco

1. MCpl Matthew Ritco (Sergeant Ritco at the time of his testimony before the MPCC in September 2012) was the lead investigator on the investigation into the sudden death of Cpl Stuart Langridge.^{Footnote 604} He attended at the scene of Cpl Langridge’s death with Sgt Jon Bigelow on March 15, 2008.^{Footnote 605}

2. MCpl Ritco first joined the CF in 1988 and completed boot camp at CFB Cornwallis, Nova Scotia. He was posted to Wainright, Alberta, where he completed his infanteer schooling. MCpl Ritco was then transferred to Winnipeg, Manitoba, where he was stationed with 2 Princess Patricia’s Canadian Light Infantry until 1996. At that time, MCpl Ritco left the CF in order to pursue a career in youth corrections.^{Footnote 606}

3. In the fall of 2001, MCpl Ritco rejoined the CF as an MP member. He completed his six-month MP Qualification Level (QL) 3, or basic training, before being posted to Winnipeg in 2002.^{Footnote 607} MCpl Ritco completed his corporal-level qualification course (MP QL5A) in 2005. He was promoted to Master Corporal in June, 2006 and transferred to the CFNIS in July, 2006,^{Footnote 608} when he was posted to Edmonton, Alberta with CFNIS WR.^{Footnote 609} MCpl Ritco completed his MP Criminal Investigator training – generally considered to be a prerequisite to join the CFNIS^{Footnote 610} – in November, 2006.^{Footnote 611}

4. During his time with the MP, MCpl Ritco completed three tours of duty – to Croatia, United Arab Emirates, and Cyprus.^{Footnote 612} He completed a number of police training courses, including a forensic interviewing course run by the RCMP in 2007^{Footnote 613} and Reid’s advanced interviewing skills course.^{Footnote 614} MCpl Ritco also completed MP training in criminal investigations in 2006 and search and seizure in 2007.^{Footnote 615}

5. On the day of Cpl Langridge’s death, MCpl Ritco was on call as the CFNIS duty investigator.^{Footnote 616} He had no prior experience in conducting sudden death investigations.^{Footnote 617}

Sergeant Jon Bigelow

6. Sergeant Jon S. Bigelow (Warrant Officer Bigelow at the time of his testimony before the MPCC in September 2012) was one of the two CFNIS investigators who attended the scene of Cpl Langridge's suicide on March 15, 2008. He joined the CF in September 1995, and served first as an infanteer, and then a driver (with the 2^nd Battalion, Royal Canadian Regiment at CFB Gagetown).^{Footnote 618} He deployed overseas to Bosnia in 1999. It was during this time he applied to join the military police, and he transferred to CFB Borden for his trades training as an MP in January 2000.^{Footnote 619}

7. Following his six month training period to become an MP, Sgt Bigelow was posted ^{Footnote 620} to CFB Winnipeg between 2000 and 2004. He performed general patrol duties there until late 2001, when he was sent to the United Arab Emirates as part of the first rotation of personnel to serve in the war in Afghanistan. Sgt Bigelow took his forensic evidence collection course online through the Canadian Police Knowledge Network (CPKN) while overseas.^{Footnote 621} Upon his return to Canada in 2002, he was assigned to the position of Court NCO, where he was responsible for ensuring key documents were provided to the courts. Sgt Bigelow also completed a number of MP training programs during the course of this assignment – including taking an investigation course at CFB Borden, and learning how to process crime scenes, document evidence, and conduct basic mobile and on-foot surveillance.^{Footnote 622} He also completed a search warrant training course.^{Footnote 623}

8. Sgt Bigelow assisted the CFNIS with several investigations during his time as an MP at CFB Winnipeg.^{Footnote 624} As a consequence of that exposure, he was invited to join the CFNIS in 2004. Sgt Bigelow completed the MP Criminal Investigator course in May 2004 and the Forensic Interviewer course in December 2005.^{Footnote 625}

9. When Sgt Bigelow joined the CFNIS, there were no specific training programs, but rather an internship program, which lasted one year.^{Footnote 626} In 2004, he was posted to Edmonton as a member of the CFNIS Western Region, beginning his internship with the CFNIS. He remained at Western Region as an investigator until July 2008. As a CFNIS investigator, Sgt Bigelow was responsible for investigating serious and sensitive offences – such as sexual assault or fraud. Sgt Bigelow was involved in one suicide investigation while with the CFNIS.^{Footnote 627} He was seconded to the RCMP for ten months, where he worked in the General Investigation Section in 2005-2006, during which time he was assigned to work with the RCMP Major Crimes Unit.^{Footnote 628} During his work with the RCMP, he gained experience with sudden death investigations, becoming involved in approximately four to six such investigations.^{Footnote 629}

10. At the conclusion of this ten-month secondment, Sgt Bigelow returned to the CFNIS and was subsequently given a new position as the member in command of the CFNIS WR’s National Drug Enforcement Team section.^{Footnote 630} He continued to undertake training in investigative techniques including interrogations and interviews, using the Internet as an investigative tool, and conducting drug investigations. Because of his posting with the National Drug Enforcement Team, he was not routinely available to lead death investigations despite being one of the investigators at CFNIS Western Region with experience in the conduct of such investigations.

11. At the time of Cpl Langridge's suicide in March 2008, Sgt Bigelow had not yet obtained his QL6A qualifications, which are the leadership courses necessary for promotion to sergeant.^{Footnote 631} While not formally qualified as a sergeant in March 2008, he nevertheless held that title contingent upon the completion of the QL6A.^{Footnote 632}

12. Sgt Bigelow was not a part of the investigator’s cell in the Detachment; he was part of the Drug Enforcement Team whose mandate was to engage in drug investigations.^{Footnote 633} From time to time, he was assigned, on a temporary basis, to assist with investigations when manpower was severely limited.^{Footnote 634}

Warrant Officer Ross Tourout

13. WO Ross Tourout (Master Warrant Officer Tourout at the time of his testimony before the MPCC in September 2012) was MCpl Ritco’s case manager on the investigation into the sudden death of Cpl Langridge.^{Footnote 635} In that capacity, he was generally responsible for providing direction and oversight on active investigation files,^{Footnote 636} as well as conducting resource and equipment needs assessments and coordinating investigative team members and specialty support.^{Footnote 637}

14. WO Tourout joined the CF in 1987 as an artilleryman. After completing his basic training, he was posted to the artillery regiment at CFB Shilo, Manitoba,^{Footnote 638} where he completed several artillery-related training courses.^{Footnote 639} He also completed a tour of duty in Cyprus.^{Footnote 640}

15. In 1993, WO Tourout was accepted into the MP branch and was sent to CFB Borden for six months where he completed his QL3. He was then posted to CFB Gander, Newfoundland, as a patrolman. In 1997, WO Tourout was posted to CFB Winnipeg, Manitoba, again as a patrolman, holding the rank of Corporal.^{Footnote 641}

16. While posted to Winnipeg, WO Tourout completed a tour of duty in Kosovo. He transitioned from patrolman to MP investigator. Upon promotion to Master Corporal, he was employed as a shift commander. WO Tourout continued to advance, being placed in command of investigations and then training. Upon his promotion to Sergeant in 2003, WO Tourout was employed as Sergeant in command of police operations, patrols.^{Footnote 642}

17. In the summer of 2003, WO Tourout was posted back to Gander as the second in command of the MP Detachment. He spent three years in that position. WO Tourout was promoted to Warrant Officer in 2006 and posted to CFNIS WR as a case manager.^{Footnote 643}

18. In the course of his career with the MP and CFNIS, WO Tourout has completed a number of MP training courses, including his QL5A in 1995, QL6A in 2003, and QL6B in 2006.^{Footnote 644} He completed training as an MP criminal investigator in 2001 as well as receiving training in major case management in 2007.^{Footnote 645} He also completed courses with civilian police forces, including: crime scene investigation, search and seizure with the Winnipeg Police Force; major case management with the Ontario Provincial Police; the RCMP investigator’s course; and the Reid’s interview and interrogation course.^{Footnote 646}

19. Prior to supervising MCpl Ritco’s investigation, WO Tourout had not conducted or supervised any sudden death investigations.^{Footnote 647}

Master Warrant Officer Barry Watson

20. Master Warrant Officer Barry Watson (Retired CWO Watson at the time of his testimony before the MPCC in October 2012) was the detachment Master Warrant Officer and Acting OC for the CFNIS Western Region in 2008 and, in that capacity, oversaw the 2008 Sudden Death Investigation. At the time of his testimony, he had 21 years of policing experience.^{Footnote 648} He joined the CF in 1985 and initially served as a member of the infantry, including an overseas posting in Cyprus in 1988. In 1989, he became a member of the military police.^{Footnote 649} He was posted as a corporal to CFB Suffield in 1990, where he was engaged in patrol duties. In 1994, he was promoted to Master Corporal and posted to CFB Cold Lake, where he was engaged in both patrol duties and security operations.^{Footnote 650} In 1997, he was promoted to the rank of Sergeant and was posted to CFB Dundurn as the MP detachment commander. In 2000, he was posted overseas to Bosnia, and in 2002, he was posted to Israel and Syria.^{Footnote 651}

21. In 2004, MWO Watson was posted to the CFNIS WR as the detachment Master Warrant Officer. He was assigned to an overseas posting in Afghanistan in 2007. He then continued in the position of detachment Master Warrant Officer at CFNIS WR, the position he occupied at the time of Cpl Langridge's suicide. His duties included providing oversight of all ongoing CFNIS investigations. He was also responsible for recruiting, discipline, and the day-to-day operations of the detachment.^{Footnote 652} He was not involved in the day-to-day conduct of investigations, of which there would usually be between 30 and 50 at any given time. Instead, case managers would brief him regarding the status of the investigations, as they would have direct interactions with investigators. He did not review SAMPIS entries on a daily basis and did not attend meetings between the case managers and investigators.^{Footnote 653} He only became more directly involved with a given investigation if it was necessary.^{Footnote 654} Between March and July 2008, MWO Watson was the Acting OC of the CFNIS WR.

22. In terms of training as an MP and CFNIS investigator, MWO Watson completed basic training for military police, the MP QL3 qualification, in 1989,^{Footnote 655} and QL5A in 1991. He completed the QL6A, which requires approximately one month, at the time of his promotion to sergeant,^{Footnote 656} as well as the one-month QL6B qualification in 2001, with his promotion to Warrant Officer.^{Footnote 657} In 2004, he completed the MP Criminal Investigator course, an essential qualification for joining the CFNIS,^{Footnote 658} which lasts approximately three weeks and covers advanced investigative techniques. MWO Watson's other qualifications at the time of the 2008 Investigation included the Out of Service Training (OST) Major Case Management training course, a three-week course concerning managing major cases across multiple jurisdictions and with multiple forces,^{Footnote 659} which he completed in 2006.^{Footnote 660}

23. MWO Watson had experience conducting and supervising sudden death investigations, having been involved in approximately 26 sudden death investigations in Afghanistan, generally concerning battlefield deaths, and roughly three sudden death investigations in Canada. ^{Footnote 661} While he had never conducted a suicide investigation as a lead investigator, he had experience supervising suicide investigations as well as accidental deaths and combat deaths.^{Footnote 662}

Major Brian Frei

24. Maj Brian Frei (Lieutenant-Colonel Frei at the time of his testimony before the MPCC in October 2012) was the Deputy CO CFNIS at the time of the investigation into Cpl Langridge’s sudden death.^{Footnote 663} He reviewed the investigation report and concurred with its findings on July 3, 2008.^{Footnote 664}

25. Maj Frei first joined the CF in 1991 and attended the Royal Military College of Canada until his graduation in 1995.^{Footnote 665} He completed a master’s degree in Physics^{Footnote 666} at Queen’s University before attending MP training at CFB Borden in 1997.^{Footnote 667} He was posted to CFB Esquimalt in January, 1998, where he acted as Security Operations Officer for approximately a year and a half prior to being appointed Deputy PM for the Pacific area.^{Footnote 668}

26. In 2000, Maj Frei was posted to the CFNIS as an investigator in the Sensitive Investigation Detachment in Ottawa. He remained in Ottawa for approximately two years and completed his posting as the Operations Officer.^{Footnote 669}

27. Maj Frei was deployed to Bosnia as the CFNIS Detachment Commander in 2003. He returned to Canada in the summer of 2003 and was posted to CFNIS Atlantic Region as Detachment Commander. He remained in that position for two years before returning to Ottawa as Executive Assistant to the CFPM, a position he held for the next two years.^{Footnote 670}

28. In the summer of 2007, Maj Frei was posted back to the CFNIS as Deputy CO under LCol Garrick. He held that position until the fall of 2008 when he was selected as CO CF MP Company in Afghanistan; he deployed in October 2009. In June, 2012, Maj Frei was appointed CO CFNIS.^{Footnote 671}

29. Maj Frei had conducted a variety of investigations during his time as an investigator. However, he had never conducted a sudden death investigation.^{Footnote 672}

Lieutenant-Colonel Bud Garrick

30. LCol Bud Garrick (Retired LCol Garrick at the time of his testimony before the MPCC in October 2012) was the CO CFNIS at the time of the investigation into Cpl Langridge’s sudden death.^{Footnote 673} There is no indication LCol Garrick was involved in the investigation in an investigatory, supervisory, or advisory capacity. He does not appear to have been consulted on the file while he was the CO CFNIS.

31. LCol Garrick first joined the MP in 1981 as a private. He was posted to CFB Edmonton following his basic MP training and employed in patrols and criminal investigations. He remained in this position for five years before being posted to Cold Lake, Alberta, as an MP for a further five years. Following that, he was again employed in patrols and criminal investigations.^{Footnote 674}

32. LCol Garrick was subsequently accepted into the university training program for NCOs and attended the University of Manitoba, obtaining a degree in Criminology. He then entered the MP Officers course. Following his Officer training, LCol Garrick was posted as the Section Commander for the Special Investigations Unit in Winnipeg.^{Footnote 675}

33. In 1997, following the creation of the CFNIS, LCol Garrick was transferred to Ottawa as the Operations Officer of CFNIS Central Region, a post he held for two years. He was then posted to the Sensitive Investigations section of CFNIS, where he also remained for two years. He was subsequently deployed to Syria and Bosnia where he led a team of investigators focused on corruption and black market activity.^{Footnote 676}

34. Upon returning to Canada, LCol Garrick was posted to the Investigations Support Detachment of CFNIS, focusing on surveillance, criminal intelligence, polygraph and computer crime. He held that position for two years before being posted as the Deputy PM, overseeing policy development, records management and ATI requests. He remained in that position for a year and was then posted to Greenwood, Nova Scotia, as OC MP Detachment for two years.^{Footnote 677}

35. In 2005, LCol Garrick returned to Ottawa as Senior Operations Officer for CFNIS. In 2006, he was promoted to Lieutenant-Colonel and assumed the position of CO CFNIS. He held that position for two years before taking a position as the Deputy Director General of Criminal Intelligence Service Canada in June 2008. In 2009, he went into private practice as a consultant.^{Footnote 678}

The 2009 and 2010 Investigations: Primary Next of Kin and Criminal Negligence

Master Seaman Eric McLaughlin

36. MS Eric McLaughlin (PO2 McLaughlin at the time of his testimony before the MPCC in September 2012) was one of the initial investigators assigned to the 2009 investigation.^{Footnote 679} He worked on the investigation with Maj Dandurand between November 2009 and mid-January 2010 when he deployed to Haiti.^{Footnote 680} He also had some very limited involvement in the 2008 investigation, taking notes during the interview of MCpl Fitzpatrick conducted by MCpl Ritco.^{Footnote 681}

37. MS McLaughlin joined the CF in September 2001.^{Footnote 682} After completing basic training, he was sent to the Military Police Academy for his QL3 training.^{Footnote 683} He graduated in February 2003,^{Footnote 684} and for the three years following, he was posted to CFB Edmonton as an MP on the base.^{Footnote 685} In 2006, he was seconded to the CFNIS WR.^{Footnote 686} The secondment lasted for one year and permitted MS McLaughlin to get involved in the work of the CFNIS.^{Footnote 687} At the end of the year, he returned to his Unit to complete two more months of patrol duties until he was officially posted to the CFNIS in 2007.^{Footnote 688} He completed his MP criminal investigator course in November 2007.^{Footnote 689} He remained at CFNIS WR until 2012.^{Footnote 690} At the time of the hearing, he was posted to the CF Military Police Academy.^{Footnote 691}

38. At the time of his involvement in the 2009 investigation, he had been a member of the CFNIS for a little over two years, not including his period of secondment. He had experience in conducting less than ten negligent-performance-of-duty investigations.^{Footnote 692} His formal police training up to that point of time, other than his required MP training courses and Criminal Investigator course, consisted of training in use of force, statement admissibility and as a sexual assault investigator.^{Footnote 693}

Master Corporal David Mitchell

39. Following the departure of MS McLaughlin, MCpl David Mitchell (Sergeant Mitchell at the time of his testimony before the MPCC in June 2012) assisted Maj Dandurand on the 2009 investigation from mid-February to the end of March 2010.^{Footnote 694} At the end of March, MCpl Mitchell assumed a more central role, in effect, leading the investigation until early September 2010 when he left the detachment for a secondment.^{Footnote 695} He was designated the lead investigator from the outset of the 2010 investigation in May 2010 until he left in September 2010.^{Footnote 696}

40. MCpl Mitchell joined the Canadian Forces in 2002 and received his military police credentials in the summer of 2003.^{Footnote 697} His first posting was to 5 Wing Goose Bay in Northern Labrador where he remained until 2006.^{Footnote 698} He was then posted to 1 Military Police Platoon in Edmonton where he spent two and half years,^{Footnote 699} followed by a posting to the Military Police Guardhouse at CFB Edmonton where he spent a short time on patrol before being posted to the CFNIS WR in August of 2009.^{Footnote 700} He remained at CFNIS WR until early September 2010 when he was tasked to complete the residency component of his PLQ course and, immediately afterwards, he began a yearlong secondment with the RCMP.^{Footnote 701} At the time of the hearing, he was posted to Afghanistan in his capacity as a military police officer.^{Footnote 702}

41. MCpl Mitchell began as an intern when he joined the CFNIS in August 2009.^{Footnote 703} During the period of his internship, he worked under the supervision of a qualified member and was not designated as lead investigator on any files.^{Footnote 704} Maj Dandurand was formally in charge of the 2009 investigation until the completion of MCpl Mitchell’s internship in late March 2010. However, MCpl Mitchell was responsible for most of the legwork on the file.^{Footnote 705} He also demonstrated himself to be ahead of his peer group and his internship was written off ahead of schedule.^{Footnote 706}

42. MCpl Mitchell did not have much experience in conducting serious and sensitive investigations prior to becoming the lead investigator of the 2009 and 2010 investigations. When he began at the CFNIS, a sizable portion of his time was taken up with completing required training courses. He participated in a week-long CFNIS indoctrination course in September and the MP criminal investigation course, which ran from mid-October 2009 to the end of November.^{Footnote 707} This means, prior to his involvement in the 2009 investigation, MCpl Mitchell had, by his own estimation, a little over three full months experience in serious and sensitive investigations.^{Footnote 708} During that three-month period, MCpl Mitchell had been involved in a few serious and sensitive investigations including a forged documents case, several sexual assault investigations and investigations of other military police members, but, because he was an intern, he was not lead investigator.^{Footnote 709} He had not been involved in any negligent-performance-of-duty investigations nor any criminal negligence investigations as a member of the CFNIS prior to his involvement in the 2009 and 2010 investigations.^{Footnote 710} Other than the required MP training, it does not appear MCpl Mitchell had taken any other courses related to police investigations prior to undertaking either the 2009 or 2010 investigations.^{Footnote 711}

Sergeant Scott Shannon

43. Sgt Scott Shannon took over as lead investigator on the 2009 investigation in September 2010 following the departure of MCpl Mitchell.^{Footnote 712} He remained lead investigator until the conclusion of the investigation.^{Footnote 713} Though he was never formally assigned to the 2010 investigation, he completed an academic review of the complaint which was included as part of the concluding power point presentation to the command team.^{Footnote 714}

44. Sgt Shannon joined the CF in July 1999.^{Footnote 715} Following basic training, he completed his QL3 training at the Military Police Academy in February 2001.^{Footnote 716} He was then posted to 17 Wing Detachment Dundurn in Saskatchewan where he served for the next four and half years, which included his first international deployment to the Persian Gulf where he performed general patrol duties.^{Footnote 717} In September 2004, Sgt Shannon completed the MP Criminal Investigator course,^{Footnote 718} and in 2005, he became a member of the CFNIS.^{Footnote 719} Sgt Shannon served with the CFNIS in Halifax for the next six years,^{Footnote 720} transferring to Edmonton and the CFNIS WR detachment in September 2010.^{Footnote 721} At the time of the hearing, he was posted to 1 Military Police Regiment in Edmonton where he was the Support Platoon Warrant Officer.^{Footnote 722}

45. With respect to his training, Sgt Shannon had completed a number of police courses prior to his involvement in the 2009 and 2010 investigations, including an RCMP course on crime scene investigation as well as internal courses on the identification and collection of forensic evidence, cybercrime, sexual assault investigation and electronic crime scene examination.^{Footnote 723} He had not taken the forensic interviewing course offered by the CF.

46. In addition to completing police courses taken during the course of his employment, Sgt Shannon was awarded a diploma in Law Enforcement, an Honour’s degree in Criminal Justice and, at the time of the hearing, was studying for his Master’s degree in Public Administration.^{Footnote 724}

47. Sgt Shannon conducted 109 criminal investigations as the primary lead investigator in the course of his career.^{Footnote 725} Prior to becoming involved in the 2009 investigation, he had conducted three different investigations into the negligent performance of a military duty.^{Footnote 726} He also had been involved in drafting and reviewing military policy, specifically the CFNIS SOP with respect to sudden deaths,^{Footnote 727} but did not have any prior experience in investigating a charge of criminal negligence causing death or any charge involving criminal negligence.^{Footnote 728}

Warrant Officer Blair Hart

48. WO Blair Hart was the Operations Warrant Officer and acted as the Case Manager from the outset of both the 2009 and 2010 investigations until July 2010.^{Footnote 729} His posting as Operations Warrant Officer coincided with the period of time MS McLaughlin was assigned to work on the 2009 investigation and with MCpl Mitchell’s subsequent work on both the 2009 and 2010 investigations. In the summer of 2010, WO Hart assumed the position of Support Operations Warrant Officer.^{Footnote 730} Despite having significantly less involvement in the day to day management of the investigation files, including the 2009 and 2010 investigations,^{Footnote 731} he was still a member of the command team and would fill in when WO Bonneteau was unavailable.^{Footnote 732}

49. WO Hart began his military career as a reservist in 1980.^{Footnote 733} In 1986, he joined the regular force and, following basic training, completed his QL3 training at the Military Police Academy in November 1986.^{Footnote 734} In 1987, he was posted as a trained MP to CFB Shilo in Manitoba,^{Footnote 735} then subsequently to the Military Security Guard Unit at the Canadian High Commission in New Delhi, India, and to the CF Military Police Academy, first in a security and then in a teaching role.^{Footnote 736} In July 2001, he was posted to the CFNIS in Borden, completing his MP Criminal Investigator training in October 2001.^{Footnote 737} During this posting, he was deployed to Bosnia as a CFNIS investigator.^{Footnote 738} In 2005, he was posted to CFNIS WR, and, during that posting, he was deployed to Afghanistan.^{Footnote 739} Upon his return to Canada, he was posted to CFB Edmonton and, in 2009, he returned to CFNIS WR.^{Footnote 740} He served as the Operations Warrant Officer for approximately 12 to 14 months, after which, he became the Support Operations Warrant Officer, overseeing criminal intelligence and drug programs.^{Footnote 741} In 2011, he was posted to Halifax and the CFNIS Atlantic Region office, where he remained at the time of his testimony.^{Footnote 742}

50. WO Hart had been a military police officer for 23 years and with the CFNIS for six of those years when he became involved in the 2009 investigation.^{Footnote 743} He was promoted to acting WO in December 2008, meaning he appears to have had about a year of supervisory experience before he became involved in the 2009 investigation.^{Footnote 744}

51. WO Hart did have experience investigating a spectrum of cases dealing with allegations of negligent performance of duty.^{Footnote 745} He also acted in a supervisory capacity for an investigation with allegations similar to criminal negligence causing death but with facts in no way similar to the factual background of Cpl Langridge’s suicide.^{Footnote 746} He did not have any experience with the Criminal Code offence concerning the duty of persons directing work to prevent bodily harm, nor had he ever heard of it being laid in the context of the CF.^{Footnote 747}

Warrant Officer Sean Bonneteau

52. WO Sean Bonneteau (Retired Warrant Officer Bonneteau at the time of his testimony before the MPCC in September 2012) was the Operations Warrant Officer on both the 2009 and 2010 investigations from the summer of 2010 until the conclusion of both files.^{Footnote 748} His time as Operations Warrant Officer coincided with Sgt Shannon’s role as lead investigator on the 2009 investigation and Sgt Shannon’s review of the 2010 investigation.

53. WO Bonneteau joined the CF in July 1987.^{Footnote 749} He began his career in the Air Force as an air weapons technician until he moved in January 2001 to the Military Police Branch.^{Footnote 750} In October 2001, he completed his MP QL3 course and was posted as a patrolman to the MP detachment at CFB Edmonton.^{Footnote 751} He was posted to the CFNIS WR in April 2003 as an investigator.^{Footnote 752} He completed the MP Criminal Investigator course in October 2003.^{Footnote 753} In July 2006, WO Bonneteau was posted to Afghanistan where he ensured security for a team working outside of the CF base and later worked as a CFNIS investigator.^{Footnote 754} In August 2007, he was posted back to CFNIS WR and was selected to become a polygraph examiner, undergoing an intense period of study and training from August 2007 until March 2008 for the polygraph examiner course, following which he became the polygraph examiner for Western Region.^{Footnote 755} During the following years, he also completed three short postings to Afghanistan.^{Footnote 756} In July 2010, he was assigned as the Operations Warrant Officer for CFNIS WR and named the polygraph co-ordinator for the CFNIS.^{Footnote 757} He retired from the military in May 2011, shortly after the 2009 and 2010 investigations closed.^{Footnote 758}

54. WO Bonneteau had been a military police officer for only 17 months when he became a member of the CFNIS.^{Footnote 759} This was a very quick move up from regular MP to what was considered to be the more elite ranks of the CFNIS.^{Footnote 760} While at the CFNIS, WO Bonneteau moved quickly through the ranks to a supervisory position, advancing from the rank of Corporal to Warrant Officer in his five years with the CFNIS.^{Footnote 761} He became a WO in June 2010,^{Footnote 762} only weeks before taking over supervisory duties on both the 2009 and 2010 investigations. His only other supervisory experience prior to his involvement in the 2009 and 2010 investigations appears to have been as team leader on an investigation in Afghanistan over a two-week period.^{Footnote 763}

55. In terms of training, WO Bonneteau took an adult/child sexual assault investigator’s course, the polygraph course, a forensic interviewing course, a major crime investigator’s course and attended numerous seminars on a number of different topics including major case management and informants.^{Footnote 764} WO Bonneteau had investigated a wide range of service and Criminal Code offences, but was unable to say with certainty whether he had ever investigated allegations of criminal negligence or of negligent performance of a military duty.^{Footnote 765} He had not ever been involved in any investigation regarding the failure to provide the necessaries of life or regarding a failure of the employer to ensure a safe work environment for employees.^{Footnote 766}

Major Daniel Dandurand

56. Maj Daniel Dandurand was the Officer Commanding of the WR detachment throughout the entire course of both the 2009 and 2010 investigations.^{Footnote 767} He was also the OC when the failure to disclose Cpl Langridge’s suicide note was discovered after the completion of the 2008 investigation and the note was later sent to the Fynes.^{Footnote 768}

57. Maj Dandurand joined the CF in 1994 as part of the regular officer training program.^{Footnote 769} He was unsuccessful in becoming a pilot, and, instead, he attended the Military Police Academy at Borden, completing his training in May 2002.^{Footnote 770} He began his career in the MP branch by first completing a year-long provisionary employment period for officers.^{Footnote 771} His first six months were spent at CFB Petawawa learning the procedures of a detachment and working on patrols.^{Footnote 772} He then went to the CFNIS in Ottawa for six months where he worked with the Sensitive Investigations cell of the CFNIS, a detachment which dealt with the most sensitive and serious crimes the CFNIS was investigating.^{Footnote 773} He deployed to Afghanistan in 2003 as a multinational MP platoon commander and spent approximately eight months there,^{Footnote 774} subsequently returning to Ottawa to work as the executive assistant to the Provost Marshall.^{Footnote 775} In the summer of 2005, he was posted to the United Kingdom as second in command of an MP company. While on this posting, he deployed to Iraq as part of the U.K. involvement in the region.^{Footnote 776} From the U.K., he came directly to Western Region in July 2008 as the Officer Commanding.^{Footnote 777} He remained in the position until July of 2011.^{Footnote 778} At the time of his testimony, Maj Dandurand was the Commandant of the Military Police Academy.^{Footnote 779}

58. Prior to assuming the Officer Commanding position, Maj Dandurand had been an MP for six years, but his experience within the CFNIS came from the six months he spent with the CFNIS during his provisionary employment period,^{Footnote 780} five years previous to becoming OC.^{Footnote 781} He did not complete his MP Criminal Investigator course until several months after he became OC, a circumstance he did not consider unusual.^{Footnote 782} He did have some limited exposure to MP investigations during his provisionary employment. The rest of his experience was overseas with a significant portion in conflict zones.

59. Maj Dandurand had not done any sudden death investigations, any investigations for failing to provide the necessaries of life, nor any investigations related to the duties of an employer to maintain a safe workplace.^{Footnote 783} He had participated in an investigation involving allegations of the negligent performance of duties, which included an allegation of a poor application and understanding of policy,^{Footnote 784} but it was not otherwise similar to the 2009 investigation. Maj Dandurand’s training included completing the MP course, the MP criminal investigators course and a course on Major Case Management,^{Footnote 785} as well as professional development seminars. The evidence suggests he did not complete any other specialized investigative training.^{Footnote 786}

Lieutenant-Colonel Gilles Sansterre

60. LCol Gilles Sansterre was the CO CFNIS from August 2008 until April 2011.^{Footnote 787} He was the CO during all but the very final weeks of the 2009 and 2010 investigations. He was also the CO when the failure to disclose Cpl Langridge’s suicide note was discovered after the completion of the 2008 investigation and the note was later sent to the Fynes.

61. LCol Sansterre joined the military in March 1985^{Footnote 788} and completed his QL3 course in July of that year.^{Footnote 789} He was posted to Halifax as an MP, completed university in 1993 and was then commissioned as an officer in the Military Police branch.^{Footnote 790} From there, he went on to postings in Halifax, Winnipeg, and Borden at the MP Academy.^{Footnote 791} He completed tours in Kosovo and had been to Afghanistan on three separate occasions to conduct investigations.^{Footnote 792} In 2001, he was posted to Ottawa as Deputy Provost Marshal, National Investigation Service.^{Footnote 793} Over the following three years, he commanded two different detachments – the support detachment and central region detachment.^{Footnote 794} He was promoted to Lieutenant-Colonel in 2006 and went on to hold the position of Deputy Provost Marshal, Resource Management and Deputy Provost Marshal, Professional Standards.^{Footnote 795} In August 2008, he assumed the position of Commanding Officer of the CFNIS.^{Footnote 796} At the time of the hearing, he was the Deputy Commander of the newly formed military police group.^{Footnote 797}

62. LCol Sansterre did not take the MP Criminal Investigator course but had taken a general investigations techniques course given by the Ottawa Police.^{Footnote 798} On two occasions he had worked on sudden death investigations involving suicide, but only as a first responder.^{Footnote 799} He had not had the occasion to investigate an allegation of criminal negligence, but he had investigated allegations of negligent performance of a military duty.^{Footnote 800}

4.1 The 2008 Investigation

4.1.1 Investigating the Sudden Death

Issues Raised by the Complainants

1. The complainants raise numerous concerns about the way the 2008 investigation into the sudden death of Cpl Stuart Langridge was conducted. They allege the CFNIS investigators tasked with investigating Cpl Langridge’s death conducted their investigation with no clearly defined or understood purpose and failed to address the issues to be investigated properly.^{Footnote 801} They allege the investigators failed to define the scope of the investigation appropriately and the CFNIS as a whole failed to provide appropriate direction in this regard. In general, they allege the CFNIS members involved in the investigation lacked the necessary experience and training to conduct it.^{Footnote 802}

2. In addition to these general allegations, the complainants raise a number of specific issues, many focused on the manner in which the death scene was processed, including allegations of disrespect shown to Cpl Langridge’s body.

3. The subjects of the complaint deny the allegations and state they adhered to all relevant policies and procedures for general police investigations in force at the time. They also deny the specific allegations related to processing the death scene and, in particular, they deny Cpl Langridge’s body was shown any disrespect.

4. A detailed review of the events surrounding the discovery of Cpl Langridge’s body and of the CFNIS investigators’ actions at the scene is essential to assess both the general and the specific allegations about this aspect of the 2008 Investigation.

Initial Response to Cpl Langridge’s Death

5. At 1520 hrs on Saturday, March 15, 2008, Cpl Roger Hurlburt unlocked the door to room F314, Barrack Block 164 and discovered the body of Cpl Langridge hanging by a ligature tied around his neck.^{Footnote 803} Cpl Langridge had failed to check in at the duty desk as scheduled (as required by the conditions imposed upon him by the Regiment). When Cpl Langridge did not answer his phone or respond when verbally hailed from outside the locked door of the barracks room in which he spent much of his last 24 hours, Cpl Hurlburt returned to the duty centre to report the situation. Cpl Hurlburt was given a key by Sgt Trent Hiscock, the duty NCO that day, and was ordered to unlock the door and enter the room. When he returned to the barracks and discovered the body, Cpl Hurlburt observed Cpl Langridge's skin was cold and found no pulse.^{Footnote 804} Cpl Hurlburt drove back to the duty centre and informed Sgt Hiscock of Cpl Langridge's death. Sgt Hiscock ordered Cpl Hurlburt to return to the barracks room and await the arrival of the military police.

6. It is not known precisely when the Regiment alerted emergency personnel to the death but, at 1545 hrs on March 15 2008, Pte Jesse Neill from the CFB Edmonton Garrison Fire Service (EGFS) contacted the 1^st Military Police Unit.^{Footnote 805} He advised Sgt Pierre Rioux base fire personnel were responding to a call reporting a death had occurred in room F314 at 164 Ortona Road. MP members Cpls Scott Broadbent and Tyler James Bruce-Hayes were dispatched. They arrived at approximately 1546 hrs, at the same time as base fire hall personnel.^{Footnote 806}

7. MCpl Ken Munro of the EGFS was let into the room by Cpl Hurlburt, the first to enter after Cpl Langridge's body had been discovered.^{Footnote 807} Cpl Bruce-Hayes entered at the same time, crossing the threshold into the room but without going past the body.^{Footnote 808} MCpl Munro checked for vital signs and detected no pulse or respiration. He observed Cpl Langridge's face was pale and exhibited evident cyanosis (the appearance of blue or purple colouration of the skin caused by a lack of oxygen in the blood) around his lips and mouth.^{Footnote 809} These observations were confirmed by MCpl Bob Bowen of the EGFS.^{Footnote 810} MCpl Munro then moved past Cpl Langridge's body and retrieved his wallet and identification from the desk.

8. The fire personnel then remained outside the room with MP members. Cpl Bruce-Hayes observed the body was suspended from a chin-up bar in the room, and the arms were purple from the elbow down.^{Footnote 811} At 1555 hrs, Cpl Bruce-Hayes began to interview Cpl Hurlburt about what had happened.^{Footnote 812} During this time, Sgt Marty Van Delen of the EGFS contacted the Office of the Chief Medical Examiner (ME) in Edmonton, and was informed an investigator from the ME’s office was on his way.^{Footnote 813}

9. At 1556 hrs, eleven minutes after the death was reported to the MP, the 1^st MP Unit duty dispatcher contacted WO Ross Tourout of the CFNIS and notified him about the death.^{Footnote 814} At 1602 hrs, paramedics Jacques Coppens and Steve Gillingham of St. Albert Fire Service Ambulance attended the scene. They confirmed there were no vital signs, noting the skin was cold and clammy, and purple in colour, and departed at 1610 hrs.^{Footnote 815}

10. At 1605 hrs, Sgt Jon Bigelow of the CFNIS National Drug Enforcement Team received a telephone call from MWO Barry Watson, the detachment MWO and Acting OC for the CFNIS Western Region (WR) in March 2008.^{Footnote 816} MWO Watson informed Sgt Bigelow of the discovery of Cpl Langridge's body at the barracks and requested his assistance in conducting a sudden death investigation under the lead of MCpl Matthew Alan Ritco, who was assigned as the lead investigator because he was the CFNIS duty investigator on call that day.^{Footnote 817} Although Sgt Bigelow was a drug investigator, MWO Watson sought his assistance because the CFNIS WR was experiencing a personnel shortage.^{Footnote 818} Sgt Bigelow readily agreed to assist and was directed to contact MCpl Ritco to advise him of the situation. Sgt Bigelow proceeded to instruct MCpl Ritco to meet him at CFNIS WR.

11. At 1608 hrs, Cpl Bruce-Hayes was informed MWO Watson had dispatched CFNIS investigators to the scene. Cpl Bruce-Hayes was ordered to secure the scene and told not to let anyone into the room.^{Footnote 819} Cpl Bruce-Hayes and Cpl Broadbent kept the door closed, remaining outside the room and ensuring unauthorized personnel did not enter.^{Footnote 820} Before the CFNIS investigators arrived, Cpl Bruce-Hayes and Cpl Broadbent recorded their observations of the room and Cpl Langridge's body, noting he was hanging from a combat belt tied around his neck,^{Footnote 821} also recording the manner in which he was dressed, the fact there was a chair immediately behind the body, and noting some of the contents of the room.^{Footnote 822}

CFNIS investigators attend at the scene

12. There was some delay between the report of Cpl Langridge's death to the CFNIS at 1556 hrs and the commencement of the investigation. Prior to attending at CFB Edmonton, MCpl Ritco and Sgt Bigelow had to change into their uniforms, retrieve equipment and travel to the base. ^{Footnote 823} The investigators loaded investigative kits (comprised of evidence collection materials, statement forms, cameras, and equipment) into a Unit vehicle.^{Footnote 824} Sgt Bigelow testified the work at the detachment took approximately 15 minutes, followed by a five-minute drive to the base MP detachment.^{Footnote 825}

13. At 1655 hrs, MCpl Ritco and Sgt Bigelow arrived at the CFB Edmonton MP guardhouse. There they spoke with Sgt Rioux and were briefed about what was known at that point about the incident and the identity of the deceased. Sgt Bigelow wrote in his notes the events giving rise to Cpl Langridge's death were still uncertain, but Cpl Langridge had last been seen at 1230 hrs and was possibly on the defaulters’ parade.^{Footnote 826} MCpl Ritco recorded this information in a SAMPIS entry for the investigation. Sgt Rioux also informed MCpl Ritco the fire department and base MPs were at the scene.^{Footnote 827}

14. Seeking more information about the deceased before attending the scene, MCpl Ritco and Sgt Bigelow conducted a SAMPIS check on Cpl Langridge while at the MP detachment.^{Footnote 828} They were told a representative of the ME's office was on his way, and they waited for him to arrive at the MP detachment.

Arrival of investigator from the Alberta Chief Medical Examiner’s office

15. In the province of Alberta, the Chief Medical Examiner is mandated under the provincial Fatality Inquiries Act^{Footnote 829} to investigate unexpected or unexplained deaths.^{Footnote 830} The Chief Medical Examiner must determine, to whatever extent possible, the medical cause of death, the manner of death, the identity of the deceased, the date, time and place of death, and the circumstances under which the death occurred.^{Footnote 831} Mr. Dennis Caufield, an investigator from the Alberta Office of the Chief Medical Examiner (“ME Investigator”), arrived at the MP detachment at 1712 hrs.^{Footnote 832}

16. Mr. Caufield testified he had 27 years of experience with the Office of the Chief Medical Examiner, and 23 years of experience as a senior medical investigator.^{Footnote 833} He testified his duties begin with responding to any incoming calls reporting deaths. He then ascertains whether the death is one that is, in fact, reportable to the ME and requires an investigation under the Fatality Inquiries Act.

17. After Mr. Caufield’s arrival at the MP detachment, he, MCpl Ritco, and Sgt Bigelow attended the scene of Cpl Langridge's death at 1721 hrs.^{Footnote 834} Owing to time differences on their respective watches, MCpl Ritco's notes recorded their arrival at 1724 hrs.^{Footnote 835} This caused small discrepancies in the notes and records generated in the course of the investigation.

18. The investigators arrived at the scene approximately one and a half hours after the CFNIS was informed of the death. They met with Cpls Bruce-Hayes and Broadbent and were briefed about fire and ambulance personnel attending, checking vital signs and confirming Cpl Langridge's death. The wallet containing Cpl Langridge's military identification and driver's licence retrieved from the room was turned over to MCpl Ritco at 1728 hrs.

Understanding the Allegations: Some Key Questions

What was done and why?

19. The complainants allege MCpl Ritco and Sgt Bigelow conducted the 2008 Sudden Death Investigation with no clearly defined or understood purpose, and lacked the skills, experience and competence necessary to conduct the investigation. The subjects responded that the CFNIS investigators worked thoroughly and with professionalism throughout the investigation, and CFNIS members must handle a sudden death with the same stringency as a homicide. The subjects submit, even if a sudden death looks like a suicide at the scene, the CFNIS will exhaust every avenue and work to avoid tunnel vision.^{Footnote 836}

20. An initial issue arising from the allegations is the understanding MCpl Ritco and Sgt Bigelow had as to why they were at the death scene and what they did as a consequence. The CFNIS investigators and the Medical Examiner (ME) investigator had different mandates and differing expertise. Did the CFNIS investigators understand these differences? Did they make use of the expertise of Mr. Caufield, the ME Investigator, and his experience at the scenes of apparent suicides? Did they adjust their approach in any way based on what they found at the scene? Did they take reasonable measures consistent with the investigation of a homicide?

What did the CFNIS members do to analyze the information and evidence available?

21. From the available evidence and information, it should have been apparent early in the 2008 Sudden Death Investigation Cpl Langridge’s death was not a suspicious one. Yet, there is no evidence the strong likelihood of suicide was taken into consideration even as a working hypothesis. The absence of ongoing evaluation and analysis of information can have significant consequences for the quality of the initial investigation, as well as the planning and conduct of the ensuing Sudden Death Investigation. To assess the investigation, it is necessary to determine why so many clear indications about the nature of Cpl Langridge’s death went unnoticed, as well as to understand the purpose of the meticulous steps taken at the scene before and after his body was removed. It is also necessary to examine what these steps accomplished and whether they were consistent with their stated aim.

Was disrespect shown to Cpl Langridge’s body?

22. The allegations of disrespect are of particular concern for the complainants, so the evidence must be examined to determine what in fact happened concerning Cpl Langridge’s body and whether there was any element of disrespect.

23. The Fynes allege the CFNIS investigators showed disrespect to Cpl Langridge when they did not immediately lower his body. They also allege his body was not concealed from view during the processing of the scene and the body should have been covered or obscured to prevent it from becoming a spectacle.

24. According to the subjects, Cpl Langridge's body was treated at all times in a respectful manner.^{Footnote 837} Their position is the ME Investigator was the individual responsible for deciding when the body could be moved. They also argue it was not appropriate or necessary to cover Cpl Langridge’s body during the processing of the scene, and the CFNIS did not have the authority to lower the body.

How was the scene processed following the removal of the body? How should this be done for a sudden death?

25. After Cpl Langridge’s body was removed, the CFNIS investigators continued to process the scene and gather evidence. MCpl Ritco and Sgt Bigelow seized what they believed were relevant exhibits and collected all of Cpl Langridge’s personal effects. Was the evidence seized helpful? Was important evidence overlooked? What was the value in proceeding as they did, and what were the implications of doing so?

26. Each of these sets of questions will be examined in turn.

Processing the Scene: What Was Done and Why?

27. The CFNIS investigators and the ME Investigator took possession of the scene shortly after they arrived.^{Footnote 838} The small, rectangular barracks room was normally intended for a single CF member holding the rank of trooper or corporal.^{Footnote 839} The door opened into a narrow hallway spanned by a chin-up bar several feet from the threshold. To the left of the doorway was a wardrobe and cupboards, and to the right was a door to a shared bathroom. Cpl Langridge's body was suspended from the chin-up bar by a military, webbed belt tied into a ligature around his neck. Behind Cpl Langridge was a black chair. The room also had a single bed, a small desk and a vanity and sink. An open window with opened blinds was situated in the middle of the north-facing wall between the bed and the desk. Atop the desk were some books, magazines and papers belonging to Cpl Langridge, along with his suicide note and a pen. Clothes were piled atop a suitcase on the bed. MCpl Ritco prepared a drawing of the room and included it in the GO File.^{Footnote 840}

28. Before the investigators began to process the scene, Mr. Caufield began examining Cpl Langridge's body. Mr. Caufield testified his primary focus is the examination of the body and making observations about its position and condition to ascertain whether there is any sign the death is the result of a criminal act:

That's really important to us because it changes the nature of the investigation. If we were to see something that suggested that there was some injury or something that might suggest that some other person was involved, we stop that process at that point and we involve other layers of law enforcement, Forensic Identification Section, in this case it would be RCMP Major Crimes, those types of things. So that's one of our functions, when we go there, is to have that look to make sure that we're confident this is not appearing to be a criminal death.^{Footnote 841}

29. Mr. Caufield testified he might be called out for two to three similar deaths each day, so he had a mental checklist of information to obtain.^{Footnote 842} He testified he would have also asked the CFNIS members for information such as the deceased's name, his date of birth, the time when he was found dead, when he was last seen alive, and if they had found a suicide note.^{Footnote 843} He quickly formed the view that the death was consistent with a classic suicidal hanging.^{Footnote 844}

30. MCpl Ritco testified, after Mr. Caufield’s initial examination of Cpl Langridge’s body, he sought Mr. Caufield's permission to take photographs and video of the scene.^{Footnote 845} At approximately 1733 hrs, MCpl Ritco began to photograph the scene.^{Footnote 846}

31. MCpl Ritco testified the steps differ for processing each scene. He said the first priorities upon arriving at the scene are officer safety and the preservation of life. The next priority is the preservation of evidence.^{Footnote 847}

32. When asked if he formulated a plan of what needed to be done before he entered the room, MCpl Ritco testified his focus was to ensure the continuity of evidence, if there was any, was not compromised.^{Footnote 848}

33. MCpl Ritco testified he would not, at that time, have engaged in a discussion with Mr. Caufield to formulate a preliminary hypothesis as to whether the death was suspicious. He stated, “[i]n my experience, I treat every investigation keeping an open mind. Even though the ME says [...] ‘it appears to be a suicide,’ that’s fine, I take that into consideration, but at the end of the day I conduct my investigation with an open mind.”^{Footnote 849} This need to keep an open mind, even in the face of information and evidence suggestive of a conclusion of probable suicide, meant that from this point forward the focus would be on completeness of information rather than on drawing any inferences from the information already gathered.

Expert testimony on processing a death scene

34. The Commission heard the testimony of major crimes investigators from the Edmonton Police Service (EPS), the Ontario Provincial Police (OPP), and the Royal Canadian Mounted Police (RCMP). Their approaches to responding to sudden death reports and processing a death scene are not identical. The common thread is each step is purpose-driven and performed without unnecessary delay. It is essential to avoid tunnel vision or unfounded conclusions at the outset of the investigation. They are trained to assess a death scene on the information available and to form opinions as to whether a death is suspicious. This essential step guides the subsequent work at the scene.^{Footnote 850}

35. The EPS has extensive experience conducting death investigations, with its members conducting from one to two per day.^{Footnote 851} Staff Sgt William Clark, who supervises the homicide section of the EPS, described how the approach depends on the information available at the scene. He testified patrol officers who respond to an initial call of a death make a determination, based on available information, whether the death is criminal in nature. Nothing is touched and the scene is kept secure. Regardless of the nature of the death, the individual who reported the death must be interviewed at the scene. The responding officer then consults a sergeant, watch commander or other superior to make a finding about the nature of the death. Where it is decided the death does not appear suspicious, an ME investigator is called in to take charge of the scene and lead the investigation.^{Footnote 852} If the officers at the scene believe a death is suspicious, a forensic identification team is first sent to gather all evidence. In such cases, homicide detectives are called in to investigate the death, but they will not normally even enter the scene until the Identification team has examined the scene and finished collecting evidence. For a criminal death in the Province of Alberta, only after the police have processed the scene, is the ME normally contacted to remove the victim's body.^{Footnote 853}

36. S/Sgt Clark stated an officer might consider, when determining whether an apparent hanging was a suicide, whether the scene appears consistent with the manner of death. The position and condition of the body should be assessed for consistency with a death by suicide. For example, suicidal hangings often end with a person hanging relatively low – so, where a person was hanging well off the ground, was there a means for that person to have been suspended on their own and without another's effort? Essentially, the question is, does the scene as a whole make sense and is anything incongruous with the apparent manner of death? The officer investigating will also want to obtain the background of the deceased and gain some perspective as to what may have led the individual to suicide.^{Footnote 854} The presence or absence of a suicide note per se will not be a determining factor when considering whether a death was suspicious.^{Footnote 855} Where the constable at the scene or a superior considers anything to be suspicious or in question, homicide detectives will be contacted for their opinion; detectives may even be dispatched to the scene for an expert opinion. Often the ME may also be contacted, given the ME’s considerable expertise with death scenes.

37. Det. Insp. William Olinyk of the OPP's Criminal Investigation Branch (CIB) testified, if the initial responding officer or a supervisor has any suspicion the death could be criminal in nature, the area crime supervisor (a detective sergeant) will be brought into the discussion.^{Footnote 856} The detective sergeant will assess the scene and make a determination as to whether it fits the criteria to be assigned to a criminal investigation member – that is, a detective inspector. The detective inspector is then responsible for determining whether a major case manager needs to be involved.

38. Det. Insp. Olinyk testified the initial approach to an apparent suicide is the same as for a known homicide,^{Footnote 857} and the subsequent investigation is very similar to that of a homicide. Officers wear full biohazard suits to ensure nothing is disturbed, picked up, or left behind.^{Footnote 858} The scene and the evidence are secured, and no one is permitted in or out.^{Footnote 859} A decision regarding the nature of the death will be made in consultation with the coroner, bearing in mind the post-mortem examination could change the nature of the investigation. Once the post-mortem is complete and the available evidence has been assessed to show nothing suspicious, the OPP will be in a position to conclude the death was by suicide.^{Footnote 860}

39. Insp. Brendan Fitzpatrick, of the RCMP “E” Division Major Crimes Section in British Columbia, testified the RCMP’s approach to death scenes was similar to those described by S/Sgt Clark and Det. Insp. Olinyk. He testified, “[t]he number one rule would be that any death investigation is suspicious until proven otherwise,”^{Footnote 861} but added the RCMP’s approach to the scene is also dependent on forming opinions about the nature of the death as suspicious or non-suspicious. The constable or investigator at the scene should obtain information concerning the witnesses present or the circumstances concerning the report of the death. He or she must also preserve evidence by securing the scene and would contact an NCO or senior investigator, if available, to attend.^{Footnote 862} The RCMP also makes available advisory NCOs who will attend the scene and assist with the assessment.^{Footnote 863} The RCMP members at the scene then analyze the information available, and their determinations dictate the next steps.

40. Insp. Fitzpatrick testified the RCMP members in “E” Division, as a general rule, do not release the scene until after an autopsy is complete.^{Footnote 864} If there is a suicide note, or the means of death suggest a suicide, it is important to corroborate such evidence and seek information from the family and neighbourhood inquiries as to the deceased’s state of mind. The coroner will be involved and will provide direction as to where the investigation is going.^{Footnote 865} Until there has been a determination the death is non-suspicious, the RCMP preserves and gathers evidence as though conducting a criminal investigation, to ensure any prosecution is not compromised.^{Footnote 866}

41. Where a death is determined to be non-suspicious, the RCMP “E” Division conducts an investigation on behalf of the coroner.^{Footnote 867} A non-suspicious death will probably remain with the responding constable or investigator, who will coordinate with the coroner.^{Footnote 868} All evidence at the scene of a non-suspicious death is seized at the direction of the coroner.^{Footnote 869} The investigating officer should conduct neighbourhood inquiries to determine whether there are observations or other circumstances needing to be considered and take a statement from the last person to see the deceased alive.^{Footnote 870}

42. Insp. Fitzpatrick testified that, when there is any belief the death is suspicious or was an outright homicide, it becomes an investigation for the RCMP or for the local police force, and all evidence will be seized by the police. Forensic identification specialists will be called to attend, examine, process and document the scene, and the coroner will be consulted about the actions being taken and the extent to which the remains can be disturbed. The forensic identification specialist video-records and photographs the scene, and takes DNA swabs of material such as blood. A blood-spatter analyst could be called in for a suicide where necessary.^{Footnote 871}

Initial investigation failures at the death scene

43. In this case, the investigators do not appear to have fully understood either the purpose of the sudden death investigation or their role in that investigation – which was, from the outset, to determine whether there was any indication Cpl Langridge had died as a result of foul play.^{Footnote 872} When asked if the entire focus was to determine whether any foul play was involved, Sgt Ritco agreed, but then added his function was also “to find out what actually happened to Cpl Langridge.”^{Footnote 873}

44. That said, the CFNIS investigators did not ask themselves why they were at the scene of Cpl Langridge’s death or what specifically needed to be done in the circumstances. The investigators failed to assess the scene and death critically and failed to determine the level of suspicion associated with the death to focus and adjust their approach. The CFNIS members appeared to appreciate the fact the Office of the Chief Medical Examiner had authority in sudden death investigations, but did not appreciate the nature of Mr. Caufield’s function as the ME Investigator, which was to investigate the cause and manner of Cpl Langridge’s death.^{Footnote 874} The CFNIS members also did not appreciate their own function, which was to determine whether there was anything suspicious about the death that required further investigation by the police.

45. Unlike the EPS,^{Footnote 875} the CFNIS WR does not conduct investigations of sudden deaths for the benefit of the ME.^{Footnote 876} As a result, the role of the CFNIS investigators is limited to aspects requiring police investigation, and does not involve conducting a more general investigation into the cause and manner of death. The investigators involved in this case did not appear to appreciate this distinction.

Incorrect understanding of jurisdiction by CFNIS investigators

46. Police services can become involved in sudden death investigations in either of two ways: pursuant to their police jurisdiction or on behalf of an ME or Coroner.^{Footnote 877} The National Defence Act^{Footnote 878} authorizes MP to exercise police powers in enforcing the Code of Service Discipline over CF members who are subject to it.^{Footnote 879} In 1972, the Criminal Code^{Footnote 880} was amended by the Criminal Law Amendment Act,^{Footnote 881} bringing MP members into the definition of “peace officers” under the Code.^{Footnote 882} The Supreme Court of Canada has ruled, following this amendment, MP members are authorized to enforce the Criminal Code on CF property and with respect to CF members subject to the Code of Service Discipline.^{Footnote 883}

47. The closing submissions of the subjects incorrectly frame the jurisdictional issue as “who owns the scene?” Their submissions state, “[...] the scene belongs to the ME or Coroner, depending on the jurisdiction. This means the NIS was working alongside and collecting evidence on behalf of the ME, whose job is to determine conclusively the cause of death.”^{Footnote 884} The subjects submit MCpl Ritco and Sgt Bigelow were investigators acting under the authorization of the ME and the provincial Fatality Inquiries Act at the scene of Cpl Langridge’s death, which conferred upon them the powers and responsibilities of an ME Investigator.^{Footnote 885}

48. The subjects’ submissions provide inconsistent and contradictory explanations of the CFNIS’ role at the scene. The subjects maintain Mr. Caufield “owned the scene” and they took direction from him. Yet they also maintain they were conducting an independent investigation.^{Footnote 886} This explanation suggests confusion as to the role of the CFNIS in investigating a suicide, which also appears in the evidence before the Commission.

49. Maj Daniel Dandurand responded to the Fynes’ concerns about the time that elapsed before Cpl Langridge’s body was removed, by stating:

Here's the thing -- the thing is, Sheila, the medical examiner owns the scene [...]. It's actually not my scene until he attends, and until he says what's to happen. And actually [...] the military police follow his directions explicitly. I mean, he's going to -- if he says "do this", then we do it. If he says ‘seize that bottle’, ‘Grab that 26-ounce bottle’, ‘Grab that pill case’, then that's what we do [...]. And then once he's satisfied – or she -- once they are satisfied that their direction has been followed, and they determine what occurs, then we have the scene, and we can process it for all the other criminal/forensic processing that we need to do.^{Footnote 887}

50. For his part, MWO Watson testified that, while the CFNIS would be wholly in charge of the scene and the investigation in the event of a criminal offence like a sexual assault within their jurisdiction, CFNIS investigators will in practice take direction from the ME in the case of a sudden death.^{Footnote 888} Although it was his view the MP are not within the scope of the Alberta Fatality Inquiries Act and cannot act as ME Investigators,^{Footnote 889} he testified: “When there is a sudden death the ME owns that scene and he can provide direction on what he wants to be conducted,” adding, every investigator who has ever worked for him would follow the ME’s directions in a sudden death investigation.^{Footnote 890}

51. According to Sgt Bigelow, when MWO Watson contacted him about Cpl Langridge’s death and requested his assistance with the investigation, he was instructed to wait along with MCpl Ritco before going to the scene because, in sudden death investigations, the death scene is controlled by the ME.^{Footnote 891}

52. MCpl Ritco testified the scene “belonged” to Mr. Caufield as the ME Investigator. As such, MCpl Ritco waited for Mr. Caufield to grant him permission to enter the scene before he began to examine and process the room.^{Footnote 892} He testified the ME is “the one that does the autopsy or the toxicology. He is the one that gives the final report to say what the cause of death was [...] And how. It's his crime scene or his scene, I should say.”^{Footnote 893} However, MCpl Ritco also testified when a sudden death occurs, he would effectively be conducting a parallel investigation into the death. He stated he does not require the permission of the Chief Medical Examiner to commence such an investigation, but the investigation should not interfere with the ME’s investigation:

[The ME] has primary [jurisdiction] over the scene and, if need be, witnesses and all that if there is anybody there, right? He dictates what – like this person to be interviewed or you're not allowed to go into here. You're not allowed to touch this or I need this. So I'm still doing my investigation but I still have to – he still has say in the matter.^{Footnote 894}

53. Just like the subjects did at the outset of the investigation, it should be noted the complainants also misconstrued the roles of the CFNIS and the ME Investigator. They did not appreciate the different requirements for CFNIS members and the ME Investigator. The submissions of the complainants discuss who owns the scene. The opinion obtained by the complainants through the Solicitor General and Public Safety for Alberta, upon which the complainants’ view of this question appeared to be based, seems to have been premised on an assumption only one entity – the CFNIS or the ME Investigator – has jurisdiction to investigate a sudden death on a CF base. In reality, each has different roles.

54. The police and the ME or ME investigator have somewhat overlapping but largely complementary jurisdiction with respect to a sudden death scene. In Alberta, legislation gives MEs the function of determining the cause and manner of death as well as the identity of the deceased, the date, time and place of death, and the circumstances under which death occurred.^{Footnote 895} In pursuing this function, the ME or ME investigator at a sudden death scene has the power to cordon off or secure the scene, to enter the scene without a warrant, and to seize anything that may be directly related to the death without a warrant.^{Footnote 896} Additionally, the ME has the power to authorize members of the RCMP, other peace officers and members of police services responsible for policing in Alberta to assist the ME in carrying out his or her investigation. In such cases, the authorized police officers exercise the powers of the ME to secure a scene, enter a scene, and seize items related to the death.^{Footnote 897} However, they can only exercise these powers if authorized to do so by an ME.^{Footnote 898}

55. In this case, it appears the CFNIS investigators were unable to act as ME Investigators at all. The CFNIS is not identified in the provincial legislation and does not appear to meet the statutory criteria for designation as a ME Investigator. Even if the statute did allow for the CFNIS investigators to act in this case as ME Investigators, nothing Mr. Caufield did indicated he authorized the CFNIS to act on his behalf, nor was there an indication anything the CFNIS investigators did at the scene was done on his behalf. In fact, MCpl Ritco testified before the Commission his investigation was conducted “on behalf of the military”, and not on behalf of the ME.^{Footnote 899} He remarked the items he seized were taken under his powers as a peace officer, stating, “It was DND property. Corporal Langridge, it was his room. So I seized it under [...] my investigation.”^{Footnote 900}

56. The coroner or ME has a primary mandate to draw conclusions about the cause and manner of death through an examination of the body. While a coroner or ME does not “own” the scene, he or she can seize evidence in furtherance of that investigation. The CFNIS, like any police force, is responsible for investigating the possibility of foul play or criminal activity. A coroner or ME’s office typically leads investigations into non-suspicious or non-criminal deaths, with police acting in support.^{Footnote 901} Meanwhile, police forces will lead investigations into suspicious or criminal deaths, and the ME or ME Investigator at the scene takes a more passive role and completes their work when it will not interfere with the police effort.^{Footnote 902} The ME will normally not be called in as quickly for a suspicious or criminal death in order to give police at the scene time to assess the scene and to bring in forensic personnel as needed.^{Footnote 903}

Assessing the Scene and the Evidence

57. Given the complex nature of sudden death investigations, there is no exact formula to follow in order to determine when and on what basis foul play can be ruled out. However, there are certain issues an investigator ought to have foremost in mind. They include examining the death scene and body for evidence of foul play; creating a chronology of the deceased’s final hours and days; and investigating whether there were any circumstances in the deceased’s life to suggest foul play was more or less likely as contributing to the death. These inquiries generally focus on three key elements of the investigation, sometimes referred to as the “Golden Triangle”:^{Footnote 904} the scene, the post-mortem examination, and the history of the deceased. They may require the employment of a variety of police investigation techniques, including but not limited to: crime scene investigation, forensic analysis, interviewing, and documentary review.

58. Other police investigators outside the CFNIS make assessments about the scene and the nature of the death from the information available. The police panel members were conscious of the need to avoid tunnel vision and foreclosing of options but also stressed the importance of forming hypotheses.^{Footnote 905} The investigators at the scene must decide whether the death is suspicious. The circumstances of the scene dictate what will be necessary to properly make that determination.

59. Both the scene and Cpl Langridge’s body provided information. That information ought to have been identified and analyzed to establish the circumstances of Cpl Langridge’s death. Investigators should be cautious not to rush to conclusions. They must remain open to the possibility of information arising at a later date, inconsistent with the prevailing theory of the case and capable of changing the entire nature of the investigation. As a result, reasonable measures must always be taken to gather and preserve evidence, whose relevance may only become clearer at a later date. However, an investigator’s job is to analyse and form opinions based on the information available to determine what needs to be investigated and how.

60. A February 2008 draft revision to Chapter 7, Annex I to the MPPTPs stated, “There shall be no presumption of suicide at the outset of any death investigation. All manners of death must be considered and eliminated through investigation.”^{Footnote 906} Colonel R.M. (Rod) Lander, who was the Deputy Provost Marshal Police between 2004 and 2007 and Army Provost Marshal in 2008, testified he issued a Police Policy Bulletin containing this amendment in 2005 as a temporary revision to the 2004 Annex to the MPPTP, and stated “[...] this [draft 2008 revision] or something very close to it was the amendment that was issued.”^{Footnote 907}

61. The evidence suggests this was the policy in place at the time of Cpl Langridge’s death. The subjects of the complaint knew there was a need to rule out the possibility of foul play in Cpl Langridge's death and a need to keep “an open mind.”^{Footnote 908} However, the extent to which any possible manner of death was investigated or eliminated by MCpl Ritco and Sgt Bigelow is unclear. The 2008 draft revision of MPPTP Chapter 7, Annex I (as well as the July 2004 version)^{Footnote 909} directed members investigating a suicide to “focus on determining that the wounds to the subject were in fact, self-inflicted.”^{Footnote 910} The work done by the investigators following their arrival at the scene provides no indication they understood what to look for at the scene of a sudden death. It appears their approach did not include reading the scene and the area around the building for information and evidence as to whether anyone else was involved in the death. Instead, they proceeded to process the scene in minute detail, but apparently without thinking about the purpose of the evidence gathered.

Determining whether the death was suspicious

62. From the outset, it should have been clear Cpl Langridge’s death was not suspicious. This went unnoticed. Although the investigators testified their goal was to rule out foul play,^{Footnote 911} nothing in the investigative record reveals any attempt to link what they observed at the scene with any conclusion about the likelihood of foul play. In fact, many revealing signs of a non-suspicious death were present, but there was no attempt to identify and record these for the purpose of analyzing the scene.

63. The CFNIS members did not adapt their process to respond appropriately to the circumstances. MCpl Ritco testified he did not make any initial determination as to whether the scene was suspicious or whether there was anything to indicate the death was other than a suicide by hanging. He appeared to form no opinions at all, testifying, “I can't make that determination at that point in time. I had just got there. I needed to process the scene entirely to find out what exactly was going on.”^{Footnote 912} In his testimony, Sgt Bigelow acknowledged, at that point in time, he did not suspect foul play,^{Footnote 913} but stated he believed no assessment could have been made until the scene had been processed. Notably, Sgt Bigelow’s notes from the evening of March 15, 2008, refer to the barracks room as a “suicide scene,” perhaps suggesting he was more influenced by the ME Investigator’s evidence at the scene than he recalled in testimony.

64. ME Investigators, with considerable experience in assessing sudden death scenes, assess the evidentiary requirements of the scene and the body in deciding how best to proceed. Mr. Caufield testified his initial examination of the body is his primary concern because this determines the nature of the investigation.^{Footnote 914} If the death appears to be non-suspicious, he will take approximately six to eight photographs of the body, search the scene for items potentially connected to the death, and await the arrival of the removal service.^{Footnote 915} If there was an injury to the body or some other indication making the death appear suspicious, the ME Investigator would notify law enforcement, such as the EPS or the RCMP, to have forensic identification officers and major crimes investigators attend.^{Footnote 916}

65. If evidence of foul play had been uncovered by the CFNIS members or the ME Investigator at the scene, it is unlikely Mr. Caufield would have ordered Cpl Langridge’s body moved or removed before the scene had been fully processed. Mr. Caufield’s readiness to move Cpl Langridge’s body and his opinion the death was consistent with a classic suicidal hanging^{Footnote 917} strongly reflect an assessment that no foul play was involved in the death. This is also reflected in the fact Mr. Caufield informed the investigators an autopsy would not be conducted on the body, and he would only run a series of toxicology tests on samples from Cpl Langridge's body. He informed them this would take several months to complete.^{Footnote 918}

66. Had the CFNIS investigators analyzed the scene purposefully, they should have understood what steps were necessary for the investigation. This initial analysis would have told them what to look for as they searched for evidence. If they were investigating the possibility of foul play, they should have identified all potential points of entry to the room and assessed if there were any indications of another person entering or exiting.^{Footnote 919} Nothing about the doors and the window in the room suggested any forced entry into Cpl Langridge's room or indicated anyone was present when he died. Neither MCpl Ritco nor Sgt Bigelow appeared to draw any inferences from the fact the door to the room was locked when MCpl Hurlburt attempted to enter. Sgt Bigelow was asked whether he or MCpl Ritco had checked the door to the barracks room for any sign of forced entry while they photographed. He replied, “I don’t think we went out of our way to check it but it was observed that there was no forced entry.” He did not recall who made this observation.^{Footnote 920} It did not appear in either his notes or MCpl Ritco's notes, or otherwise within the GO File. MCpl Ritco acknowledged during his testimony there was no sign of forced entry, but he did not consider this during the investigation.^{Footnote 921} During the video recording of the scene, MCpl Ritco opens the door to the shared washroom, noting the door was locked from the side of Cpl Langridge's room. This made the bathroom another very unlikely point of entry or exit.

67. The one plausible means of entry or exit was hardly noted. The barracks room was on the third floor of the building and the window to the room was open. This was readily apparent to the CFNIS members – the video recorded at the scene featured the sound of wind rattling the blinds, and MCpl Ritco referred to the open window as the cause of the noise. An investigator attempting to determine if foul play occurred should have identified the window as a plausible point of entry or exit. As the room was on the third floor, significant effort would have been required to enter the window, and this could leave behind impressions in the ground or even rope, a ladder or other climbing equipment. The CFNIS investigators did not examine the window or search the grounds below the window for evidence of entry or escape. They did not examine and photograph the exterior of the building^{Footnote 922} or search the area outside the building where the room was situated for anything of evidentiary value.^{Footnote 923}

Drawing inferences from the body

68. A great deal of information can also be obtained from the body itself, through both an investigator’s own observations and relying upon the observations of a coroner, medical examiner or ME Investigator. While death scene investigators will not have the expertise of these medical professionals, a competent and experienced investigator will nonetheless be aware of and draw inferences from what the state of the deceased’s body may reveal about how he or she died.

69. S/Sgt Clark of the EPS testified the opinion of the Medical Examiner as to whether a death was suspicious is very important.^{Footnote 924} An ME has a great deal of credibility and will be specifically asked to examine sudden death scenes when there is uncertainty as to whether a death was suspicious. Where a representative of the ME’s Office concludes, for example, the bruising of a body is not suspicious for a given reason, this will be given considerable weight by the investigators in making determinations about the nature of the death. Det. Insp. Olinyk testified OPP investigators also consider the opinion of the coroner to be very important.^{Footnote 925}

70. Mr. Caufield expressed his opinion Cpl Langridge’s death was a suicidal hanging. He began his assessment by confirming Cpl Langridge was deceased^{Footnote 926} and, within approximately ten to 15 minutes,^{Footnote 927} had formed the opinion “ [...] it was pretty classically a suicidal hanging.”^{Footnote 928} He observed Cpl Langridge did not have any visible injuries, suggesting there was no attack or struggle prior to his death.^{Footnote 929} Mr. Caufield also observed Cpl Langridge's feet were in contact with the ground the entire time, meaning all he had to do at any point was stand up (or otherwise put his weight on his feet), and take the pressure off of his neck, to stop himself from asphyxiating. Further, it would have been nearly impossible for someone to maintain Cpl Langridge in this position without creating injuries or marks. The ligature itself was secured with knots tied around his neck and the chin-up bar. This was a relatively simple contrivance a person could prepare and carry out alone.^{Footnote 930}

71. Mr. Caufield testified about other indications of suicidal hanging, including the dark patches of lividity evident in Cpl Langridge’s arms, hands and feet. Lividity is dependent on gravity relative to the body at the time of death. The patterns were entirely consistent with hanging and not consistent with the case of a person who died in a different position and was subsequently posed in a hanging position.

72. Mr. Caufield testified hangings are generally suicides and, conversely, homicidal hangings are “extremely rare and quite obvious when you see them.”^{Footnote 931} Similarly, he testified accidental hangings, such as in the case of autoerotic asphyxiation, are also rare.^{Footnote 932}

73. MCpl Ritco did not have sufficient understanding of matters such as post-mortem lividity or how it was significant with respect to analyzing the scene in a sudden death investigation.^{Footnote 933} Specifically, he did not appreciate the pooling of blood observed on Cpl Langridge’s hands and arms provided a strong indication the position Cpl Langridge was found in was the position he was in when he died.^{Footnote 934} MCpl Ritco was correct in testifying lividity can have bearing on determining the time since death,^{Footnote 935} but this was not its chief significance to an immediate appraisal of the scene – and there is no evidence he gave the implications of this post mortem indicator any consideration at the time. In fact, MCpl Ritco was so guarded against forming any opinions at the scene, he did not realize the significance of Mr. Caufield’s opinion that it would be highly unlikely there would be no visible wounds or signs of a struggle if a healthy young man was conscious while someone attempted to hang him against his will.^{Footnote 936} He did not or could not form an opinion from the information about the position of the body and the evident lividity about the nature of the death and whether it was likely other persons were involved.

74. Later, in the video taken by MCpl Ritco, when the body is lowered and placed onto a stretcher, Mr. Caufield explains Cpl Langridge had no signs of petechial hemorrhaging in his eyes. These marks appear where asphyxiation was interrupted by relaxation of the pressure around the neck and then tightening again. The presence of petechiae could indicate there was some manner of struggle where the pressure came off and was reapplied. The absence of these marks suggests there was no struggle. Sgt Bigelow noted the absence of petechiae in the GO File.^{Footnote 937}

75. The information available to Mr. Caufield at that time indicated Cpl Langridge did not attempt to stand up to relieve the asphyxiation prior to his death. This further contributed to the ME Investigator’s conclusion the death was consistent with a suicidal hanging.

Failing to apprehend the clear indications

76. Between the information readily apparent to an experienced investigator and the information provided by the ME Investigator, it was clear:

The door to the barracks room was locked from the inside, as was the door to the shared washroom, and there was no sign of forced entry into the room;
Room F314 was on the third floor of the building, meaning it could not have been easily entered through the window;
There was no sign of a struggle within the room, which would be expected if a physically healthy young man was hanged against his will;
Post-mortem lividity indicated the position in which Cpl Langridge’s body was found was the same position in which he died;
Cpl Langridge had no injuries on his body which suggested an assault or a cause of death other than hanging, and there were no defensive wounds;
Cpl Langridge did not exhibit any petechiae, strongly suggesting there was no struggle;
Cpl Langridge’s feet were in contact with the floor, meaning he could have stood up at any time before losing consciousness;
The knots of the ligature around Cpl Langridge’s neck, and the point at which it was affixed to the chin-up bar in the room, were simple knots a single individual could have tied for himself;
A chair was found immediately behind Cpl Langridge, possibly for Cpl Langridge to stand on before dropping to the floor to hang himself.^{Footnote 938} Its relevance did not appear to have been noted;
Cpl Langridge left a suicide note to his family;
Cpl Langridge had removed his watch, necklace, and rings, and placed them beside the suicide note; and
Information was received before attending the scene indicating Cpl Langridge had spoken of suicidal ideation in the past.

77. The initial information was overwhelming that the cause of death was suicide. Mr. Caufield’s investigation led him to quickly form the opinion the death was a classic suicidal hanging.^{Footnote 939} He testified, “[...] there was nothing from the death scene and Cpl Langridge’s body or any of those types of things that made us feel it was anything other than a suicide.”^{Footnote 940}

78. Sgt Bigelow recorded in his notes Mr. Caufield had provided his opinion the death was the result of an “obvious hanging” at the scene, but Sgt Bigelow testified this did not mean the death was a suicide but, rather, meant only “ [...] the person that was in front of us is deceased, was deceased because of hanging.” ^{Footnote 941} He conceded he did not have an independent recollection of the events and was relying on his notes in providing that interpretation. In fact, as noted above, the video recording of the scene commenced with MCpl Ritco reporting the ME Investigator had previously entered the room and given his opinion he suspected the death was a suicide. Sgt Bigelow testified he did not suspect foul play had been involved at the time Cpl Langridge’s body was lowered, adding, however, that he could not “make that assessment until we’ve processed everything.”^{Footnote 942}

79. Sgt Bigelow testified he and MCpl Ritco were bound by standards and rules for processing a scene, making it necessary to do a thorough job to rule out foul play. He stated, “We're trained to process it to a certain standard, right, and we're not going to deviate from that just because [Mr. Caufield] says it's an obvious suicide, right? It's our credibility on the line.”^{Footnote 943}

80. Both MCpl Ritco and Sgt Bigelow claimed not to have placed much weight on Mr. Caufield’s opinion. They were asked if Mr. Caufield's opinion had any bearing on their approach. MCpl Ritco testified he was unable to make any assessments before processing the scene.^{Footnote 944} He maintained he could not narrow down the possibilities at that stage and had to keep an open mind.^{Footnote 945} For his part, Sgt Bigelow testified the opinion of the ME Investigator had no impact on the decisions he made for processing the scene.^{Footnote 946}

81. The investigators recorded Mr. Caufield’s observations^{Footnote 947} and took pains to document the scene precisely as it was found, but it does not appear they put this information to use in terms of making a preliminary assessment about the scene or the manner of Cpl Langridge’s death. They failed to analyze the information and evidence gathered at the scene and apply it to any hypotheses. The only guidance MCpl Ritco and Sgt Bigelow were given by their superiors on the day of the suicide was to take their time and be thorough.^{Footnote 948} This they did. However, lacking in experience and adequate supervision in conducting his first sudden death investigation, MCpl Ritco did not appreciate whether any pieces were missing and had little idea of what to do with the evidence and information he so painstakingly gathered.

Specific Issues Regarding the Processing of the Scene: Handling the Suicide Note

82. Cpl Langridge left a suicide note for his family and placed it prominently on the desk in his barracks room. He wrote:

Sorry but I can’t take it anymore. I love you Mom, Shaun, James, Mike, Grandma, Aunti, Tom. Please know that I needed to stop the pain. XOXO Stu

PS I don’t deserve any kinda fancy funeral just family. TY.^{Footnote 949}

83. The suicide note was collected as potential evidence, but the note was never the subject of any investigation or forensic examination.

84. The note was not revealed to the family for over fourteen months, long after the conclusion of the 2008 investigation.^{Footnote 950} This meant Cpl Langridge’s last wishes were not known to his family until long after his funeral. The failure to disclose even the existence of the note was, naturally, the cause of considerable frustration and pain for the complainants.

Expert views on handling suicide notes

85. The value of a defined plan and methodical analysis is illustrated by how other police services adapt their investigation process based on the circumstances of the death and the scene. Where a suicide note is found at the scene, a number of steps can be taken, including seizing the note, maintaining continuity, and authenticating it through testing. However, these are only undertaken when there is actual suspicion about the death because such steps require significant expenditures of time and resources.

86. All three members of the police panel agreed they would only seize the original suicide note as evidence for their own investigation if there was suspicion about the death. In such a case, they would take measures to authenticate the note.

87. S/Sgt Clark explained the ME Investigator leading the investigation is responsible for seizing all exhibits where the death is believed to be non-criminal in nature and will take possession of any suicide notes found at the scene. The police only take a copy of the suicide note.^{Footnote 951} However, in the case of a suspicious or criminal death, where investigators have reason to believe the suicide may have been staged, it becomes essential to seize the original suicide note and retain its continuity as evidence. In such cases, S/Sgt Clark testified the EPS will “absolutely” test the note for authenticity, using methods such as handwriting analysis and fingerprinting.^{Footnote 952}

88. Similarly, Insp. Fitzpatrick testified the RCMP will only seize the original of a suicide note for their own investigation if a death was considered suspicious and otherwise will only seize it under the direction of the coroner.^{Footnote 953} Where a death appears suspicious, the RCMP will authenticate the suicide note through fingerprinting, DNA swabs, and handwriting analysis. They will even seize the pad of paper used for the suicide note and the pens in the house.^{Footnote 954}

89. Det. Insp. Olinyk testified, where a death appears to be the result of a suicide, the suicide note is only seized at the coroner’s direction and for the benefit of the coroner’s investigation.^{Footnote 955} Where there was any belief the death might have been suspicious, the OPP will test the suicide note to confirm its authenticity. The investigators obtain handwriting samples from the family of the deceased and submit the note for examination at their Centre of Forensic Sciences.^{Footnote 956}

How was the suicide note handled by the CFNIS?

90. In contrast, the suicide note, like the rest of the evidence collected at the scene, was never evaluated or later examined or even revisited by the CFNIS members. Between 1733 hrs and 1821 hrs, Sgt Bigelow took notes concerning the contents of the barracks room. He copied out the text of Cpl Langridge's suicide note word-for-word.^{Footnote 957} A copy of the note was scanned into the GO File, and the text of the note was typed into a text box by Sgt Bigelow.^{Footnote 958} At 1912 hrs, MCpl Ritco seized the suicide note, placed it into an evidence bag and gave it to Sgt Bigelow.^{Footnote 959} As he did with the other items seized at the scene, he wore latex gloves to prevent contamination of any latent fingerprints or DNA evidence, which may have been present.^{Footnote 960}

91. The precautions taken with the suicide note indicated MCpl Ritco understood it could be highly relevant should evidence of foul play emerge. Keeping the suicide note in the evidence bag at all times,^{Footnote 961} Sgt Bigelow photocopied the note and provided a copy to Mr. Caufield.^{Footnote 962} The next day, it was placed into MCpl Ritco’s temporary evidence locker, where it remained until April 9, 2008, when it was transferred to the CFNIS evidence room.^{Footnote 963} The suicide note was not accessed or noted again until June 1, 2009.^{Footnote 964}

92. Had there been any real question whether Cpl Langridge died of foul play, the note should have been tested to verify its authenticity. Sgt Bigelow was asked if any thought was given to running fingerprinting or handwriting analysis tests to authenticate the suicide note. He replied, “At that time, no.”^{Footnote 965} Nevertheless, he explained a handwriting sample should have been obtained in case it became necessary to confirm Cpl Langridge wrote the note. He testified he did not know why a handwriting sample was not obtained in this case.^{Footnote 966} For “equivocal” death investigations (that is, investigations in which the conclusions are open to different interpretations depending on the facts, victimology and circumstances of the death), the CFNIS SOP states handwriting samples of the deceased should be collected for comparison, even if a suicide note is not immediately found.^{Footnote 967} This SOP was not in effect in March 2008, but it reflected best practices with respect to a suicide note found at a sudden death scene.^{Footnote 968}

93. In this case, the ME Investigator did not require the original of the suicide note. That is a telling fact. During his testimony, Mr. Caufield explained his office’s practice with respect to suicide notes found at the scene of a sudden death

The practice has changed. There was a time that we always -- we would always seize the original suicide note, primarily for concerns about the possibility of questions being raised that would require perhaps handwriting analysis, that type of thing. We did that for many years. We would seize the original, photograph it, keep it and then try to get, you know, property back to the family, those types of things. It was decided -- because we never, ever had an issue with handwriting analysis, we decided we're complicating things by doing that, so we had come to agree that a photocopy of a note was fine if, you know, someone else needed it, whether that's a significant grieving relative or, like in this case, another agency wanted it. As long as we had a good facsimile of the note, we're satisfied to have that.^{Footnote 969}

94. Mr. Caufield testified he would want to have the original suicide note in circumstances where a suicide did not appear to be straightforward, such as when a family is concerned the deceased had been murdered and the suicide staged to deflect suspicion. Where criminal aspects to the death are suspected, the Office of the Chief Medical Examiner of Alberta will “absolutely [...] seize the note.”^{Footnote 970} In the case of Cpl Langridge’s suicide note, Mr. Caufield testified he had no reason to be uncomfortable with only a photocopy of the suicide note because it was such a clear case of suicide and mere analysis of the evidence, without forensics, was enough to establish there was no foul play.^{Footnote 971}

95. As was the case with Mr. Caufield’s expressed view to the effect Cpl Langridge’s death was consistent with suicide, MCpl Ritco testified the presence of the suicide note did not influence his view of the scene or cause him to discard the possibility of foul play.^{Footnote 972} Sgt Bigelow testified the suicide note was kept in the evidence bag from the moment it was seized and was retained as potential evidence. He explained if it was determined Cpl Langridge’s death had been the result of foul play, it would be essential to preserve the potential to retrieve fingerprints from the note. MCpl Ritco testified he also thought about the possibility of testing for fingerprints and traces of DNA as well as handwriting analysis when he seized the suicide note.^{Footnote 973} Yet nothing relating to the suicide note appeared in MCpl Ritco’s Investigation Plan (IP).^{Footnote 974}

96. Given the lack of evidence suggesting anything other than suicide, there was objectively no need to conduct tests on the suicide note. MCpl Ritco’s testimony only illustrates the confusion as to purpose with which the CFNIS members acted when processing the scene.

Specific Issues Regarding the Processing of the Scene: Was Disrespect Shown to Cpl Langridge’s Body?

97. The complainants allege Cpl Langridge’s body was treated with disrespect in a number of ways. From their perspective, the nearly two-hour period between the arrival of the CFNIS and the removal of Cpl Langridge’s body was unreasonable. They contend unnecessary investigative steps taken prior to the removal of Cpl Langridge’s body compounded the delay. They allege Cpl Langridge’s body was not lowered sooner because the CFNIS members viewed Cpl Langridge as a defaulter, unworthy of the respect otherwise shown to a deceased soldier. They allege he was simply dismissed as a troublemaker and a “waste of rations” by those present at the scene of his death.^{Footnote 975} They were concerned anyone entering or exiting the barracks room had to squeeze past Cpl Langridge’s body to avoid disturbing it. They contend no evidence would have been lost by lowering Cpl Langridge's body sooner.^{Footnote 976} The complainants also submit the proper procedure would have been to lower Cpl Langridge’s body promptly and check for vital signs.

98. The position of the complainants is the CFNIS members possessed the authority to order Cpl Langridge’s body lowered prior to being removed. Mr. Fynes testified the ME Investigator had no jurisdiction over a body on federal property.^{Footnote 977} He also testified he obtained an opinion, via email, from the office of the Solicitor General and Public Safety for Alberta stating the primary jurisdiction to investigate a sudden death on a Canadian Forces base within the province lies with the military police and the CFNIS.^{Footnote 978}

Who had authority over Cpl Langridge’s body?

99. The subjects of the complaint and the ME Investigator are in agreement Mr. Caufield had the sole authority over any decision to lower or remove Cpl Langridge’s body. When Maj Dandurand and MS Eric McLaughlin interviewed the complainants in November 2009, they explained the provincial ME possessed jurisdiction over the body even on federal property, and the CF relied on provincial coroners and MEs just as civilian police forces did.^{Footnote 979} Maj Dandurand stated the ME “owns” the scene. When the Fynes raised these concerns with Col Gerard Blais, Director of Casualty Support Management in 2010, the CFNIS provided a written explanation concluding the provincial coroner or ME had responsibility over the movement of a body. It read, “The decedent cannot be removed until authorization has been provided by the Lead Investigator who receives direction from the coroner.”^{Footnote 980}

100. The evidence confirms the CFNIS investigators were not empowered to decide when Cpl Langridge’s body could be lowered or removed. The police panel unanimously confirmed the police should not move or disturb the body at the scene unless absolutely necessary – for example, where it may be possible to preserve a life – and, with few exceptions, will not touch or move a body without the authorization of the coroner or ME.

101. Insp. Fitzpatrick testified that, in British Columbia, under no circumstances can the deceased be touched or tampered with until the coroner has given police the authority to do so.^{Footnote 981} S/Sgt Clark testified it was the ME’s responsibility to lower a body in a case of suicide by hanging and the authority to move the body rests with the ME.^{Footnote 982} Det. Insp. Olinyk testified bodies in criminal and non-criminal deaths are the responsibility of the coroner’s office, and any time the OPP members at a death scene cut down, move or touch a body, this is done in discussion with the coroner and forensic officers.^{Footnote 983}

102. Depending on the circumstances of the death, either the ME’s Office or the investigating police force of jurisdiction has the overall lead on the investigation. In all cases, the Fatality Inquiries Act makes it clear the Chief Medical Examiner has statutory authority over the body at a sudden death scene in Alberta. Certain deaths, including sudden deaths, must be reported to the ME’s Office,^{Footnote 984} and an ME must investigate the death once such deaths are reported.^{Footnote 985}

103. Mr. Caufield testified this authority covers the entire province of Alberta, including military bases. No other agency has this jurisdiction.^{Footnote 986} Moreover, under the statute, the ME is deemed by law to have taken possession of the body as soon as he or she has been notified of the death.^{Footnote 987} There is no evidence a CF base in Alberta is excluded from the application of the provincial Fatality Inquiries Act. It was Mr. Caufield’s evidence the ME has sole authority to determine whether, when and how a body can be moved – both in cases where the body is on a military base and in all other cases.^{Footnote 988}

104. In light of these facts, the only reasonable conclusion is Mr. Caufield had the sole authority over the handling and movement of Cpl Langridge’s body.

Why was Cpl Langridge’s body not lowered sooner?

105. Since a fairly lengthy period of time passed before Cpl Langridge’s body could be removed, Mr. Caufield was asked what the practice of his office was with respect to potentially lowering a hanged individual’s body prior to the arrival of the removal service. He said his office generally will not lower or cut down a hanging body until the ME or ME Investigator present are ready to remove the body from the scene.^{Footnote 989} In exceptional circumstances, where the body is in a public area and its presence would be disruptive, they might take steps to lower the body. The medical examiner’s strong preference is to leave the deceased in place until removal.

106. Mr. Caufield stated he requires 30 to 40 minutes at most to examine the body in a case such as this.^{Footnote 990} In fact, within 12 minutes^{Footnote 991} of attending the barracks room, Mr. Caufield completed his initial examination and photography commenced.^{Footnote 992} According to MCpl Ritco, the scene belonged to the ME Investigator, and thus he waited for permission from the ME Investigator to enter the scene.^{Footnote 993} MCpl Ritco testified he sought Mr. Caufield's permission to take photographs and video of the scene after the latter’s initial examination of Cpl Langridge’s body. MCpl Ritco testified Mr. Caufield had no difficulties and advised he could begin examining the scene; this did not impede his work. He noted Mr. Caufield’s only comment at that point was to ask for medical records of Cpl Langridge’s medication.^{Footnote 994} MCpl Ritco began to photograph and video-record the entire barracks room prior to the removal of Cpl Langridge’s body.

107. MCpl Ritco and Sgt Bigelow were asked to explain the length of time to remove Cpl Langridge’s body. MCpl Ritco was puzzled by the complaint he let Cpl Langridge’s body hang for four or even five hours. MCpl Ritco did not believe he was responsible for any delay. He emphasized first, he thought only an hour and a half had elapsed between his arrival at the scene and the removal of Cpl Langridge’s body; and second, he was not in a position to decide when Cpl Langridge’s body could be lowered.^{Footnote 995} MCpl Ritco explained, “[…] if he [Mr. Caufield] wanted Corporal Langridge to be cut down, he would have directed me to cut him down.”^{Footnote 996} His recollection was there had been a lengthy wait for the body removal service to attend the scene, and he photographed and video-recorded the scene with Mr. Caufield’s permission while they awaited the arrival of the body removal service.^{Footnote 997}

108. MCpl Ritco’s initial approach was to catalogue everything at the scene by taking photographs of the room and its layout, the position and state of the deceased, and then to video-record the entirety of the scene.^{Footnote 998} The investigators processed the entire room, rather than only the area around Cpl Langridge's body.^{Footnote 999} MCpl Ritco testified, when starting to process a scene, the CFNIS' “mandate” is to take photographs and video of the scene – both, if possible.^{Footnote 1000} MCpl Ritco took approximately 85 photographs of the scene. Sgt Bigelow remained in the room and took notes during this phase. His 11 pages of notes describe the scene and the appearance of Cpl Langridge's body, details about the ligature, and even the temperature of the room (18 degrees Celsius).^{Footnote 1001} At 1821 hrs, Sgt Bigelow wrote in his notebook, “MCpl Ritco starts to videotape suicide scene.” He encountered technical problems, however, and the recording was interrupted. The videocassette was replaced and recording resumed at 1841 hrs.^{Footnote 1002} The video begins with Sgt Bigelow opening the door to Cpl Langridge’s room and with MCpl Ritco reporting the ME Investigator had previously entered the room and had given his opinion he suspected the death was a suicide.

109. The video progresses to a close-up of Cpl Langridge's face and shows images of the chin-up bar, the ligature and Cpl Langridge's body hanging in place. The video records details such as Cpl Langridge's clothing, the lividity patterns evident in his arms and hands, the cyanosis in his face, and also demonstrates his feet are in contact with the floor as he continues to hang.

110. The video records the small bed along the west wall, Cpl Langridge’s clothing and the suicide note on the desk. It provides a close-up of the suicide note and then shows MCpl Ritco, while wearing gloves, moving the pen, which had been laid on the note, away so he could read the message aloud.

111. It is not clear everything MCpl Ritco documented was relevant to the investigation or at least necessary to be recorded prior to removing the body. Essentially, all contents of the room, down to minute details, were noted on video and identified by MCpl Ritco. Excluding footage of the body, its immediate surroundings, and a quick sweep of the room, this detailed survey of the contents of the room lasted approximately from 1848 hrs until 1906 hrs, at which point the body removal technicians entered with Mr. Caufield. This meant the detailed survey of the room accounted for nearly 20 minutes of the 27 minutes of footage recorded by MCpl Ritco before Cpl Langridge’s body was removed.

112. The photographing and video-recording of the scene took slightly over an hour and a half with Cpl Langridge’s body still hanging throughout the period.^{Footnote 1003} Mr. Caufield and two personnel from the body removal service entered the room at 1907 hrs.

113. Mr. Caufield testified the process of lowering and removing Cpl Langridge’s body depended, to some extent, on the nature of the scene and the circumstances of the body, including whether the knot around the neck of the deceased is simple or complex. In Cpl Langridge’s case, both knots were simple. The belt could not be cut because it would likely have untied itself. For that reason, Mr. Caufield stated it was best to simply untie the knot at the point it connected to the chin-up bar, and leave the slip knot tied around Cpl Langridge’s neck, so at least the knot around his neck was preserved.^{Footnote 1004} Accordingly, the removal personnel wrapped a sheet around the body (in order to avoid any contamination, as well as for ease of movement and to avoid biohazard exposure),^{Footnote 1005} and then lifted the body to take the weight off the knot tied to the chin-up bar. Mr. Caufield untied the knot at the point where it was attached to the chin-up bar and Cpl Langridge’s body was lowered onto a stretcher.

114. In all, three hours and 47 minutes had elapsed since Cpl Langridge’s body was discovered, and one hour and 46 minutes had elapsed since the CFNIS investigators arrived at the scene. Cpl Langridge’s body was removed from the scene at 1916 hrs.^{Footnote 1006}

115. Sgt Bigelow testified they discussed the ME Investigator’s expectations concerning the scene and evidence after they had arrived at the scene and the ME Investigator had conducted his assessment of Cpl Langridge's body. Sgt Bigelow indicated they wanted to understand what Mr. Caufield wanted, so as to avoid “stepping on his toes” or otherwise doing anything incorrect.^{Footnote 1007} Sgt Bigelow testified he and MCpl Ritco also discussed their own expectations with the ME Investigator as to what was necessary for them to properly process the scene. He indicated it was important to address these points before the processing of the scene began.^{Footnote 1008} MCpl Ritco elaborated in his testimony Mr. Caufield was unfamiliar with how the CFNIS conducted a sudden death investigation. MCpl Ritco and Sgt Bigelow explained what they intended to do and the ME Investigator had no problems with their approach.^{Footnote 1009}

116. Mr. Caufield testified the time span between his arrival at the scene at 1721 hrs, and removal of the body nearly two hours later, seemed “a little bit unusual” for a case such as this.^{Footnote 1010} When asked why so much time had elapsed, Mr. Caufield testified he was waiting for the CFNIS investigators to complete processing the scene:

Well, I think just primarily that we had that secondary investigative unit involved, the military police investigation. And it's simply that we have another -- you know, they have other policies and procedures that take longer. For instance, we wouldn't – we certainly wouldn't videotape a suicidal hanging, so that amount of time just would have just not been there. A suicidal hanging, we may have taken, you know, anywhere from maybe four to six or eight photographs in total. So they did a very thorough investigation, and that took longer than what we would normally do in this type of setting.^{Footnote 1011}

117. Mr. Caufield testified MCpl Ritco had asked him to wait before removing the body to allow him to photograph and videotape the scene precisely as it was. In the spirit of cooperation, he agreed with the request.^{Footnote 1012} He also testified, had there been a pressing need to wrap the matter up – for example, if another death report had come in where Mr. Caufield was required to attend – he would have asked the CFNIS investigators to “wrap it up.”^{Footnote 1013} Mr. Caufield testified, while the CFNIS investigators processed the scene, he spent most of his time simply waiting.^{Footnote 1014}

118. Determining the time the body removal service arrived is important because Mr. Caufield would not have moved the body before their arrival – meaning, had they arrived later, any delay would have been the removal service’s responsibility. There are conflicting versions of the timing leading up to the removal of Cpl Langridge’s body. Either the removal service personnel were delayed and did not arrive until approximately 1900 hrs, and MCpl Ritco worked to process the scene while awaiting them, or they arrived early at approximately 1748 hrs (nearly an hour and a half before the body was removed), and the delay was caused by MCpl Ritco’s photography and video-recording.

119. Mr. Caufield testified, in general, the precise time at which the ME Investigator will contact the removal service is dependent on how long the investigator believes he or she will need to complete the initial assessment of the scene and the body. The removal service is responsible for other contractual work, such as funeral homes, and their time of arrival at a sudden death scene is situation-dependent. However, there is a contractual requirement for them to endeavour to arrive within one hour of being contacted.^{Footnote 1015}

120. Mr. Caufield testified timing is relatively important when making use of the body removal service. Should a case be more complicated and require additional investigative processes, the result will be in the removal personnel “just kind of standing about not doing anything. They can ultimately be paid overtime for being there over a certain period of time.”^{Footnote 1016} The overtime clause in the contract with the body removal service is evidence of normal practice. Ordinarily, one would expect the service to arrive and work quickly.

121. Mr. Caufield testified where the ME Investigator wanted the removal service to attend at the scene at their first available opportunity, he or she would contact the removal service while en route to the scene.^{Footnote 1017} This was Mr. Caufield's usual practice.^{Footnote 1018}

122. MCpl Ritco and Mr. Caufield had no actual recollection or notes of the arrival of the body removal service. MCpl Ritco believed they waited until after 1900 hrs for the removal service to arrive, testifying “And when the body removal came – the exact time of the body removal, I don’t know, ‘cause I was still in the room. But when the body removal came, they removed Corporal Langridge.”^{Footnote 1019}

123. Although there were no explicit records kept, nor testimony heard, concerning the time the body removal service arrived, there is documentary evidence suggesting they arrived shortly after MCpl Ritco, Sgt Bigelow and Mr. Caufield. Sgt Van Delen gave a statement to the CFNIS at the base fire hall in which he reported the CFNIS members and the ME Investigator arrived at 1725 hrs.^{Footnote 1020} He indicated, when he spoke to Mr. Caufield, he was told the assistance of the fire department was not required because Mr. Caufield was expecting two more personnel to arrive shortly. Sgt Van Delen then wrote the fire personnel waited until the additional “medical personnel [likely the body removal service] arrived before turning control of the scene over to NIS at 1748 hrs.”^{Footnote 1021} No other medical personnel arrived at the scene after the paramedics of the St. Albert Fire Service Ambulance had attended at 1602 hrs and departed at 1610 hrs, and there is no evidence of any personnel other than the removal service attending the scene to assist the ME Investigator.

124. While MCpl Ritco and Sgt Bigelow testified they did not ask Mr. Caufield to wait to remove the body and were waiting for the arrival of the removal service while they worked, they also stated the time taken was reasonable and the extensive and detailed photographs were absolutely necessary.

125. In effect, it was MCpl Ritco’s testimony he was going about his business processing the scene and waiting for Mr. Caufield to make a decision about when to lower Cpl Langridge’s body.^{Footnote 1022} Then, when the body removal service personnel arrived, they removed Cpl Langridge’s remains, and he resumed processing the scene.^{Footnote 1023} On the other hand, MCpl Ritco also testified he made the decision about the extent of photography necessary prior to removal of the body. He explained the determination was based on his training regarding how crimes scenes are processed.^{Footnote 1024} This is inconsistent with any suggestion the CFNIS members were not responsible for the time taken in the removal of the body and were simply doing what they could while waiting for the removal service to arrive.

126. Sgt Bigelow, similarly, testified he did not recall a request by either himself or MCpl Ritco for Mr. Caufield to wait until the processing of the scene was complete before removing the body. He only recalled, “We asked him if it was okay to process and he gave us the thumbs up.”^{Footnote 1025} Nevertheless, Sgt Bigelow also testified the scene was treated as an unexplained sudden death and not an apparent suicide. He testified the reason Cpl Langridge’s body was not removed earlier was because it would not have been appropriate. “[I]t was still part of the crime scene and for us to do our job properly, an assessment of what we’re capturing, unfortunately the body had to remain.”^{Footnote 1026} The necessary implication of this testimony is the investigators would not have thought it appropriate to interrupt the filming had Mr. Caufield wished to proceed with lowering and removing Cpl Langridge’s body.

127. Further, MWO Watson had informed Sgt Bigelow he and MCpl Ritco should take all the time they needed to process the scene:

I would have -- paraphrasing, but I'm going to get to the gist of it -- don't rush that scene, I don't care if -- and don't release that scene until you're done processing it, I don't care if that body stays four days, don't release it until you're done processing that scene.^{Footnote 1027}

128. He explained he gave this direction because, in a previous negligence investigation, he had authorized the release of a scene too quickly and important evidence was jeopardized.^{Footnote 1028} He did not want MCpl Ritco and Sgt Bigelow to make the same mistake. MWO Watson testified he expected MCpl Ritco and Sgt Bigelow to exercise their judgment and discretion in determining when to move the body, but he believed it appropriate to take over 90 minutes to process the scene.^{Footnote 1029}

129. MCpl Ritco may well have kept Mr. Caufield and two contracted body removal personnel waiting as he photographed and video-recorded the scene, during which time they could do nothing. The evidence from the firefighter’s statement suggests the body removal personnel attended the scene very shortly after the CFNIS investigators and ME Investigator did. Furthermore, Mr. Caufield was a disinterested party and his evidence about the usual practice with respect to the body removal service and about being asked to wait before removing the body, supports the conclusion the service arrived long before Cpl Langridge’s body was removed. In light of this, it appears quite likely there was no long wait for the removal team to arrive. Moreover, it may well be the case the body removal service was waiting at the scene since 1748 hrs, roughly one and a half hours before Cpl Langridge’s body was finally taken out of the room. However, the exact timing of the arrival of the body removal service was not definitively determined.

Assessing the investigative steps taken by CFNIS investigators before the body was removed

130. The subjects submit Cpl Langridge’s body was not left hanging for an inappropriate amount of time^{Footnote 1030} and, in processing the scene, MCpl Ritco behaved professionally in keeping with his training. They also submit the CFNIS expects its investigators to document the scene of a sudden death thoroughly. This includes videotaping the scene and taking photographs. According to the subjects' closing submissions, investigators must document the crime scene as they would a homicide, even when it appears to be a suicide.^{Footnote 1031} The main objective is to determine whether the death was caused by a criminal act and to ensure evidence is preserved.

131. Det. Insp. Olinyk provided a clear description of what the OPP major crimes investigators do before the body is moved. The approach to the body and the area immediately around the body is video-recorded and photographed prior to the removal and post-mortem; the focus is entirely on the area around the deceased to preserve potential evidence.^{Footnote 1032} A description of the room is also written. The body can be moved after this is complete. In fact, the OPP go even further to protect the integrity of the scene and the evidence after the body is removed. The scene will be kept secure and not searched until the completion of the post-mortem examination.^{Footnote 1033} Evidence is only seized when the failure to seize something immediately could potentially compromise the evidence.^{Footnote 1034}

132. Insp. Fitzpatrick testified the RCMP “E” Division takes similar steps, videotaping the approach to the scene from the outside in, recording the body from multiple angles and taking close-ups, and making every effort to avoid contaminating whatever evidence may potentially be present. The same process is followed until a death is determined to be suspicious or non-suspicious, and the RCMP are extremely careful to avoid losing or contaminating evidence. Thus, the scene is not released until the conclusion of the autopsy.^{Footnote 1035}

133. S/Sgt Clark testified the steps required prior to removing a body differ depending on whether the death is deemed suspicious or non-suspicious. In the case of a non-suspicious death, no photographs are taken by the EPS, but the ME will photograph the body and the area around the body. The body is then removed and there is no video recording.^{Footnote 1036}

134. Mr. Caufield and the police panel members provided a range of durations considered typical from the initial arrival at the scene to the removal of the body. Mr. Caufield testified that, in a case such as this, no more than 30 to 45 minutes would have been required before the body could be moved.^{Footnote 1037} Det. Insp. Olinyk testified, assuming the location was not remote, the body would likely be removed within six to eight hours.^{Footnote 1038} Insp. Fitzpatrick testified, in the case of a non-suspicious and straightforward death, the body would generally be removed within hours. S/Sgt Clark testified, in the case of a non-suspicious death in Edmonton, his experience was, the time between the arrival of the first member at the death scene and the removal of the body by the ME Investigator and the body removal service was anywhere between one and three hours.^{Footnote 1039}

135. It is the Commission’s view there was nothing unreasonable about the length of time between the arrival of the CFNIS investigators at the scene and the time when Cpl Langridge’s body was removed. The steps taken and the time involved in processing the scene and removing the body certainly fall within the reasonable range of what could have been done. The elapsed time was close to the ranges established by the testimony of the policing panel, although somewhat longer than what would be required in a similar case by either the Edmonton Police Service or by the ME Investigator.

136. Less than four hours elapsed between the discovery of Cpl Langridge’s body and its removal from the scene, but less than two hours of that time is attributable to the actions of the CFNIS investigators. While the inexperience of the investigators may have resulted in their taking more time, it is not appropriate to fault them. The CFNIS investigators did what they thought they had to do to process the scene and preserve evidence. The evidence and the testimony indicate they were making a genuine attempt to do a good job. It is difficult to fault the CFNIS investigators for doing too much.

137. The question, nevertheless, must be asked whether the steps taken by the CFNIS prior to the removal of Cpl Langridge’s body were reasonable in the circumstances. Mr. Caufield was asked to describe what he normally requires from the scene prior to the removal of a body in a case like that of Cpl Langridge. He testified, in addition to gathering the information required under the Fatality Inquiries Act and carefully examining the body, he and the police officers present will search the scene as well. The time taken to search the scene depends on the location and the area to search.^{Footnote 1040}

138. MCpl Ritco’s initial work was of assistance and there is no suggestion it was unnecessary to photograph and video-record Cpl Langridge’s body. Mr. Caufield requested some of the photographs MCpl Ritco had taken of the body because his camera malfunctioned, and he was unable to take photographs of his own as he normally would. MCpl Ritco provided all of the photographs he took at the scene.^{Footnote 1041} The question is whether it was necessary in the circumstances to then exhaustively document the scene before Cpl Langridge’s body was removed.

139. Mr. Caufield was asked whether, for his purposes as a medical examiner investigator, certain steps taken by MCpl Ritco and Sgt Bigelow were necessary prior to removing the body:

Q. Now, for your purposes, prior to removing the body, is it necessary to fully inventory the contents of the room?

A. No.

Q. Is it necessary to take pictures of the items in the room?

A. No.

Q. Is it necessary to videotape the items in the room?

A. No.

Q. Is it necessary to videotape the room and the body?

A. For our purposes, no.^{Footnote 1042}

140. In his approach, MCpl Ritco did not assess the information available at the scene to make even a tentative determination as to whether the death was suspicious. He did not limit the recording to the body and the area around the body, which would generally be the focus prior to the removal of the body to capture the relevant areas exactly as they were. In Sgt Bigelow’s assessment, it was not sufficient to limit the initial processing to photographs and video-recordings of the area surrounding Cpl Langridge’s body. This was because, “[…] if there’s anything potentially proven later, through the course of the investigation, to say that there was foul play, if we don’t do our process proper, that’s evidence lost, right, and that doesn’t help to support the case of potential foul play.” ^{Footnote 1043} It was, in his opinion, both reasonable and necessary to completely photograph and take video of the entire scene, including the comparatively lengthy process of video-recording the contents of the room and the washroom, prior to the removal of Cpl Langridge’s body.^{Footnote 1044}

141. The evidence amply establishes the value and importance of conducting investigations with focus and purpose – and, in particular, that skilled investigators guide those investigations by formulating sound hypotheses, relying upon and continually testing them against all the available evidence and information. A reasonable investigation begins with measures intended to further those aims, which can be adjusted and adapted, as the circumstances require. This flexibility is important because what is reasonable for investigators to do during a suspicious death may not be reasonable for a death that is not suspicious. “Keeping an open mind” at the expense of critical thought and analysis is just as counterproductive to a sudden death investigation as rigidly engaging in tunnel vision. Here, not everything done by MCpl Ritco and Sgt Bigelow prior to the removal of Cpl Langridge’s body was reasonable in the circumstances.

142. Certain steps were taken because the process was given more importance than the analysis. The usefulness or reasonableness of photographing and recording video of the entire scene beyond the immediate area of Cpl Langridge’s body has not been established. The meticulous cataloguing of the entire scene contributed to most of the delay before Cpl Langridge’s body was removed. Under the circumstances, and in view of the abundance of available evidence, there was simply no reason to suspect Cpl Langridge’s death was in any way suspicious. These steps do not seem to have been taken because they were reasonable or helpful, or because important evidence might be lost, but essentially in the interest of completeness.

143. MCpl Ritco was instructed to take his time and be thorough. However, the evidence beyond the area immediately around Cpl Langridge’s body would not have been altered by the removal of the body and there was no urgent requirement to capture it. The extensive photography and video-recording came at the expense of removing Cpl Langridge’s body at the first realistic opportunity. The delay in the removal of Cpl Langridge’s body caused great distress to the family. The delay cannot be attributed to Mr. Caufield, who agreed to wait in the spirit of cooperation.

144. While the time taken by the CFNIS to process the scene was within a reasonable range, and it cannot be known with certainty whether the body removal service was kept waiting or whether they arrived later, the Commission is not convinced all the steps taken by the CFNIS members before removing the body were necessary or reasonable in the circumstances.

145. However, there was no evidence of any disrespect to Cpl Langridge in following this process. While a lack of experience on the part of the CFNIS investigators may well have played a role in the delay, there is no evidence this delay was in any way motivated by any negative opinions about Cpl Langridge.

Should Cpl Langridge’s body have been covered?

146. In addition to complaints about the delay before Cpl Langridge’s body was lowered and removed, the complainants allege the CFNIS investigators showed disrespect to Cpl Langridge’s body because they failed to cover the body before it was lowered and removed. The complainants’ belief is, because of the rumours Cpl Langridge was a defaulter, his remains were not shown the same respect as would have been accorded another CF member. It is their belief this was the reason Cpl Langridge’s body was left uncovered, and they are greatly concerned by the implication his body was on display for any gawkers to see.

147. The evidence received and the testimony heard by the Commission was clear, unequivocal and unanimous in establishing the body of the deceased should not be covered at the scene, as evidence could be compromised, contaminated or removed by any sheet or similar item draped over the body.

148. Insp. Fitzpatrick testified he could not imagine a situation where a body would be covered by police – even where it was in plain view to the public. There are other ways to conceal the body than draping anything over it. To do otherwise would contaminate the evidence.^{Footnote 1045}

149. S/Sgt Clark agreed a body should never be covered. Where a body was hanging in view of the public, he would take steps to control traffic and block access to the scene.^{Footnote 1046}

150. Det. Insp. Olinyk testified he would not cover a body in any way, and the dignity of a deceased was better protected by barricading the area or closing off an area or scene.^{Footnote 1047} Mr. Caufield likewise testified the essential principle was the preservation of information and evidence. He testified the ME’s Office does not cover a body while awaiting removal regardless of the location.^{Footnote 1048}

Was Cpl Langridge’s body exposed to passersby?

151. There is no evidence Cpl Langridge’s body was made into a spectacle or was the subject of either gawking or of the general curiosity of passersby. It is true, as is clearly shown in the video, Cpl Langridge's body was immediately visible to anyone passing by the room if the door were open.^{Footnote 1049} However, there is ample evidence the MP members kept the door closed or guarded to ensure both the scene and Cpl Langridge’s body were secure and off-limits prior to the arrival of the CFNIS investigators.^{Footnote 1050}

152. While the evidence indicates the door was open for some duration of the processing of the scene, there is also ample evidence military police members remained in the corridor to divert anyone not connected to the investigation away from the doorway and into the stairwells at opposite ends of the corridor.

153. MCpl Bruce-Hayes testified the door to the barracks room was generally open while the scene was processed.^{Footnote 1051} He was outside in the hallway in this time, and he and Cpl Broadbent instructed persons in the hallway not to walk past the barracks room when the door was open, but to turn around and go on to the exits at either end of the corridor.^{Footnote 1052} Mr. Caufield testified he specifically recalled at least one instance of MP or CFNIS members stopping individuals in the hallway and refusing to allow them to proceed until the work had completed and the door could be closed.^{Footnote 1053}

154. Kirk Lackie, who was a comrade and friend of Cpl Langridge from 2004 onwards, described his experience of the efforts by Military Police members to protect Cpl Langridge’s body and secure the scene immediately after the discovery of his death:

[...] [After realizing that Cpl Langridge was dead] I just left and I ran across the fields to the shacks, and by the time I got there, there's, you know, several EMs, firemen and military police there. And then I tried to go down the hallway to Stu's room and the military police officers stopped me. He goes, "You can't go down there right now". I was like, "I'm just going down and check on my friend". And he goes, "You can't go down there right now". And I said, "Well, can you tell me what's going on?" and he was like, "No, I can't tell you". And I said, "Well, can you tell me if it's my friend?" I said, "His name is Stu Langridge". He says, "I can't you [sic] anything right now." He says, "You're going to have to go outside and wait until everything gets cleared up".^{Footnote 1054}

155. The evidence supports the conclusion the integrity of the scene and the dignity of Cpl Langridge’s body were protected by the CFNIS and military police members. There is no basis for concluding disrespect was intended or shown to Cpl Langridge by not covering his body or allowing it to be viewed by passersby.

Contact with the body

156. In their final submissions, the complainants also suggest the failure to promptly lower Cpl Langridge resulted in further indignity and disrespect because the CFNIS members allegedly had to “squeeze” past his body when moving into and out of the room. The subjects submit, to the contrary, MCpl Ritco was careful not to disturb anything in the room, and there was enough space to get past Cpl Langridge's body without touching him.^{Footnote 1055}

157. Sgt Bigelow testified it was possible to move past Cpl Langridge's body without touching it. He estimated there was a two-foot gap between Cpl Langridge's body and the wall.^{Footnote 1056} Cpl Hurlburt, on the other hand, testified it was not possible to move past Cpl Langridge's body without touching it.^{Footnote 1057} Mr. Caufield testified it was “fairly easy” to enter the room and move past Cpl Langridge without touching his body.^{Footnote 1058} MCpl Bruce-Hayes testified a stockier person would have had difficulty going past Cpl Langridge without touching his body.^{Footnote 1059} In the video taken at the scene, it is clear the space available was narrow. Mr. Caufield is a tall, slim man and is shown in the video easily moving past Cpl Langridge’s body without making contact. On the other hand, the video appears to show two somewhat stockier body removal personnel both jostling Cpl Langridge’s body slightly as they entered.

158. Overall, the evidence shows, so long as care was taken, it was possible to move carefully past Cpl Langridge’s body without contacting it. Such movements appear to have been infrequent. It is perhaps possible MCpl Ritco and Sgt Bigelow may have touched Cpl Langridge’s body on the way in or out of the room. That does not amount to any show of disrespect. The evidence establishes it was inappropriate for the CFNIS to lower or move Cpl Langridge’s body without the authorization of the ME Investigator. Any access to the barracks room required some movement past Cpl Langridge’s body until he could be removed. While it appears MCpl Ritco’s investigative steps created a delay before Cpl Langridge’s body could in fact be removed, there is absolutely no evidence of any intention to show disrespect. There was also no evidence proper care was not taken to avoid disturbing his body.

159. In the end, the evidence does not establish any disrespect to Cpl Langridge’s body.

Processing the Scene After the Removal of the Body

160. After Cpl Langridge’s body was removed, MCpl Ritco and Sgt Bigelow processed the scene and seized exhibits seemingly at random. They do not appear to have asked themselves what they were investigating, whether the death appeared suspicious, or what might be relevant evidence of foul play. They did not seize or take custody of exhibits for the benefit of Mr. Caufield.^{Footnote 1060} Sgt Bigelow testified, although he and MCpl Ritco understood the ME had authority over the body, “it was our investigation so we were allowed to process this.”^{Footnote 1061}

161. The CFNIS investigators believed their role was to treat all scenes precisely the same way, and did not take measures to focus or adjust their approach based on an analysis of the circumstances and information available. Sgt Bigelow testified the approach to processing the scene and seizing exhibits was in no way related to the level of suspicion surrounding the circumstances of the death. Any scene would be processed the same way, whether foul play was suspected or not.^{Footnote 1062}

162. In all, MCpl Ritco and Sgt Bigelow seized a number of items to be used as exhibits, divided into 12 bagged collections. These included:

Exhibit 1: Cpl Langridge's ID card and Alberta drivers licence, a money clip, a leather card holder, a debit card, and a medical card;

Exhibit 2: Cpl Langridge’s suicide note;

Exhibit 3: Cpl Langridge's Blackberry device and its charger and leather case;

Exhibit 4: An MP patrolman's notebook;

Exhibit 5: Pamphlets, medical forms and an envelope pertaining to the Mental Health Act belonging to Cpl Langridge;

Exhibit 6: Literature pertaining to ending drug and alcohol abuse;

Exhibit 7: Personal correspondence received by Cpl Langridge including get well cards;

Exhibit 8: A Holy Bible (New International Version);

Exhibit 9: A blue water bottle containing approximately 500 ml of clear substance that they believed (but were not sure) was water;

Exhibit 10: A Tim Horton’s coffee cup approximately half full of what they believed (but were not sure) was coffee;

Exhibit 11: Paperwork concerning admittance to a medical facility and a biohazard bag; and

Exhibit 12: An XXX video, a collection of tools, a book, and a teddy bear.^{Footnote 1063}

163. MCpl Ritco and Sgt Bigelow also seized all personal items in the room, expecting these would be returned to the next-of-kin. They then made a video recording of the bagged exhibits and personal effects. Ultimately they removed everything belonging to Cpl Langridge from the barracks room, acting more or less as a clean-up crew.

164. It is important to understand why some items were seized as exhibits, and why some were not. MCpl Ritco testified about his thinking in determining what to seize at the scene:

The other stuff, the evidence, where the 12 or 13 items, like the suicide note, the water bottle, the coffee cup with the coffee in it, the Bible, the -- the AA literature and all that. That stuff, I felt, could have been relevant to me in my investigation. As I was at the beginning of the investigation, treating it as a sudden death, I don't know what direction it's going to go at. I find a suicide note, I find the stuff around it, so, yeah, it may have something to do with – with if there was foul play.

Q: Okay. Do I understand, then, that you seized these items for their physical properties, that is whether you would find fingerprints on the --

A: Fingerprints, DNA, possible writing analysis, possible numbers, names that may -- because I'm keeping an open mind. I just walk in there, I don't really know – not that I don't really know, I don't know what's going on, so I'm treating it as the worst-case scenario, and then I'll rule out -- I'll rule out as I go. So I'm not going to discard something because it appears to be a suicide. And there's a suicide note, so I'm not going to say, yeah, it's definitely a suicide, and just leave it as that. I'm going to say, okay, fine, there's -- it appears to be a suicide, the ME had mentioned that it's consistent with a suicide, there's a suicide note; however, I'm keeping an open mind. Maybe there's foul play; maybe there's not. So I'm gathering the items as the big picture [...].^{Footnote 1064}

An erratic approach

165. Throughout their testimony, the subjects of the complaint reiterated a belief the steps taken in processing the scene, and the length of time which elapsed in doing so, were necessary to avoid contaminating evidence in case it was later determined the death was the result of foul play.

166. An investigative aid included in July 2004 and February 2008 revisions of Annex I to MPPTP Chapter 7, titled “Guide: Deaths, SA/SAA and Sexual Assaults,” states, “All deaths must be handled [in accordance with] the same stringent standards as [a] homicide.”^{Footnote 1065} MCpl Ritco testified he believed this policy was in effect in March 2008, and he processed the scene accordingly.^{Footnote 1066} When the Fynes raised their concerns with Col Blais in 2010, the CFNIS provided a written explanation concluding the process was treated like a homicide. It stated, “In matters where the cause of death is unknown, all incidents shall be treated as homicide investigations. The intent is to secure the scene and prevent the loss of potential evidence, and to ensure that the scene is not contaminated”.^{Footnote 1067}

167. It is unclear this standard applied in a case like Cpl Langridge’s death scene. If the CFNIS investigators were treating the barracks room as a homicide scene, they did not do a very good job of it. At times, they applied exaggerated or unnecessary caution while missing obvious and essential steps for preserving and collecting evidence. As a result, the goals of the 2008 Sudden Death Investigation – and of any potential homicide investigation that could have become necessary – were frustrated.

168. The investigators did process the scene in the manner they thought best. They cannot be faulted for not knowing in advance what evidence would prove to be relevant. But the fact remains they did not exercise solid judgment in determining what to seize. MCpl Ritco’s thinking concerning the exhibits cannot be discerned from his notes or actions, and it is difficult to understand why he chose to seize certain items but not others, or what he intended to investigate in doing so. For example, a teddy bear sitting in Cpl Langridge’s window was collected as potential evidence for no apparent reason, and nothing further was done with it. On the other hand, the pen left on top of the suicide note, and likely used to write it, was moved close to the time the note was seized, but the pen was not seized as an exhibit.

169. MCpl Ritco took photographs of the sink in Cpl Langridge’s barracks room, focusing on several cigarette butts lodged in the sink’s drain and a wad of used chewing gum several inches to the right of the drain. He also recorded close-up video footage of the sink’s contents. However, not one of these items was seized into evidence nor referred to again. It is possible MCpl Ritco was simply taking photographs and recording the video of everything at the scene as a matter of routine without questioning the usefulness of such photographs or videos.

170. MCpl Ritco transferred the exhibits seized at the scene to his temporary locker on March 16, 2008.^{Footnote 1068} They were transferred to the evidence room on April 9, 2008. Although he seized some items that could be tested to reveal potential evidence of a crime, such as the water bottle, the coffee cup, or the suicide note, MCpl Ritco ultimately did not test any of these items. He testified tests were not warranted because the indications at the time pointed to suicide. He retained the evidence in the event evidence of foul play emerged as the investigation progressed.^{Footnote 1069} MCpl Ritco testified he treated the evidence as potentially pointing to a worst-case scenario of homicide and seized it with this in mind. His aim was to rule out foul play as he went.^{Footnote 1070}

171. However, MCpl Ritco and Sgt Bigelow took no fingerprints from the scene and collected no evidence samples from either the scene or Cpl Langridge’s body. Because the pen apparently used to write the suicide note was never seized, there was no way to test it for fingerprints or to confirm it was indeed the pen used. Had any indication of foul play emerged, vital evidence would have been missing.

172. The nature of the death made it clear there was no need to test any of the exhibits and MCpl Ritco cannot be faulted for not having done so. What is more important, and of much more concern, is MCpl Ritco never seemed to ask: “Do I need to seize this and, if so, why?” and “Will I need to test this?” He did not return to examine the evidence and assess whether it was still potentially relevant, and what, if anything, should be done with it to aid the investigation. The items were, in effect, seized as a matter of course and then forgotten. It was never clear why some steps were taken and some steps were not.

Preserving evidence and preventing contamination

173. The CFNIS and the subject members explained the preservation of evidence and the prevention of any contamination of the scene or the body were of the greatest importance, because failing to take all due care could have jeopardized any criminal investigation or proceedings that might have followed. The written response from the CFNIS to the Fynes following their complaint to Col Blais about their belief Cpl Langridge’s body was not treated respectfully indicates concerns about contamination were paramount:

The methodology used to collect evidence at a potential homicide scene is extremely lengthy and labour intensive. Due care to collect all possible evidence is paramount as once the crime scene is released, any uncollected evidence not seized may be lost to the investigation admissible in criminal proceedings. If Corporal Langridge had been taken down during the process, it would have further contaminated the crime scene and which [sic] could potentially have had a significant impact on the criminal investigation.^{Footnote 1071}

174. Although the CFNIS members explained their process as being necessary, the work done was incomplete and insufficient for the purposes of meeting the rigorous evidentiary requirements of a criminal prosecution. Worse, the hypothetical prosecution of a suspect in Cpl Langridge’s death could have been jeopardized by problems such as the failure to conduct a forensic examination of the scene and to prevent its contamination, as well as the failure to obtain complete evidence about who may have entered the scene or come into contact with Cpl Langridge’s body and any items within the room.

175. If the CFNIS investigators were processing the scene as a crime scene, effort should have been made to follow the existing policies and procedures.^{Footnote 1072} The 2004 revision of Annex C (“Evidence Procedures”) to MPPTP Chapter 7 makes clear the importance of preventing contamination and preserving evidence at a crime scene.^{Footnote 1073}

176. MCpl Ritco was questioned about his efforts to determine whether there had been any contamination of the scene or any disturbance to the continuity or preservation of evidence between the time of the hanging and the time he arrived. He testified he spoke with Cpl Bruce-Hayes, who was the first MP to arrive at the scene, and gained information concerning who entered the room, what they did, the path they took, and whether they touched or removed anything.^{Footnote 1074} Cpl Bruce-Hayes noted Cpl Langridge’s body had been touched by personnel from the fire department when they checked for any vital signs.^{Footnote 1075} Statements from MCpl Munro and MCpl Bowen indicated both had entered the room and touched the body when confirming a lack of vital signs.^{Footnote 1076} MCpl Munro had also taken the wallet from the desk in Cpl Langridge's room. Paramedics also attended the scene and checked the body for vital signs.^{Footnote 1077} MCpl Ritco did not interview the ambulance personnel who attended the scene.^{Footnote 1078}

177. There is no information as to precisely who touched the body or whether any other items in the room were disturbed. MWO Watson recognized in his testimony the notes taken by Cpl Bruce-Hayes were not sufficient for investigators to know the path ambulance personnel took into the room or whether the ambulance personnel touched other objects in the room.^{Footnote 1079} To the extent it was necessary to confirm the evidence at the scene, the investigative team should have considered immediately interviewing Cpl Hurlburt, who discovered Cpl Langridge’s body,^{Footnote 1080} the firefighters who attended at the scene and confirmed the death,^{Footnote 1081} and the ambulance crew who also entered the scene and reconfirmed the death.^{Footnote 1082} All of these persons should have been questioned in regards to: the path or paths they took into and out of the room where Cpl Langridge was found; whether they touched or moved the body, and if so, where and how; and whether they touched or moved anything in the room aside from the body.

178. MCpl Ritco testified, as he progressed through the scene, he would avoid contaminating evidence and make a written or mental note of anything that stood out and then avoid that area. Seeing Cpl Langridge's body at the entrance to the barracks room, he was concerned not to touch the body “in any way, shape or form until I absolutely photographed and videotaped the entire scene to preserve anything because once he is moved then the continuity, if there was evidence is lost.”^{Footnote 1083} MCpl Ritco entered the scene relying only on latex gloves to prevent contamination. This suggests either he did not believe the death was at all suspicious, or if he did, he did not grasp the need for taking strict precautions at the scene of a potential homicide.

179. Including Cpl Hurlburt, who had discovered the body of Cpl Langridge, at least five people had touched the body before MCpl Ritco and Sgt Bigelow arrived at the scene. At least one item at the scene was handled, and MCpl Ritco testified he did ask whether any other items were disturbed, although he did not believe so.^{Footnote 1084} Knowing there had been some disturbance of the room and some contact with the body prior to his arrival at the scene, MCpl Ritco testified he would have to rule out the DNA or fingerprints of the first responders should the evidence suggest Cpl Langridge died as a result of foul play. However, MCpl Ritco and Sgt Bigelow took no fingerprints from the scene, collected no evidence samples from the scene or the body, and in general did not take the measures for gathering and preserving evidence that would have been expected in a homicide investigation.

180. MCpl Ritco testified he never followed up on the possibility of contamination because, “There was no indication of foul play at the end.”^{Footnote 1085} Indeed, there was no reason in the circumstances to expect an investigator to collect fingerprints or DNA evidence from the scene – or from any of the personnel who had entered the room. The Commission would not expect MCpl Ritco to have done so. However, there is a fundamental problem with the approach taken by the CFNIS members if one takes at face value the repeated assertion the scene had to be processed to the standard of a homicide. The rationale for the manner in which the scene and the body were to be handled is inconsistent with what was actually done. Neither the body nor the scene were treated in accordance with that standard.^{Footnote 1086} It would have been impossible to perform any analysis had evidence later come to light Cpl Langridge had died as a result of foul play.

181. Evidence was inconsistently packaged in evidence collection bags – sometimes individually, sometimes in lots with other items. Exhibit 12, as described earlier in this chapter, contained a jumble of personal items.^{Footnote 1087} Seized items should not be packaged together, so as to prevent cross-contamination and loss of evidence, as is made clear in the 2004 revision of Annex C (“Evidence Procedures”) to MPPTP Chapter 7.^{Footnote 1088} Moreover, the manner in which some evidence was photographed is not consistent with notes recorded at the scene by Sgt Bigelow.^{Footnote 1089}

182. The protective clothing worn was insufficient to prevent the contamination of the scene. According to a 2011 revision of CFNIS Standard Operations Procedure 237, “Locard's Principle postulates that there will be an exchange of material any time objects come into contact with one another. To avoid contaminating the scene, ensure all persons entering the scene wear proper forensic protective clothing.”^{Footnote 1090} This provides a clear indication of best practices for ensuring the integrity of the evidence-gathering process. Sgt Bigelow was asked to explain when investigators are required to go through a scene in a full forensic suit and the circumstances in which wearing gloves would be sufficient. He believed it depended on the expectations of the department. When he worked with the RCMP, where the death was the result of a suicide or was not suspicious, the general practice was for investigators to use gloves and exercise caution as to what they touched. Where the death was, in his words, a “serious homicide,” however, forensic analysts, “the CSI guys,” would process the scene wearing full body suits.^{Footnote 1091}

183. The evidence from the police panel indicates factors such as the nature of the death and the conditions at the scene itself tended to dictate the forensic evidence gathering requirements and precautions against contamination. S/Sgt Clark testified the EPS will only send out its Identification teams, who wear full protective forensic suits, to the scenes of suspicious deaths. Non-suspicious death or apparent suicides are too numerous to be treated the same way, and in such cases forensic evidence gathering and precautions against contamination are “a non-issue.”^{Footnote 1092}

184. Insp. Fitzpatrick testified, for major crime investigations, forensic specialists were required to wear full forensic “bunny suits,” protective footwear, and possibly even masks and breathing apparatuses depending on the biohazard risks. Otherwise, the use of protective forensic clothing depends on the situation, with an emphasis on good judgment, training, and best practices to determine how to proceed.^{Footnote 1093}

185. Det. Insp. Olinyk testified forensic officers will normally wear biohazard suits at a scene examination as much for their own protection as for protecting potential evidence.^{Footnote 1094}

186. To process a scene to the standard of a homicide demands far more stringent measures than simply wearing latex gloves. The Commission is left wondering how CFNIS members believed they were facing even a potential homicide when they entered the barracks room and interacted with the scene and Cpl Langridge’s body, given they did so inadequately prepared and protected.

187. MCpl Ritco may himself have caused evidence to be lost. In the video-recording made of the processing of the scene – both before and after Cpl Langridge’s body was removed – MCpl Ritco wears gloves throughout his exploration of the room and its contents, but does not wear them after the contents of the room had been moved. At 2259 hrs, MCpl Ritco and Sgt Bigelow finish removing the evidence and effects from the barracks room. MCpl Ritco then performs a final walkthrough of the empty room. He is shown on video opening doors and drawers with his bare hands to demonstrate all of Cpl Langridge's personal effects had been removed. If any fingerprints or other relevant forensic evidence were present in the room, they could have been contaminated or obliterated at this point.

188. Had MCpl Ritco and Sgt Bigelow actually thought themselves to be at the scene of a suspected homicide, it is almost unthinkable they would have entered the scene without taking the most exacting measures to prevent the loss or contamination of evidence.

Developing a Flexible Approach to Sudden Death Investigations

189. A responsive, appropriate and purposeful approach to scene contamination was at least contemplated by some of the MP policies. The 2004 revision of Annex C to MPPTP Chapter 7 called for the use of protective clothing when gathering evidence and advised, “[t]he scene to be examined will dictate the type of protective clothing to be worn, boots, hats, gloves, suits, etc.”^{Footnote 1095}

190. The evidence gathering and preservation approaches taken by the CFNIS investigators in this case would make much more sense if they were treating the investigation as a probable suicide –a non-suspicious death. It would not have been necessary to take exhaustive measures to prevent the loss or contamination of evidence, to wear more protective gear than latex gloves, to gather handwriting samples to verify the authenticity of the suicide note, to seize the pen apparently used to write the suicide note, and to collect fingerprints and trace evidence from the scene. Under this scenario, it would become clearer why Cpl Langridge’s Bible was seized with its bookmark and an underlined passage (Revelations 21) noted as a potential indicator of his state of mind.^{Footnote 1096} It is difficult to reconcile the fact MCpl Ritco stated he treated the scene as a potential crime scene with the actions he took.

191. It may well be MCpl Ritco’s understanding of his approach to processing the scene was influenced by the MPPTP policy in place at the time which required that all deaths be handled in accordance with the same stringent standards as homicide.^{Footnote 1097}

192. The expert evidence heard by this Commission establishes the importance of a flexible approach to sudden death investigations.^{Footnote 1098} While it is likely all death scenes should initially be approached with the premise they may be homicides, an overly rigid approach, which results in every sudden death literally being treated in an identical manner, discourages and impedes investigators from assessing the evidence and facts and forming hypotheses about what has happened. Although it is essential an investigation not be constrained by tunnel vision or rigid conclusions, these hazards are wholly distinct from the formulation of working hypotheses. A sound hypothesis must be continually and rigorously tested, but it is a fundamental guide for an investigation. For these reasons, thought should be given to carefully developing an investigation policy which abandons a one-size-fits-all approach for every sudden death, and instead promotes the use of good judgment and the ongoing assessment of the facts and evidence obtained to test hypotheses and allows for CFNIS resources to be used accordingly. Here, once the likelihood of suicide became stronger, the investigators ought to have conceived of a hypothesis about Cpl Langridge’s death and ascertained what would be necessary to confirm or challenge this theory.

193. Whenever the “potential homicide” approach is taken, it should be done properly and consistently. Rigorous steps should be taken to prevent contaminating the body or the scene and prevent any potential loss of evidence. If CFNIS policy continues to require any sudden death to be handled with the same stringent standards as a homicide until it is proven to be a result of suicide,^{Footnote 1099} care should be taken to avoid any contamination of the scene or the body. The scene should only be entered and processed while investigators are wearing appropriate protective clothing. Anyone who has entered the room since the discovery of the death should be interviewed to identify what may have been disturbed or touched.

194. In all cases, the scene should be processed purposefully, based on an evaluation of the evidence and information available. CFNIS members at the scene should report their observations and the available information to a superior (such as a case manager) with significant experience in the conduct and supervision of sudden death investigations. Together with the coroner or ME, the CFNIS members at the scene and their superior should make an initial determination as to the possible nature of the death and the most appropriate approach to gathering evidence. However, if there is any reason to believe the death may have been the result of foul play or is otherwise suspicious, investigators should proceed as though the death were a homicide.

195. As an alternative, consideration could be given to sealing a sudden death scene wherever possible and feasible until the medical cause of death has been determined, avoiding both contamination of evidence and the loss of evidence.

196. Consultation and evaluation between CFNIS members and the ME or coroner should aid investigators in identifying what will be important for search and seizure purposes. Once the body is removed, evidence should be collected with a view to determining the manner of death, and investigators should revisit and evaluate the evidence as the investigation progresses. All evidence seized should be carefully preserved and stored in separate evidence collection containers.

Proceeding With the Sudden Death Investigation

Understanding what to investigate

197. Following their processing of the scene, the removal of Cpl Langridge’s body, and the collection of evidence, the investigators were in a position to determine what, if anything, was necessary for the purposes of a sudden death investigation. The members of the CFNIS investigative team testified the purpose of their investigation was to rule out foul play.^{Footnote 1100} To the extent this means they were focused on foul play as an alternative to suicide, the actual investigation conducted does not seem focused on that issue. Most of the investigative work undertaken was primarily concerned with investigating the suicide watch issue.^{Footnote 1101} The other investigative steps taken appeared to lack focus and direction. It was not clear their potential relevance to ruling out foul play was thought through or understood by the investigators.

198. Gathering and assessing evidence regarding Cpl Langridge’s final days may have assisted investigators in creating a chronology of the sequence of events leading to his death. This may be important to ruling out foul play or identifying issues related to the death which merit further investigation. In creating a chronology, investigators may identify potential witnesses or avenues of investigation and may improve their own understandings of the events leading up to the death. This can assist investigators in making a timely determination of whether foul play was involved and may help them identify any inconsistencies in the evidence that require further investigation. At the very least, investigators should aim to gather information with respect to the deceased in the hours preceding the death^{Footnote 1102} and should likely focus on at least the final three days.^{Footnote 1103} In this case, the investigative team did not create any such chronology.^{Footnote 1104} There is no record in the investigation file of Cpl Langridge’s final hours to help establish where he was or what he was doing with any certainty.

199. Indeed, there is no chronology of the period of time following Cpl Langridge’s discharge from his thirty-day stay in hospital^{Footnote 1105} until his death, representing the final ten days of his life. The investigation file contains only small glimpses of Cpl Langridge’s activities following his discharge. There is no indication the circumstances of the discharge were investigated, and no indication Cpl Langridge’s living arrangements and work situation during this ten day period were investigated in any depth.

200. To the extent they felt unable to come to a conclusion after processing the scene, the investigators ought to have considered the two most plausible theories of how the death resulted; either it was a suicide, or it was in some way the result of foul play. In developing their IP, the investigators should have been guided by the evidence from the scene and should have directed their investigation towards challenging these theories. The investigative team did not appear to use the evidence from the scene, interviews, or other investigations in any such manner. The evidence does not appear even to have been reviewed aside from MCpl Ritco tagging as personal property on March 19, 2008, certain items initially seized as evidence.^{Footnote 1106}

201. Rather than analyze the evidence at hand, the investigators seem to have been focused on gathering even more evidence. MCpl Ritco did testify, “I go into an investigation and I let the evidence dictate on what the outcome is going to be [sic],”^{Footnote 1107} and emphasized he kept an “open mind” throughout the course of the investigation. He only reached a conclusion on the cause of death when he concluded his investigation report,^{Footnote 1108}which was on or about June 2, 2008.^{Footnote 1109} He stated, in the course of the investigation:

[...] everything I was gathering -- all of the evidence that I was gathering, it obviously was pointing toward a suicide, but I didn't want to make that determination right then and there, because I hadn't gathered everything up yet. So, yeah, it was pointing toward a suicide, and there was no suspected foul play, but it wasn't until the end of May that all of the pieces of the puzzle were put together, and it was a suicide.^{Footnote 1110}
[Emphasis added]

202. It appears, however, from the conduct of the investigation and his testimony, MCpl Ritco misunderstood the meaning and purpose of keeping an open mind. Far from suggesting an open-minded approach, his evident reluctance to actually follow the evidence suggests an exagegerated fear of premature conclusions – a fear that was perhaps the combined result of inexperience, limited supervision, and official admonishments against succumbing to police tunnel vision.^{Footnote 1111} The investigative team appeared to believe they could not make a determination on the issue of foul play until every possible piece of evidence was collected, as though an exercise of judgment or selectivity would amount to police tunnel vision. This is not a correct investigative principle. Worse, the evidence the investigators continued to collect was not always relevant to this determination, and where it was, its relevance did not always appear to be understood by the investigators.

Witness interviews

203. The CFNIS investigators should have considered canvassing the residents of the floor of the building in which Cpl Langridge’s barracks room was located and possibly those on adjacent floors. As it stands, there is very little information in the investigation file relating to his activities and state of mind on the day of, and in the days preceding, his death. It is not known who the last person to see Cpl Langridge alive was, as the issue does not appear to have been investigated. There is nothing in the investigation file to confirm what Cpl Langridge was doing on the day of his death aside from accounts from duty staff they were told he was doing laundry.^{Footnote 1112} Ascertaining Cpl Langridge’s activities during his final days and on the day of his death may have been valuable in helping the investigators form an impression of his state of mind. Cpl Langridge’s neighbour was interviewed on March 17, 2008, by a base MP member,^{Footnote 1113} but provided little information aside from stating he had heard noises in Cpl Langridge’s room such as the door being opened and closed and a chair being moved in the early morning.^{Footnote 1114} MCpl Ritco indicated in his notes he “determined that [the neighbour] still may be needed to be interviewed as his statement was vague.”^{Footnote 1115} There is no indication the neighbour was subsequently interviewed by the investigators.

204. If there are unanswered questions following the investigation of the death scene and neighbourhood canvass, investigators may conduct witness interviews to help determine whether foul play may have been involved. It is difficult to overstate the value of witness interviews to any investigation, and this value is even greater when the focus of the investigation is upon the events of a deceased person’s last days. Mr. Caufield testified, when investigating suspected suicide, investigators should attempt to identify any history of suicidal ideation or past suicide attempts, as well as any evidence of significant life events which may have prompted an individual to take her or his own life.^{Footnote 1116} The information obtained from witnesses depends first upon successfully identifying the witnesses most likely to have the most pertinent information. Investigators must be prepared to expand and amend their witness list depending on what they learn.

205. In this case, the investigators conducted several interviews in the months following Cpl Langridge’s death. They did not interview Cpl Langridge’s family, common-law partner, or any of his treating physicians, either civilian or military. They did interview Cpl Langridge’s Adjutant,^{Footnote 1117} the Duty Staff,^{Footnote 1118} and his work supervisor,^{Footnote 1119} although the latter was interviewed about a month after Cpl Langridge’s death. The RSM was interviewed over two months after the death.^{Footnote 1120} The only friend of Cpl Langridge’s interviewed was Cpl Jon Rohmer.^{Footnote 1121}

206. The failure to interview the Fynes and Ms. A meant the investigative team was unaware of many potentially relevant matters, including the allegations that Cpl Langridge was ordered out of hospital and placed under a suicide watch. MCpl Ritco admitted in testimony these allegations would have been useful to him in directing his investigation.

207. The decision not to contact Ms. A appears to have been made by or in conjunction with WO Tourout on May 15, 2008,^{Footnote 1122} long after when she ought to have been interviewed. WO Tourout testified Ms. A was not interviewed because “at that point we had the medical records. So there was [...] no requirement to interview her.”^{Footnote 1123} MCpl Ritco testified it was determined “at the end of the investigation [...] it was irrelevant to interview her because it was a suicide.”^{Footnote 1124}

208. MCpl Ritco testified he had considered interviewing the Fynes. He agreed they should have been interviewed, and indicated, he believed it was an oversight on his part they were not listed as potential witnesses in his IP.^{Footnote 1125} He also recalled speaking with WO Tourout about the possibility of interviewing Mrs. Fynes and being told it was not necessary.^{Footnote 1126} WO Tourout could not recall precisely why MCpl Ritco was instructed there was no need to call Mrs. Fynes, but believed it was related to the fact the investigators had obtained Cpl Langridge’s medical records which “gave [them] the history of his service.”^{Footnote 1127} MWO Watson similarly could not recall precisely why MCpl Ritco was told there was no need to interview Mrs. Fynes. However, he testified, “I can only suggest to you that he was a 28-year-old male in the military, and I would not have seen a need to speak to the mother in this situation to further the investigation” and he added, the background information the investigators required was obtained from “medical authorities” and Cpl Langridge’s colleagues, and this information would have been sufficient for their investigation.^{Footnote 1128}

209. As the subjects pointed out in their final written submissions, it is not necessary for investigators to interview every potential witness who may have relevant information.^{Footnote 1129} However, the selection of the witnesses to be interviewed must be based on an assessment of the relevance of the information they are likely to possess and its importance to the investigation. In this case, some of the assessments made were not reasonable, and as a result, witnesses with significant and relevant information were disregarded.

Scope of the investigation

210. The bulk of the investigative work following the interview of Cpl Hurlburt on March 19, 2008, was not aimed at determining whether Cpl Langridge’s death was caused by suicide or foul play. The interviews of MCpl Fitzpatrick,^{Footnote 1130} MCpl Bowden,^{Footnote 1131} CWO Ross,^{Footnote 1132} and Capt Richard Robert Hannah^{Footnote 1133} dealt largely with issues related to an alleged suicide watch and Cpl Langridge’s conditions (which may have suggested possible negligence),^{Footnote 1134} rather than issues related to ruling out foul play as an alternative to suicide.

211. Maj Brian Frei, DCO CFNIS at the time of this investigation, testified at the hearing, “best practice would be to separate” the two investigations. However, he acknowledged it was not a common practice of the CFNIS at the time.^{Footnote 1135} MCpl Ritco was correct; the issue of negligence ought to have been investigated.^{Footnote 1136} Although it might have been better to make it the subject of its own subsequent investigation rather than diverting investigative focus from the issue of whether the death was suicide,^{Footnote 1137} the Commission understands this is not always how an investigation is conducted, nor is this necessarily the only way to investigate effectively.

Ruling out foul play

212. The investigators did not rule out foul play as an alternative to suicide until two and a half months after Cpl Langridge’s death.^{Footnote 1138} It is difficult to pinpoint with certainty exactly when, based on the facts available at the time, foul play, as opposed to suicide, could as a practical matter have been ruled out. However it seems this could have been done within days of the death, if not on the very day of the death as a result of processing the scene. Certainly, there is little reason to believe foul play as an alternative to suicide could not have been all but conclusively ruled out before Cpl Langridge’s funeral on March 26, 2008.^{Footnote 1139} MWO Watson testified this was, from all appearances, an uncomplicated investigation, and the ruling out of foul play should not have taken more than three or four days.^{Footnote 1140}

213. The delay in arriving at a conclusion, for practical purposes, that the death was a suicide appears to be rooted in a failure to differentiate between the concept of ruling out foul play as an alternative to suicide and concluding an investigative file. Concluding a file requires all investigative procedures and documents necessary for a file to be completed and in order, to the point of allowing for the investigators and their supervisors to sign off on the investigation. On the other hand, investigators can rule out foul play, for practical purposes, prior to concluding their investigative files. Investigators can make early determinations on relevant issues prior to completing all the technical requirements for the files. The investigative team may have been correct the file would require a report from the ME prior to being concluded, but it could have ruled out foul play, for practical purposes, prior to receiving the ME’s report.

214. In his testimony, MCpl Ritco did not agree he could have concluded on the cause of death sooner than he did, citing the fact this was his first investigation of a suicide. This hesitation to come to what he considered a potentially premature conclusion may be linked to the failure to analyze the investigative steps taken and the evidence collected in terms of their significance in either confirming or refuting foul play. In his testimony, he was unable to identify what sort of possible foul play he was investigating after March 19, 2008.^{Footnote 1141}

215. WO Tourout, meanwhile, testified that following the investigators’ examination of the crime scene “an analysis of that would lead [MCpl Ritco] to believe that there was no foul play.”^{Footnote 1142} He added it was a “fair assumption” the investigators knew all they would about the crime scene, physical evidence, and possible leads to foul play by March 17, 2008.^{Footnote 1143}

216. The CFNIS investigators explored Cpl Langridge’s personal life, physical and mental health, past suicide attempts, addictions issues and relationships. Notwithstanding the complainants’ allegations this sort of exploration was unnecessary and excessive in the context of a sudden death investigation, the expert evidence is to the contrary.^{Footnote 1144} Where there is an apparent suicide, aspects of the deceased’s personal life may be canvassed to discern circumstantial evidence as to whether or not it was in fact a suicide. Evidence of suicidal ideation, past suicide attempts, or chronic mental health disorders like depression or bipolarity may lead to such inferences. Evidence of personal traumas, substance abuse, or relationship problems may indicate a person’s life circumstances were unstable, again leading to possible inferences as to the likelihood of suicide. These sorts of details, though not determinative, may be of assistance to investigators in helping to understand the deceased and whether there were any signs confirming the possibility of suicide or making it unlikely.

217. The investigators received a good deal of input on these issues during their early interviews, providing a strong indication Cpl Langridge’s death was a suicide and not the result of foul play.

218. On March 17, 2008, Capt Mark Lubiniecki reportedly told the investigators Cpl Langridge had at least two prior suicide attempts and had attended and quickly discharged himself from drug rehabilitation, which was brought about after a failed drug test for cocaine. He also noted Cpl Langridge’s common-law relationship was unstable and possibly ending. Capt Lubiniecki reportedly stated Cpl Langridge was living at the Regiment under conditions in an effort to “prove he was more committed to changing his ways.”^{Footnote 1145}

219. The next day, Cpl Rohmer told investigators Cpl Langridge had attempted suicide at least twice in the past and “had an alcohol problem, drug problem, relationship issues, and financial problems.” He stated he had personally been at Cpl Langridge and Ms. A’s house to remove an electrical cord from the basement, reportedly used by Cpl Langridge to attempt suicide. Cpl Rohmer discussed Cpl Langridge’s erratic behaviour and “coke” use and alluded to rumours of a possible suicide watch for him in the weeks preceding his death.^{Footnote 1146}

220. Sgt Hiscock also provided information about the suicide watch rumour, stating he had been told on the day of Cpl Langridge’s death by either the off-going Duty Officer or MCpl Fitzpatrick about the suicide watch.^{Footnote 1147} He added he had heard Cpl Langridge had relationship problems and mental health issues.^{Footnote 1148}

221. On March 19, 2008, the investigators interviewed Cpl Hurlburt, ^{Footnote 1149}who told them there were rumours in recent weeks Cpl Langridge was suicidal and a suicide watch had been planned. He also relayed other rumours Cpl Langridge might have been suicidal in the previous year, although he added others thought Cpl Langridge’s talk about suicide at that time had not been sincere.^{Footnote 1150} The investigative team did not seem to have made use of this evidence at the time to assist in ruling out foul play.

222. On April 9, 2008, the investigators obtained a police report from the RCMP. It revealed Cpl Langridge had been reported as a “missing unstable person” on June 25, 2007,^{Footnote 1151} the date of his first suicide attempt.^{Footnote 1152} On the same date, MCpl Ritco spoke with the ME Investigator, who stated ten of the eleven tests had been conducted, and unless the final test came back as a “hit”, the death would be ruled a suicide. MCpl Ritco also noted the ME Investigator indicated, “since there appears to be no foul play of any sort, and all test [sic] are coming back negative,” all that was required from MCpl Ritco was a list of medication prescribed to Cpl Langridge.^{Footnote 1153} He further reported Mr. Caufield requested photographs of the scene and the police report for his file. MCpl Ritco wrote in his notes: “briefed him that I was not done, can wait, told I will have to speak to MWO refer report [sic].”^{Footnote 1154}

223. By this point, nearly a month following the death, in addition to unearthing no evidence to suggest foul play and having information from witness interviews pointing to a troubled medical and personal history, which included talk of suicide and suicidal attempts or gestures, the investigators now also had a tentative conclusion of suicide from the ME.

224. On April 22, 2008, the investigators interviewed MCpl Fitzpatrick. He reported he had reviewed Cpl Langridge’s personnel file when Cpl Langridge came to work for him in 2007. The file reportedly detailed the events of his first suicide attempt, which MCpl Fitzpatrick relayed to the investigators.^{Footnote 1155} He further reported, on one occasion when Cpl Langridge was working for him, Cpl Langridge had been AWOL so MCpl Fitzpatrick had called the MP, which sent a member to Cpl Langridge’s house. The MP member reportedly found him incoherent after taking a number of sleeping pills.^{Footnote 1156} That same day, according to MCpl Fitzpatrick, Ms. A went to his office and reported Cpl Langridge was “doing drugs.”^{Footnote 1157} The remainder of the interview dealt in large part with the alleged suicide watch, which MCpl Fitzpatrick described as being a pre-emptive guard list organized in the event a suicide watch needed to be held.^{Footnote 1158} His account of events was questioned by the testimony of MCpl Bowden on May 5, 2008. She stated, she had been told by MCpl Fitzpatrick the list of names was being compiled “for a watch on Langridge for suicide.”^{Footnote 1159}

225. This discrepancy notwithstanding, the evidence suggested the Regiment was concerned about the possibility of Cpl Langridge committing suicide. The concern had risen to the point where either a suicide watch was being organized or a list of names was being gathered in the event a suicide watch needed to be put in place urgently.

226. On May 15, 2008, MCpl Ritco attended at the ME’s office and met with the ME Investigator. At that time, he received various documents officially confirming Cpl Langridge died as a result of suicide by hanging.^{Footnote 1160} Even with this material in hand, MCpl Ritco was not prepared to rule out foul play. He testified before the Commission the ME’s report, “was one of the biggest pieces of the puzzle”, but he still had more to do before he could conclude his report.^{Footnote 1161}

227. On May 27, 2008, MCpl Ritco interviewed Capt Hannah.^{Footnote 1162} Capt Hannah stated it was “on the public record” Cpl Langridge was living at LDSH because he was perceived to be at a heightened risk of suicide.^{Footnote 1163} Capt Hannah went on to state Cpl Langridge was cooperative during his time at LDSH; he was not making any suicidal gestures and stated he was not suicidal.^{Footnote 1164} Capt Hannah stated he could not answer the question of why Cpl Langridge committed suicide^{Footnote 1165} but theorized it could have been the result of attention-seeking behaviour^{Footnote 1166} or cocaine use.^{Footnote 1167} He also reviewed the medical records with MCpl Ritco, which he had obtained with respect to Cpl Langridge, in order to assist MCpl Ritco in understanding what they meant. Although the records were arguably incomplete, they did contain significant information indicating Cpl Langridge was deeply troubled.

228. MCpl Ritco testified the medical records indicated Cpl Langridge “was in and out of hospitals. In the past, […] he had attempted suicide. And [...] he was … seeking counsellors for help.” However, he did not draw any inferences from these facts and only concluded they were evidence there was “something wrong.”^{Footnote 1168}

229. It is difficult not to conclude, at some point, the thread had been lost as to the purpose of the investigation, and it had been transformed into a free-floating investigation into Cpl Langridge himself. This impression is bolstered by the fact, even at this point, the investigation did not end. On May 29, 2008, MCpl Ritco requested a forensic analysis of Cpl Langridge’s BlackBerry mobile phone by the CFNIS Integrated Technological Crime Unit (‘ITCU’). He wanted an analysis of all calls, email and text messages and a search for terms like “kill”, “hurt”, “cocaine” and “suicide.”^{Footnote 1169} MWO Watson supported the request.^{Footnote 1170} He noted the analysis was to be done to find “any evidence that may explain the reason for Cpl LANGRIDGE’s suicide” and to learn who sold illegal drugs to Cpl Langridge.^{Footnote 1171} He also noted, “the investigation into this incident is complete” but still concurred with the request for the analysis.^{Footnote 1172} Ultimately, when he became aware of the technical difficulties associated with conducting this analysis, MCpl Ritco decided against proceeding further, noting, “one of the main reasons for gaining access into the BlackBerry was for intelligence purposes.”^{Footnote 1173} The mobile phone search initiative was unnecessary in the context of a sudden death investigation.

Too much investigation?

230. As was alluded to earlier, the complainants allege the CFNIS investigators were excessive in probing unnecessary and irrelevant aspects of Cpl Langridge’s life. They contend the investigators failed to focus on ruling out foul play as a potential cause of Cpl Langridge’s death in a reasonable time, examined irrelevant issues, and enlarged the scope of the investigation far beyond what was appropriate.^{Footnote 1174} It is true the 2008 Sudden Death Investigation periodically digressed into topics that were perhaps outside its proper focus and/or dwelled upon even potentially relevant topics excessively.^{Footnote 1175} With that said, however, it would be unreasonable to unduly circumscribe the investigation at an early point before knowing how it would unfold. Aside from the mobile phone search, the topics being investigated, including the details of Cpl Langridge’s personal life and medical history, were appropriate and potentially relevant to a sudden death investigation, and certainly to a police investigation of culpable negligence. However, the way those topics were pursued and the failure to use them to draw relevant conclusions and to rule out foul play in a timely manner were not appropriate. There is no basis to conclude this was the result of any improper motive. Like other flaws in the investigation, they seem largely the product of inexperience and inadequate supervision.

MP and CFNIS Policies

231. As part of their response to the complainants’ allegations, the written submissions of the subjects state the investigators adhered to all relevant policies and procedures in force at the time. It is therefore necessary to consider the relevant policies, both in terms of the subjects’ compliance and, more generally, in terms of the adequacy of those policies to provide appropriate guidance.

The policies in force at the time: MPPTP Chapter 7

232. The relevant policy in place for sudden death investigations was an MPPTP Annex regarding the investigation of deaths, sexual assaults, and offences related to small arms.^{Footnote 1176} The policy provided a general overview regarding how each of these matters should be approached, including examining potential crime scenes and what issues should be investigated.

233. The portion relating to sudden deaths occurring on or in relation to a Defence Establishment begins with a general statement for such investigations:

All deaths will be handled [in accordance with] the same stringent standards as homicide. Once a death is proven to be a result of suicide then it shall be turned over to the local CO for an administrative investigation as per CFAO 19-44. This applies as well for attempted suicides.^{Footnote 1177}

234. The expert evidence heard by this Commission establishes the importance of a flexible approach to sudden death investigations.^{Footnote 1178} While it is likely all death scenes should be approached under the premise they may be homicides and the resulting processing should be thorough and objective, all death investigations should not be handled the same way.

235. Investigators ought to use their experience and judgment, in conjunction with the input of their supervisors, to determine whether a death scene appears to be criminal or non-criminal. In this case, as discussed earlier in this chapter, the investigative team neither processed the scene nor conducted the remaining investigation to the standard of a homicide investigation. Much of what they did was likely unnecessary.

236. The 2008 revision of Annex I to chapter 7 of the MPPTP goes on to categorize deaths in three ways: (1) homicide; (2) suicide; and (3) natural death.^{Footnote 1179} If a death is deemed not to be natural, the CFNIS will be the primary investigative service.^{Footnote 1180} The policy then addresses the response of MP members to death scenes. It encourages responding MPs to take life-sustaining measures where appropriate or, if death is evident, to isolate the scene and prevent unauthorized access. MPs are directed to request an ME, coroner or medical officer to attend the scene and to notify the CFNIS. Further, they are to identify and isolate persons with knowledge of the death where possible. Finally, the policy notes, “if the coroner cannot state death was due to natural causes, CFNIS shall continue with the investigation.”^{Footnote 1181}

237. In practice, it should be noted, while it is both appropriate and necessary to report a death to the coroner or ME under provincial legislation,^{Footnote 1182} it may not be appropriate to request the coroner or ME attend the scene immediately. If the death is suspicious and the scene needs to be processed, the expert evidence heard by this Commission suggests the police force with jurisdiction should be the first to investigate it, even before the ME is called in. Investigators or forensic units, or both, should seek to examine the scene with as little potential contamination as possible, which includes waiting to call in an ME or ME’s investigator until the scene is processed.^{Footnote 1183}

238. In this case, it seems the MP members who responded to the scene followed this section of the policy. They cordoned-off the scene, notified the ME Investigator and the CFNIS, and spoke with Cpl Hurlburt, who had discovered Cpl Langridge.^{Footnote 1184} However, once the ME Investigator had made it clear he believed the death was a suicide and the CFNIS had processed the scene, they should have considered the impact of the ME’s opinion on what further steps were necessary or appropriate for their own investigation. Certainly in terms of ruling out foul play, it does not appear there were many further investigative steps necessary, although several follow up interviews may have been appropriate.

What is to be investigated according to the MPPTP

239. Annex I to chapter 7 of the MPPTP states at paragraph 6, entries reporting deaths within SAMPIS are to identify “the cause of death”, whether the member was on duty at the time of death, and “when possible, who or what caused the death.”^{Footnote 1185}

240. In terms of deaths which may have been suicides, the MPPTP states:

The investigation into suicide or attempted suicide should focus on determining that the wounds to the subject were in fact, self-inflicted. [...] Administrative details (previous attempts, possible causes, marital status[,] alcohol or drug dependencies, etc.) need not be actively pursued and should only be reported if they are offered unsolicited to MP. It must be recognized that a Board of Inquiry or Summary Investigation designed to determine the administrative details will be initiated and will report relevant facts to the appropriate departmental authority.^{Footnote 1186}

241. The second statement in this MPPTP is problematic. All of these issues, if appropriately investigated, are relevant to sudden death investigations. If investigators uncover evidence of previous issues, which could have causal links to the death, these should not be disregarded. Rather, they ought to inquire about them and question whether any such evidence suggests suicide is more or less probable as a cause of death. Despite the fact a Board of Inquiry or Summary Investigation will also address these issues, they are relevant to the police investigation to help rule out the possibility of foul play.

242. In this case, the investigators obtained information about a number of issues the MPPTP states should not be pursued or reported on, including: several previous suicide attempts;^{Footnote 1187}diagnoses made on several occasions of different mental health disorders, including possible PTSD;^{Footnote 1188} a recent separation from his common-law spouse;^{Footnote 1189} a failed drug test for cocaine;^{Footnote 1190} and a reported history of heavy drinking.^{Footnote 1191} MCpl Ritco suggested this section of the policy was inapplicable as he was investigating a sudden death, not a suspected suicide.^{Footnote 1192} It is perhaps more relevant to say this policy is an artificial limit on an investigation into either a sudden death or a suspected suicide. Evidence related to these issues may suggest a person was suicidal or suicide was a possibility and can be of great assistance in ruling out foul play as an alternative to suicide. In the particular case of Cpl Langridge, it also may have indicated the possibility of culpable negligence on the part of the Regiment in relation to his death.^{Footnote 1193}

243. The issue in this investigation was not that it ranged into “administrative details” about Cpl Langridge’s life, but instead, that this evidence was not used to test and rule out the possibility of foul play in a timely manner.

244. Overall, what is notable in the MPPTP is its failure to provide guidance about the purpose of a sudden death investigation or the rationale for the steps being mandated in light of that purpose. Ultimately, the MPPTP is too brief, provides too little guidance, and some of the guidance it does provide is problematic. The extent to which the Sudden Death Investigation was in accordance with these guidelines offers no useful response to the complaints, but the fact that elements of the guideline were not followed is also not itself a relevant criticism.

A new protocol: CFNIS SOP 237

245. Subsequent to the conclusion of the investigation into Cpl Langridge’s sudden death, the CFNIS introduced CFNIS SOP 237 (“Sudden death investigation & next of kin briefings”),^{Footnote 1194} a new SOP, which now supplements the existing MPPTP. It appears both the MPPTP and CFNIS SOP were in force as of the end of this hearing. In many ways the SOP is useful to fill in gaps in the MPPTP, but some classification and definitional problems remain, and at least one of its instructions conflicts with the MPPTP with no explanation or guidance given on how the conflict is to be resolved. As with the MPPTP, there is still no statement of purpose outlining the ultimate goal or goals of a sudden death investigation. The new SOP begins by stating, “All suspicious deaths will be handled [in accordance with] the same stringent standard as a sudden death until determined otherwise by the investigative process.”^{Footnote 1195}

246. The SOP then classifies deaths in four ways, (as opposed to the three categories in the MPPTP): homicide, suicide, accidental (motor vehicle accidents or industrial), and natural.^{Footnote 1196} It cautions investigators, “Do not make assumptions or lose evidence based on misconceptions and inexperience.”^{Footnote 1197}

247. The general meaning of this direction is clear. Investigators are to be cautious in making assumptions and slow to take steps that might compromise the integrity or the availability of evidence. It is difficult to quarrel with such advice as a guiding principle. If applied too literally, however, the result can be paralyzing and counterproductive.

248. In the case of the 2008 Investigation, the investigative approach taken was in literal compliance with the direction. MCpl Ritco and his case manager had little if any experience in sudden death investigation. They were careful not to lose any item that might perhaps at some point hypothetically become evidence. They kept an “open mind” to a fault, refusing to entertain any assumption about suicide despite an overwhelming accumulation of evidence pointing in that direction.

The respective roles of the CFNIS and coroners according to the SOP

249. The SOP addresses the relationship between the CFNIS and the ME or coroner in a sudden death investigation, stating the coroner usually determines the cause of death (e.g., “asphyxiation”) while the police determine the manner of death “through investigative steps such as interviews, canvassing, scene processing, autopsy results or lab submissions.”^{Footnote 1198}

250. The section does not differentiate between investigations of criminal or suspicious deaths and investigations of non-suspicious deaths in terms of its application. Evidence before this Commission suggests best practices mandate different divisions of responsibility between police and coroners for different death scenes.

251. The distinction set out in the section between “cause of death” and “manner of death” in terms of the respective legal jurisdiction assigned to coroners and police remains vague despite the illustrations cited as to how the police carry out their role. The notion the categories cited result in different roles is especially problematic in jurisdictions like Alberta where the Fatality Inquiries Act directs MEs are to determine, “(d) the cause of death, and (e) the manner of death.”^{Footnote 1199}

252. The SOP does attempt to offer direction with respect to the legal jurisdiction of police and coroners (or MEs). Paragraph 10 first cautions investigators to be aware of their authority at death scenes, adding, “Each region [Detachment] must consult their respective Provincial Coroner’s Act or relevant statute to ensure that their practices are congruent with Provincial requirements.”^{Footnote 1200} And continues, “Where there is no suspicion of foul play, you are generally permitted to act under the authority of the respective Province’s Coroners Act.”^{Footnote 1201}

253. These instructions require some qualification.

254. Evidence before this Commission suggests the CFNIS may not, in fact, have a well-defined legal relationship with the ME or coroner of a jurisdiction. MWO Watson and Maj Frei both testified the MP are not recognized under provincial Police Acts,^{Footnote 1202} putting in question their authority under the provincial Coroners’ Acts. Maj Frei testified the CFNIS consequently did not have a formalized relationship with the coroners and MEs and required better coordination with these officials in order to understand the ME’s or coroner’s needs for an investigation.^{Footnote 1203}

255. MP members do not appear to be authorized to act as ME Investigators under the Alberta Fatality Inquiries Act^{Footnote 1204} or to exercise similar powers under the other provincial Acts. In addition, both Ontario^{Footnote 1205} and Alberta^{Footnote 1206} require authorization from the coroner and ME respectively to do so. In the absence of formalized recognition as a police service within the meaning of provincial legislation, the CFNIS is unlikely to have the lawful ability to act.

256. The Commission heard no evidence and there were no submissions from the parties regarding any steps taken by CFNIS WR to ensure its practices are congruent with provincial requirements.

Guidance as to actions and responses at a death scene

257. The SOP goes on to detail appropriate responses and actions for CFNIS members upon arriving at a death scene. It directs investigators to:

isolate person(s) who may have knowledge of the death and request a formal interview;
request Forensic Identification services from the local police force if not readily available within CFNIS;
conduct in-person canvasses of the area; and
attempt to establish a timeline of the deceased’s movements and activities prior to the death and the subsequent response.^{Footnote 1207}

258. These directions echo expert evidence before this Commission.^{Footnote 1208}

259. Other aspects of the SOP appear more problematic. The SOP directs, “investigators must refrain from making any remarks speculating as to the cause or manner of death to the public, other professionals involved in the investigative process or other MP.”^{Footnote 1209} It also states, “Do not make assumptions in your notebook such as “I believe it is suicide” at the preliminary stages of the investigative process. Remember the investigative conclusion is at the end of the investigation.”^{Footnote 1210}

260. These directions are likely related to concerns about the possible impact on an eventual prosecution of speculative statements made by the investigators, in the event the speculation turns out to be wrong. It is understandable the CFNIS would have concerns about such early opinions being used in the context of eventual criminal proceedings to cast doubt on the subsequent investigative work having resulted in the prosecution. However, these concerns are best addressed by requiring members to identify their initial thoughts or hypotheses as such in their notes or conversations and document thoroughly any changes in those hypotheses or in the orientation of the investigation and the reasons for those changes.

261. Requiring the investigators to refrain from expressing, discussing or documenting any preliminary hypotheses about the suspected cause of death, as the current SOP does, could have negative consequences for the investigation. While there is value in having investigators approach a death scene with an open mind, there appears also to be value in having them collaborate with colleagues.

262. S/Sgt Clark testified the police may call in an ME for an opinion when they are conducting a sudden death investigation.^{Footnote 1211} It would seem counterproductive if investigators were not permitted to discuss the suspected cause of death with that ME. The ME may help to support or refute investigators’ initial impressions, or clarify any questions or concerns. The ME may also discern evidence from a body, which a police investigator may not, and may then alert the investigator to issues not otherwise apparent to her or him. While the focus should still be on thorough, dispassionate processing of the death scene, communication among and between investigators and MEs should help to ensure nothing is missed.

263. Also problematic on the basis of the Sudden Death Investigation in this case is the direction to investigators to remember conclusions come at the end of the investigation. While, in one sense, the statement is straightforward, namely an investigative conclusion marks the end of the investigation, it is also capable of a different, less straightforward interpretation, namely, conclusions can only be reached when an investigation comes to an end. Insofar as this might imply investigators should hold off coming to conclusions until every aspect of the investigation is finished, it might lead to an approach like that of the investigators in this case, resolutely holding off on drawing any conclusions until every possible investigative avenue had been exhausted and every step had been completed. That is not a reasonable approach. The evidence of the police panel members was clear. Investigators should be flexible and open-minded in their approach but must also exercise their judgment and form and test hypotheses in the course of the investigation.^{Footnote 1212}

264. The SOP does provide other useful directions regarding steps and issues to be addressed in the course of a sudden death investigation with resonance for the current case. It directs investigators to inquire into the circumstances of the reporting of the death, including identifying who called emergency services and why, and obtaining a record or recording of any such call. It instructs investigators to determine if a scene has been disturbed, and if so, how, including identifying any persons who responded to the scene and what actions they took at the scene. Investigators are directed to attempt to identify who last saw the deceased alive, where, and under what circumstances. They are further directed to identify whether the injuries and position of the body are consistent with the other purported facts at the scene.^{Footnote 1213} These directions are consistent with the expert evidence before this Commission as to best practices.^{Footnote 1214}

265. Like the MPPTP, the SOP states, “the investigation into attempted suicide or suicide should focus on determining that the wounds to the subject were in fact, self-inflicted.”^{Footnote 1215} Significantly, the SOP adds the instruction to investigators to “gain a comprehensive understanding of the background of the deceased, including medical and psychological state (medication or alcohol consumption).”^{Footnote 1216}

266. This instruction seems flatly contrary to what the MPPTP says about not pursuing such issues. In his testimony, MWO Watson agreed the MPPTP and the CFNIS SOP are contradictory on this point. When asked how he would resolve the contradiction, he stated he would refer to the more recent policy.^{Footnote 1217} While there is logical merit to this approach, it should be noted, strictly speaking, there is nothing in the MPPTP or CFNIS SOP on which to base a resolution to the conflicting instructions. The expert evidence before this Commission confirms the CFNIS SOP offers the better guide to investigating sudden deaths. However, the MPPTP still remains in force, making it desirable for steps to be taken to align the two.

267. The SOP goes on to provide direction to investigators in conducting interviews of a deceased’s family members, stating, “It is sometimes necessary to interview the family of a CF member days or weeks following a sudden death.”^{Footnote 1218}

268. Where deaths are not suspicious, investigators are instructed to advise the family’s AO, who can then “mobilize support mechanisms such as a Padre to be made available should the family member require such support after the CFNIS investigator has completed the interview.”^{Footnote 1219} This direction is relevant in terms of issues arising from the contacts between the CFNIS and the Fynes in this case.^{Footnote 1220}

269. While the SOP still lacks a clear articulation of the purpose and goals of a sudden death investigation to help investigators to contextualize the instructions it contains, based on the history of the 2008 Sudden Death Investigation and the expert evidence before this Commission, it represents a helpful improvement over the MPPTP.

270. The Commission considers it essential for future sudden death investigations to have clear policy statements and directives. To achieve such an outcome, both the CFNIS SOP and the MPPTP should be reviewed thoroughly and harmonized to the extent possible. Consideration should also be given to revise the SOP to articulate, in a clear manner, the goals and purposes of a sudden death investigation.

4.1.2 Investigating Negligence

Allegations

271. The complainants allege the 2008 Sudden Death Investigation was inadequate with respect to the question of whether possible CF negligence played a role in or was responsible for Cpl Langridge’s death. The complainants allege the CFNIS members did not properly identify the issues to be investigated and did not investigate issues that presented themselves or were specifically brought to the attention of CFNIS members by the complainants.^{Footnote 1221} Mrs. Fynes told CFNIS members she believed Cpl Langridge had not been provided adequate medical care by either the CF or the civilian medical system, and the CF inappropriately ordered Cpl Langridge to leave the hospital where he was being treated in March 2008 despite his complaints of suicidal intent.^{Footnote 1222} The complainants believe this alleged negligence contributed to Cpl Langridge’s suicide,^{Footnote 1223} and they maintain these issues were not adequately investigated.^{Footnote 1224}

272. The complainants also allege the CFNIS members did not investigate the underlying causes of Cpl Langridge’s death in a complete and unbiased manner. According to the complaint, the CFNIS members were selective in the information they obtained and included in the course of the Sudden Death Investigation, and the selection was neither objective nor impartial.^{Footnote 1225}

273. The complainants further allege the 2008 Sudden Death Investigation was aimed at exonerating the LDSH Regiment chain of command and other members of the LDSH and the CF more generally of any responsibility in Cpl Langridge’s death.^{Footnote 1226}

274. Additionally, they allege the conclusions drawn by the CFNIS members were unreliable because they were based on incomplete facts including numerous unexplored contradictions and discrepancies. In particular, they allege contradictory and inconsistent answers were obtained in the investigation regarding the question of whether a “suicide watch” was planned or conducted by members of the LDSH or base medical personnel prior to Cpl Langridge’s death.^{Footnote 1227} By way of illustration, the complainants assert in their closing submissions:

The outcome of the 2008 investigation was that there was no negligence of the LdSH Chain of Command, but this flies in the face of the fact that the only two persons who were interviewed had a vested interest in the matter. If there had been negligence associated with a suicide watch, both CWO Ross and Capt Hannah would have been involved and implicated in the negligence.

Prior to being investigated, both CWO Ross, and Capt Hannah would have been aware, at least residually, that it was their actions that were being investigated. MCpl Ritco had a duty to probe further in an attempt to corroborate the statements made by both of WO Ross of the LdSH and Capt Hannah. He did not.^{Footnote 1228}

275. The complainants allege the CFNIS failed to investigate in a timely manner the potential criminal or service offences which may have been committed by members of the CF including the LDSH chain of command, prior to Cpl Langridge’s death. According to their complaint, conduct requiring further investigation, follow-up and analysis was not adequately investigated by CFNIS members during the 2008 Sudden Death Investigation.^{Footnote 1229}

276. Finally, the complainants allege the CFNIS investigators failed to investigate potential service offences committed by CF members in the application of (or failure to apply) mandated suicide prevention policies in Cpl Langridge’s case.^{Footnote 1230} According to this complaint, CFNIS investigators failed to investigate what policies were applicable and whether they were followed, or whether a suicide prevention policy existed within the LDSH at the time of Cpl Langridge’s death. In this connection, the complainants also allege the CFNIS members failed to investigate the question of whether the CF was required to conduct a Summary Investigation for each instance of attempted suicide by a member, and whether this was done in Cpl Langridge’s case.^{Footnote 1231}

Response to the Allegations

277. These allegations are categorically rejected by the subjects. With respect to the allegation the investigation into topics such as potential negligence and the suicide watch was inadequately conducted, the subjects’ closing submissions state MCpl Ritco testified he actively pursued the investigation into the existence of a suicide watch at the time of Cpl Langridge’s suicide while he awaited the ME’s report. They note MCpl Ritco testified he was open to the possibility of finding evidence members of the LDSH had been negligent either under the Criminal Code or the Code of Service Discipline.^{Footnote 1232} Moreover, the subjects’ counsel argue WO Tourout “guided” and “supported” MCpl Ritco’s plan to look into the possibility of negligence.^{Footnote 1233}

278. In terms of the scope of the negligence investigation, the subjects argue the investigation was properly limited to the question of whether Cpl Langridge was on the defaulters list and/or under a suicide watch when he died, rather than focused on the question of whether the CF should have conducted such a watch.^{Footnote 1234} They contend this question was not within the mandate of the CFNIS, as there was no evidence of an onus on the CF to initiate a watch under the circumstances.^{Footnote 1235}

279. The closing submissions submit the evidence gathered by MCpl Ritco indicated some efforts had been made to organize a suicide watch for Cpl Langridge in March 2008, but because neither CWO Douglas Ross nor Cpl Langridge had wanted such a watch, no watch was stood up.^{Footnote 1236} They note MCpl Ritco and Sgt Bigelow interviewed witnesses directly involved in developing and implementing the conditions placed on Cpl Langridge and deny the witnesses provided inconsistent or contradictory information.^{Footnote 1237} Instead, the subjects’ counsel contend, in pursuing the question of whether Cpl Langridge was a defaulter or under a suicide watch when he died, MCpl Ritco and Sgt Bigelow learned:

This watch was organized at the request of the base hospital, in case it came to the point where Cpl Langridge needed constant supervision.

Senior members of the LdSH did not believe that Cpl Langridge was on a suicide watch or defaulters at the time he died.

The conditions in place at the time Cpl Langridge passed were for structure and Cpl Langridge agreed to them.

On March 14, 2008, the day before he died, Cpl Langridge attended at the medical unit to refill his prescription and was not documented as having any problems.^{Footnote 1238}

280. In the subjects’ view, once the CFNIS had evidence Cpl Langridge was living under conditions that were not a suicide watch, but rather were imposed for structure, they were able to rule out the possibility of negligence or negligent performance of a military duty.^{Footnote 1239} The subjects’ counsel point out the CFNIS cannot start or continue an investigation without a reasonable suspicion an offence may have been committed.^{Footnote 1240} In light of the conclusion no offence was committed, it was unnecessary for MCpl Ritco to take any further investigative steps. Any issues, such as the purpose of the conditions Cpl Langridge lived under, whether Cpl Langridge agreed to them, and whether or not a plan existed for further treatment, were irrelevant to either a service offence or a criminal investigation. These questions were, in the subjects’ submission, administrative matters for the military to examine.

281. MCpl Ritco testified he never formed a reasonable suspicion negligence was involved in Cpl Langridge’s death.^{Footnote 1241} He also testified he did not see it as his task to determine if there was any reason for someone else to investigate potential negligence.^{Footnote 1242} Instead, his investigation concerned the death of Cpl Langridge. He also testified, throughout the investigation, “nothing came up to tell me that there may have been some negligence [...].”^{Footnote 1243} He testified he was never told in any interviews of LDSH personnel the conditions Cpl Langridge lived under prior to his death were a suicide watch.^{Footnote 1244} He acknowledged receiving inconsistent information in response to various questions. This made it difficult to reach definitive conclusions concerning what happened during Cpl Langridge’s last weeks,^{Footnote 1245} and the alleged suicide watch.^{Footnote 1246} However, MCpl Ritco testified this inconsistent information did not hinder him from concluding Cpl Langridge’s death was a suicide and closing the investigation.^{Footnote 1247}

282. MCpl Ritco denied he failed to conduct the necessary follow-up and analysis to resolve the contradictions and discrepancies in the information he obtained concerning the suicide watch.^{Footnote 1248} He testified he focused his investigation on ruling out foul play since he was unable to determine whether Cpl Langridge had been subject to a suicide watch.^{Footnote 1249} MCpl Ritco testified he did not feel it was necessary, for example, to follow-up on Mrs. Fynes’ complaint that Cpl Langridge was not provided proper medical care by either the military or civilian medical systems. He kept this information “in the back of my mind” but felt it did not have a great deal of relevance.^{Footnote 1250} MCpl Ritco said this was because he believed, when he spoke to Mrs. Fynes, what he was tasked with investigating was whether Cpl Langridge died as a result of foul play.^{Footnote 1251}

283. Sgt Bigelow testified it would not have been the role of the CFNIS to investigate the suicide prevention policies in place within the LDSH at the time of Cpl Langridge’s death. It was his view the CFNIS investigates possible criminal offences, and not the policies that were or were not in place.^{Footnote 1252} He agreed, in some circumstances (such as where they were considering service offences against any individuals), investigators would look into the question of whether the policies were followed, but stated a BOI would be the more appropriate means of examining the existence and adequacy of any suicide prevention policies in place as a part of its inquiries concerning administrative processes. He also testified he was not involved in any investigation of whether the suicide prevention policies were being followed or what those policies stated.^{Footnote 1253}

284. With respect to the allegation the CFNIS failed to investigate potential criminal or service offences committed by CF members prior to Cpl Langridge’s death, WO Tourout, MCpl Ritco’s case manager during the 2008 Sudden Death Investigation, testified MCpl Ritco’s work on that file was “investigatively sound.” ^{Footnote 1254} It was WO Tourout’s view MCpl Ritco did the best job he could with the information available to him at the time.

285. MCpl Ritco disagreed with the allegation he was selective in the information he obtained and included in the investigation. He testified he attempted to gather as much information as possible “to prove without a shadow of a doubt that Cpl Langridge did commit suicide and there was no foul play.”^{Footnote 1255} He testified the CFNIS takes pride in conducting thorough investigations, and its investigators work as long as necessary. He also denied his investigation was intended to exonerate the CF of responsibility in Cpl Langridge’s death or to attack Cpl Langridge’s character.^{Footnote 1256} MCpl Ritco appeared to believe the evidence spoke for itself. He testified his investigation revealed Cpl Langridge was a troubled man dealing with many personal issues, who had attempted suicide in the past, had been in and out of hospitals, may have been on a suicide watch, may have been given conditions for structure, and who ultimately killed himself in his room.^{Footnote 1257}

286. Sgt Bigelow categorically denied the allegation the CFNIS did not investigate Cpl Langridge’s death in a complete and unbiased manner and the allegation CFNIS members were predisposed to exonerate the LDSH and the CF of responsibility in his death. According to Sgt Bigelow, if the information he and MCpl Ritco acquired during the 2008 Sudden Death Investigation led them to believe any service offences had been committed by LDSH members, “we would have gone after them, no doubts or questions at all.”^{Footnote 1258}

Negligence and the Suicide Watch

What was done to investigate potential negligence?

287. MCpl Ritco’s Investigation Plan (IP) appears to identify two questions about potential negligence to be investigated in connection with Cpl Langridge’s death:

2. was Cpl Langridge on ‘suicide watch’ or ‘defaulters’; (completed)

[…]

13. possible negligent actions on behalf of CF, resulting in possible involvement in death (completed)^{Footnote 1259}

288. In the hours following Cpl Langridge’s death, it was suggested to MP and CFNIS members he had been under a suicide watch.^{Footnote 1260} After this, the existence of a suicide watch became a central topic in the Investigation Plan and in the interviews conducted by MCpl Ritco.^{Footnote 1261} While the IP identified the potential suicide watch and “possible negligent action” related to Cpl Langridge’s death as separate items, in the investigator’s view, this was not to be a comprehensive investigation into potential negligence.^{Footnote 1262} This meant setting aside nearly any examination of Cpl Langridge’s last weeks and days, which would have determined whether or not criminal negligence or negligent performance of duty may have contributed to his death. Instead, the investigation was very narrowly defined.^{Footnote 1263} To the extent the matter of negligence was pursued, the CFNIS investigators were focused on the question of a suicide watch.^{Footnote 1264} In this view, it was only if Cpl Langridge was, in fact, subject to a suicide watch and still able to commit suicide that further investigation into negligence would have been necessary.^{Footnote 1265}

289. Asked how he pursued the question of CF negligence, MCpl Ritco testified he merely included an entry about possible CF negligence in his investigation plan as a “reminder” to himself to investigate potential acts of negligence (or have someone else investigate it) if any evidence of it surfaced during the investigation.^{Footnote 1266} According to MCpl Ritco, had some evidence arisen suggesting a service offence may have contributed to Cpl Langridge’s death, he or someone else would have investigated it.^{Footnote 1267} He testified he did not consciously bring the question of service offences to the foreground during the investigation. Rather, MCpl Ritco explained, as with other matters left unconsidered in the 2008 Sudden Death Investigation, he was “[…] keep[ing] my mind wide open. I’m not narrowing in on one thing or the other. I’m – if something comes up where it piques my interest or it’s part of the investigation, yeah, I’ll explore it. But nothing came up.”^{Footnote 1268}

290. WO Tourout, his case manager, testified, although the possibility of negligence arose early in the investigation, it did so only because of rumours of a suicide watch.^{Footnote 1269} In fact, WO Tourout testified that after March 16, 2008, the majority of the investigative activity in the 2008 Sudden Death Investigation concerned the alleged suicide watch.^{Footnote 1270} However, he testified that because MCpl Ritco ultimately concluded a suicide watch had not occurred, there was no need to investigate possible negligence.^{Footnote 1271} He did not believe it was necessary to investigate any other potential negligent acts.^{Footnote 1272} WO Tourout testified he saw questions like, “should there have been a suicide watch?” to be the domain of a BOI.^{Footnote 1273} In fact, WO Tourout testified negligence was not given any particular attention in the investigation.^{Footnote 1274}

291. MWO Watson also testified the threshold for launching a negligence investigation would have been evidence Cpl Langridge was on a suicide watch or evidence medical authorities had recommended a suicide watch before he killed himself.^{Footnote 1275} He also testified, absent such evidence of a suicide watch, he saw no need to investigate any other possible negligence by the Regiment or the potential influence the conditions Cpl Langridge lived under might have had in his decision to commit suicide.^{Footnote 1276} To do otherwise would have been to conduct “a witch hunt.”^{Footnote 1277}

292. In the course of a number of interviews with LDSH personnel and other CF members, MCpl Ritco asked a number of questions aimed at determining whether Cpl Langridge was the subject of a suicide watch at the time of his death. These included the interviews with Unit adjutant Capt Lubiniecki, Sgt Hiscock, Cpl Hurlburt, MCpl Bowden, MCpl William Fitzpatrick, Cpl Rohmer, Unit RSM CWO Ross, and Acting Base Surgeon Capt Hannah. He testified he compiled his list of witnesses based on the information he amassed between the date of Cpl Langridge’s death on Saturday, March 15, 2008, and Monday, March 17, 2008. He testified the witnesses were selected based on “who I wanted to go interview or potentially could interview or see or speak with or what I had to gain, it's just a thought process.”^{Footnote 1278}

Interview with Capt Lubiniecki

293. Capt Lubiniecki was interviewed on March 17, 2008. Notes of the conversation were taken by Sgt Bigelow,^{Footnote 1279} and he typed a more detailed account of the interview based on these notes and his own recollection into SAMPIS a day later^{Footnote 1280} – possibly with assistance about some details from MCpl Ritco.^{Footnote 1281} Regrettably, because the interview was not recorded, there is no transcript.

294. On the day of Cpl Langridge’s death, the investigators learned Cpl Langridge had failed to report in at the expected time, and he may have been under a suicide watch or defaulters when he died,^{Footnote 1282} but the evidence suggests it was during Capt Lubiniecki’s interview the investigators became aware Cpl Langridge was living under a set of conditions put in place by members of the LDSH chain of command when he died.^{Footnote 1283} Capt Lubiniecki stated Cpl Langridge was neither on defaulters nor on a suicide watch, and provided them with a copy of the list of conditions:

Cpl Langridge Will Wear uniform during normal duty hours and perform duties as directed by the RSM.
A Normal Work Day will be from Mon-Fri. 0800-1630 daily. Weekends will be free unless otherwise directed By the RSM
He will have freedom of movement with the following restrictions:
1. He will live in the Reg [Regimental] Duty Center, bedded in the defaulter’s room.
2. At no time will his door be closed.
3. He will have a curfew [of] 2100 hrs daily.
4. He will report to the Duty Officer every two hours on the hour daily.
5. There will be no escorts required except under the following conditions:
  1. He will, when required to attend any and all appointments given to him by his health care providers, do so under escort.
  2. If he chooses to attend AA Meetings he will be escorted to and from the meeting area. The escort(s) will not attend the meetings with him.
6. All prescribed medication will be held by the Duty Officer. It is still the member’s responsibility to take the prescribed dosage at the appropriate times.
7. When he leaves the confines of the Harvey Bldg he will inform the Duty Officer of where he is going and a contact phone number. Para C and D still apply.^{Footnote 1284}

295. Sgt Bigelow’s police notebook indicates Capt Lubiniecki explained to the CFNIS investigators Cpl Langridge made two previous suicide attempts before March 2008.^{Footnote 1285} The first was in the summer of 2007, when he was found intoxicated and making preparations to asphyxiate himself with carbon monoxide piped into his running Jeep. The second attempt was in February 2008 while he was a patient at a mental health facility.^{Footnote 1286} Capt Lubiniecki told the CFNIS investigators Cpl Langridge had been admitted to a drug rehabilitation program after his first suicide attempt but discharged himself shortly thereafter. The second attempt was described in SAMPIS as having taken place while Cpl Langridge was “in a mental hospital in Edmonton,” and this was made known to Capt Lubiniecki by the padre.^{Footnote 1287} Capt Lubiniecki added that in February 2008, Cpl Langridge admitted himself to the “Alberta Health Centre” (AHE) for thirty days. According to Sgt Bigelow’s notes of the interview, Cpl Langridge was scheduled to go to a rehabilitation clinic in Ontario following his thirty days of hospitalization.^{Footnote 1288} However, his request to attend was ultimately denied by the military medical community, which the written notes stated did not support sending him. This was due to missing “a couple” of AA meetings^{Footnote 1289} and Cpl Langridge’s lack of conviction at Edgewood,^{Footnote 1290} as well as the cost of the program.^{Footnote 1291} The more detailed SAMPIS entry indicates he informed the investigators the cost to attend would have been $50,000.^{Footnote 1292}

296. According to Sgt Bigelow’s SAMPIS entry, Capt Lubiniecki told the investigators, instead of attending the residential substance abuse treatment program, “Cpl LANGRIDGE was then turned over to the LDSH, where the RSM and Adj compiled a schedule of tasks that Cpl LANGRIDGE would have to adhere to, as he indicated he would like to forge forward and become more committed as a soldier.”^{Footnote 1293} Capt Lubiniecki is noted as stating Cpl Langridge was neither under a suicide watch nor part of the defaulters’ parade, but was under the conditions in order to demonstrate he was “more committed to changing his ways.”^{Footnote 1294} According to the SAMPIS entry, Cpl Langridge complied with the conditions and “went without incident” until March 12, 2008.^{Footnote 1295} At that time, the interview account reports, Cpl Langridge admitted himself to the Royal Alexandra Hospital for approximately forty-eight hours (this series of events in fact took place on March 11, 2008).

Interview with Cpl Rohmer

297. During his interview with MCpl Ritco on March 18, 2008, Cpl Rohmer, a long-time friend of Cpl Langridge, provided extensive details about a 2007 suicide attempt by Cpl Langridge, to which he and another of Cpl Langridge’s friends, Cpl Jason Hillier, had been witnesses. Cpl Rohmer informed MCpl Ritco that Cpl Hillier notified the LDSH of the suicide attempt.^{Footnote 1296}

298. Perhaps more significantly, Cpl Rohmer also discussed watches conducted or proposed for Cpl Langridge by the LDSH. He alleged one or more members of the LDSH chain of command requested he and Cpl Hillier stay with Cpl Langridge in hospital to “watch” him following the June 2007 suicide attempt. Cpl Rohmer stated Cpl Hillier was in regular contact with the Regiment during this time.^{Footnote 1297} Cpl Rohmer also told MCpl Ritco he heard a suicide watch was planned a week prior to Cpl Langridge’s death, although he was unaware whether it was ultimately carried out.^{Footnote 1298} He did not believe it was, because the check-ins and conditions Cpl Langridge lived under in his last days did not meet his understanding of a suicide watch, which he felt required direct, 24-hour monitoring.^{Footnote 1299}

299. When asked by MCpl Ritco, Cpl Rohmer expressed his opinion Cpl Langridge should have been watched before his death:

I'm kind of iffy if it's out of line, if it's bad for them, I don't know, but I want to know if the Regiment knew his condition, knew he was suicidal when he wasn't being watched, you know.

[...] I know now after talking and hearing that he had two-hour check-in times, I guess, but the Regiment knew all about all of his – I don’t know about all of his problems, but they knew that he had tried to kill himself. They knew that he had alcohol and drug problems.

And, you know, I -- I think -- this is just me finally getting up, like asking the question. Like I don't -- 'cause like why wasn't he being watched?^{Footnote 1300}

300. MCpl Ritco asked for clarification from Cpl Rohmer, clearly comprehending Cpl Rohmer was alleging the assistance provided was inadequate and asking him if he believed the LDSH could have done more because they knew he was suicidal. Cpl Rohmer confirmed this, concluding “two hours is a lot of time” to allow between check-ins and indicating a constant watch was necessary in order to “protect him from himself.”^{Footnote 1301}

Interview with Sgt Hiscock

301. MCpl Ritco and Sgt Bigelow interviewed Sgt Hiscock on March 18, 2008.^{Footnote 1302} Sgt Hiscock was the NCO assigned to the duty desk at the LDSH HQ building on March 15, 2008. One of his responsibilities was to monitor Cpl Langridge. He was on duty when Cpl Langridge died.^{Footnote 1303} Sgt Hiscock informed MCpl Ritco he relieved the outgoing duty officer the morning of Cpl Langridge’s death. The duty officer briefed him about Cpl Langridge and his conditions. Sgt Hiscock was told he was to be conducting a “suicide watch” on March 15, 2008, by either the off-going duty officer or by MCpl Fitzpatrick.^{Footnote 1304} He added that, in his opinion, what was in place was not a suicide watch; he had conducted suicide watches in the past, and those on the watch would never leave the person being watched alone. Cpl Langridge was allowed up to two hours on his own without having to report in to the duty staff.^{Footnote 1305}

302. Sgt Hiscock wavered as to the nature and purpose of the conditions. He understood the reason for monitoring Cpl Langridge related to the knowledge of his mental health problems and recent release from hospital.^{Footnote 1306} He believed the conditions had to do with providing Cpl Langridge with structure in the hope this would help him deal with his issues, but also stated this seemed “strange.”^{Footnote 1307} “[…] I should have asked a lot more questions. I should have got a lot more information, but -- I don't know. I guess it was a suicide watch, but it wasn't really a suicide watch.”^{Footnote 1308} This ambiguity may have been a consequence of a meeting he had with CWO Ross, the Regimental Sergeant Major, the day before his interview. Contrary to what Sgt Hiscock recalled having been told about the suicide watch when he spoke to the MP on the day of the suicide, CWO Ross told him Cpl Langridge was not under suicide watch, and the conditions were meant to provide Cpl Langridge with structure while also maintaining his dignity.^{Footnote 1309} Sgt Hiscock told MCpl Ritco, if the chain of command truly believed Cpl Langridge were suicidal, “these restrictions would have been vastly -- a lot more robust.”^{Footnote 1310} MCpl Ritco was left with unanswered questions about the purpose of the conditions and whether or not they were meant as a form of suicide watch.

Interview with Cpl Hurlburt

303. Cpl Hurlburt was aware of previous suicide watches in the military. During a March 19, 2008, interview, he told MCpl Ritco he took part in a suicide watch on the base when he first arrived and described his understanding of it as keeping a 24-hour watch to ensure the individual in question did not harm themselves.^{Footnote 1311} More importantly, Cpl Hurlburt told MCpl Ritco he had heard he was going to be part of a suicide watch team approximately one week prior to Cpl Langridge’s death.^{Footnote 1312} He was contacted by MCpl Bowden, who informed him she was organizing a suicide watch. The proposed suicide watch came about after Cpl Langridge “was at the CDU [Care Delivery Unit] and he freaked out and said he was gonna kill himself or something.”^{Footnote 1313} Cpl Hurlburt and a few other squadron members stood ready for suicide watch duty, but he was later notified this would not be necessary. Cpl Hurlburt knew little about Cpl Langridge’s situation after that, except some of the conditions Cpl Langridge had to live under.^{Footnote 1314} At this point in the interview, MCpl Ritco asked Cpl Hurlburt, “Would you not say that was a suicide watch?” and Cpl Hurlburt agreed Cpl Langridge was subject to a suicide watch on March 15, 2008.^{Footnote 1315}

304. Cpl Hurlburt said some troopers in the squadron office with him the day the watch was planned used the term “suicide watch” as did MCpl Bowden. It appeared Cpl Langridge’s distress was common knowledge among these CF members, who informed him about Cpl Langridge having “freaked out” at the CDU.^{Footnote 1316} Cpl Hurlburt also told MCpl Ritco, Cpl Langridge had recently been the topic of gossip within the Regiment regarding his previous suicide attempts and his substance abuse problems.^{Footnote 1317} MCpl Ritco asked Cpl Hurlburt if he recalled the names of any of the people who spoke with him, or who were to conduct the suicide watch with him, but he said there were too many new names and faces in the Regiment for him to recall.^{Footnote 1318}

Interview with MCpl Fitzpatrick

305. In his interview, MCpl Fitzpatrick stated he was contacted by MWO Kevin Mulhern, the HQ Sergeant-Major, to set up a guard list for a pre-emptive suicide watch following Cpl Langridge’s discharge from the AHE.^{Footnote 1319} The order had come down from CWO Ross. Cpl Langridge had just been released, and no one had been briefed on his condition. A list was being set up in the event a suicide watch was needed. MCpl Fitzpatrick recalled either CWO Ross or MWO Mulhern telling him Cpl Langridge “will not leave your eyesight.”^{Footnote 1320} MCpl Fitzpatrick asked MCpl Bowden to create a list of members available for the watch. She replied with an email entitled, “Here is the suicide watch list.”^{Footnote 1321} MCpl Fitzpatrick recalled printing the email, but he informed MCpl Ritco he consciously deleted the word “suicide” from the document before doing so, as he feared someone might take offence to the term “suicide watch.”

306. Shortly thereafter, MCpl Fitzpatrick was out of his office when Cpl Langridge found the email or, apparently, a different version of the same message. MCpl Fitzpatrick claimed “… somehow the e-mail got printed again without that word being deleted -- right -- and he seen it on my desk, because somebody else must have printed it and put it on my desk.”^{Footnote 1322} MCpl Fitzpatrick told MCpl Ritco and MS McLaughlin (who took notes), while he had no idea how this happened, he suspected Cpl Langridge saw the email on his computer and printed it again.^{Footnote 1323} Cpl Langridge was apparently very upset about the watch and, when he saw CWO Ross walk by, he called him into MCpl Fitzpatrick’s office where he showed him the email. CWO Ross was livid and when MCpl Fitzpatrick returned, he was told to find MCpl Bowden. She was brought to MCpl Fitzpatrick’s office, and MCpl Fitzpatrick heard CWO Ross tell her to “‘Go to my office, and fuckin’ take a seat, and I’ll be there’” before tearing up the email.^{Footnote 1324} MCpl Fitzpatrick added he was called by MWO Mulhern approximately twenty minutes later and told to “[s]tand down on the guard. There is no guard.”^{Footnote 1325} He was told all the duty staff were to do was ensure Cpl Langridge took his medication properly. MCpl Fitzpatrick told MCpl Ritco all of the materials he possessed related to the watch list were shredded.^{Footnote 1326}

Interview with MCpl Bowden

307. On May 5, 2008, MCpl Ritco interviewed MCpl Bowden about largely the same topics MCpl Fitzpatrick discussed. She was certain, even before the interview started, he would want to know about the suicide watch list.^{Footnote 1327} In her account of the watch list episode, Cpl Bowden told MCpl Ritco she was in her office approximately one week prior to Cpl Langridge’s death (likely Friday, March 7, 2008)^{Footnote 1328} when MCpl Fitzpatrick came in and stated, “‘I need a list of people who can do a watch on Langridge for suicide.’”^{Footnote 1329} MCpl Fitzpatrick asked her to send him an email with the names and contact numbers of members available to conduct the watch. MCpl Bowden canvassed the availability of the members of her squad and then compiled the list in an email and sent it to MCpl Fitzpatrick. In contrast to MCpl Fitzpatrick’s description of the format of the email message, MCpl Bowden told MCpl Ritco she would only have used the word “watch” as a subject heading or title, and certainly not “suicide watch,” if she even used a heading or title at all.^{Footnote 1330} The term “suicide” would only have appeared in the body of the message rather than as a prominent heading.

308. MCpl Bowden indicated when she spoke with CWO Ross, he asked her who had authorized her to use the word “suicide.” She answered that no one had given her authority.^{Footnote 1331} She was aware other suicide watches had been conducted, and, from her perspective, the word “suicide” had been used when she was first asked by MCpl Fitzpatrick to compile the list.^{Footnote 1332} CWO Ross told her “[a]t no point did I authorize Master Corporal Fitzpatrick to use the word 'suicide.’”^{Footnote 1333} CWO Ross ripped up the printed suicide watch email in front of her.^{Footnote 1334}

309. MCpl Bowden told MCpl Ritco that MCpl Fitzpatrick subsequently gave her the official word the watch was cancelled.^{Footnote 1335} She believed there was already someone watching Cpl Langridge at the time the watch was cancelled.^{Footnote 1336} MCpl Bowden also stated she and “the whole Regiment” were aware Cpl Langridge had attempted suicide before and had been hospitalized as a consequence.^{Footnote 1337} Soldiers would periodically be sent to the hospital to visit him.^{Footnote 1338} She was also aware of two previous suicide attempts by Cpl Langridge and stated Cpl Langridge had been put under watches in the past.^{Footnote 1339}

310. At the end of the interview with MCpl Bowden, MCpl Ritco commented he was receiving conflicting information about the nature of the watch and where it came from.^{Footnote 1340} For that reason, MCpl Ritco testified he interviewed CWO Ross to “put to bed” the issue of a suicide watch.^{Footnote 1341}

Interview with CWO Ross

311. CWO Ross was the RSM and responsible for discipline within the LDSH. During his interview on May 23, 2008, he told MCpl Ritco a “24-hour, 7-day-a-week watch” was initially organized for Cpl Langridge in March 2008 in case it needed to be put into action.^{Footnote 1342} He asked MCpl Fitzpatrick to put together a list of names for such a watch after clinical staff from the base clinic called him to ask for assistance in supervising Cpl Langridge. He explained it was initially unclear what Cpl Langridge’s circumstances were, how much freedom he would have and what the Regiment’s responsibilities might be. CWO Ross stated the abortive watch “[…] wasn’t considered or called, from me, a ‘suicide watch’; that wasn’t the purpose of it.”^{Footnote 1343} CWO Ross asserted he lacked the legal authority to impose such a watch, explaining the Regiment could have only “legally” put Cpl Langridge under a “24-hour, 7-day watch” if the “medical system” informed him Cpl Langridge was suicidal.^{Footnote 1344}

312. CWO Ross asserted it was MCpl Bowden’s mistake to call it a suicide watch, due to some miscommunication. CWO Ross advised MCpl Ritco that when a distraught Cpl Langridge approached him and showed him MCpl Bowden’s email about the watch, Cpl Langridge was the one who ripped it up. CWO Ross told him “‘[t]his is not what this is all about.’”^{Footnote 1345} CWO Ross also denied being aware of Cpl Langridge’s medical circumstances beyond addiction problems and having gone to the hospital frequently, “and that he was suffering with some sort of PTSD.”^{Footnote 1346} He denied knowing anything about Cpl Langridge’s background or current situation.

313. CWO Ross talked to Cpl Langridge’s addictions counsellor and the base surgeon to better understand the situation. To him, it became apparent “[…] this guy is not being a soldier. He needs to have some structure in his life. We can provide that for him.”^{Footnote 1347} Accordingly, on March 7, 2008, he put together a list of conditions he felt would assist Cpl Langridge and sought input by email from the base surgeon as to any medical requirements to add to the list.^{Footnote 1348} Capt Hannah replied on March 7, 2008, with a set of medical employment limitations requiring Cpl Langridge to abstain completely from alcohol and drugs not prescribed by a physician, to comply with the treatment plan including remaining under the supervision of the LDSH, and to attend all scheduled appointments directed by the medical service.^{Footnote 1349} CWO Ross incorporated these limitations into the measures he had in mind and they became part of the conditions,^{Footnote 1350} in addition to those quoted earlier. He privately explained them as a whole to Cpl Langridge.^{Footnote 1351} CWO Ross told MCpl Ritco the conditions allowed Cpl Langridge some freedom, but also:

[…] structure from a day-to-day sort of routine. Put him back in uniform, so he started acting like a soldier, not wearing civilians all the time. Getting certain things that he had to do throughout the day, and then we also provided him the opportunity, if he wished to go to one of his local meetings, addiction meetings and all that, ‘We’ll drive you there. We’ll drive you there, you call us when you’re done, we’ll come back and get you.’

So that’s the sort of latitude that we offered him. […] But here’s the medical side of the house, you’re not allowed to drink alcohol, you’re not allowed to take prescription drugs without the doctor’s consent […] or take any sort of medication without a doctor’s consent.^{Footnote 1352}

314. CWO Ross stated the Regiment watched Cpl Langridge as best they could.^{Footnote 1353} The conditions were seen as a means of helping Cpl Langridge out as best as the Regiment could, based on both “medical suggestions” and what “we felt we were legally obligated to do […].”^{Footnote 1354} CWO Ross informed MCpl Ritco the purpose of the conditions was solely to help Cpl Langridge gain the structure necessary for him to go to treatment.^{Footnote 1355}

315. According to CWO Ross, Cpl Langridge was required to come physically to the duty centre, report in, and essentially say, “Here I am. I’m still good to go.”^{Footnote 1356} This way, the Regiment would know “that there was nothing wrong, he wasn’t hurt or anything.” His curfew was to ensure he would not be going outside the building past a certain point, “regardless of what was going on, and that was it. He wasn’t going out any more of that night.”^{Footnote 1357} CWO Ross also informed MCpl Ritco the Regiment did not administer Cpl Langridge’s medication; they simply made sure it was available. Taking it was his responsibility. However, despite the clearly worded condition stating, “At no time will the door [to the defaulter’s room] be closed,” CWO Ross said Cpl Langridge could close the door to have private time. It was entirely up to him, and there were no issues with him doing so.^{Footnote 1358} MCpl Ritco did not inquire about this apparent contradiction.

316. CWO Ross stated there was no set time limit for the conditions. The determining factor would be Cpl Langridge demonstrating he could abide by rules and regulations – that he would do what he was told, keep his appointments, and so on, proving to the medical side he was on track and ready to attend residential substance abuse treatment. It could have taken two weeks, or even a month. He explained Cpl Langridge was required to prove himself before the medical side would spend more money on his treatment.^{Footnote 1359}

317. In terms of the nature of the conditions, Sgt Bigelow asked CWO Ross if the conditions were “set in stone,” as though they were orders. CWO Ross stated they were, and stated a breach of those conditions would “absolutely” be equivalent to a soldier breaching orders from a superior.^{Footnote 1360} If Cpl Langridge failed to return to the duty centre by his 2100 hrs curfew, for example, CWO Ross stated there would probably have been an AWOL charge.

318. CWO Ross told MCpl Ritco, Cpl Langridge had no problems whatsoever when told about the conditions. He was “quite happy with that,”^{Footnote 1361} and said, “‘I need structure. I need somebody to tell me what to do’, and he thanked me for doing that, sitting him down and giving him a straight-nosed talk.”^{Footnote 1362} However, Cpl Langridge soon wanted the imposed conditions relaxed, and his requests were denied. Cpl Langridge first approached Capt Lubiniecki to request greater latitude. Capt Lubiniecki spoke with CWO Ross, who decided to deny the request:

[…] I said no. I think two hours is enough. He wanted more, and I said you’ve got to prove to us that you can handle what you’re doing now. You know, can you abide by those regulations that have been set up for you now. You can abide by them, [and] then at the end of this weekend […] I’ll re-evaluate it.^{Footnote 1363}

319. On the Wednesday or Thursday prior to his death, Cpl Langridge attended at sick parade and again requested for his conditions to be relaxed:

He had gone to the doctor’s, the doctors phoned me later in the morning and said, ‘Listen, what’s going on with this guy? He’s saying he can’t handle what you’re doing,’ yada yada yada [...]

So I said we’ve been asked to help, we’re doing what we can. I think it’s just […] another ploy of him not wanting to be a soldier, and carrying on, and doing what he’s expected to do. So he said, ‘Yeah, I tend to agree with you.’

So then he hung up, and I’d say, maybe 10 minutes later, he phoned back and said, ‘Okay, he just said he’s suicidal, so I have no option other than to admit him to the hospital.’^{Footnote 1364}

320. CWO Ross said Cpl Langridge was released after spending approximately 24 hours in hospital. He stated, “And they said there's nothing we can do. He's no danger to anybody. So they released him. [...] And then, that weekend, he committed suicide.”^{Footnote 1365} CWO Ross appeared to concede even the two-hour check-in interval was too long to keep Cpl Langridge safe, but said, “I don’t know what more we could have done from there; I really don’t.”^{Footnote 1366}

321. The interview concluded with CWO Ross expressing his desire “to see some closure to this as quickly as possible.”^{Footnote 1367}

Interview with Capt Hannah

322. On May 27, 2008, MCpl Ritco met with Capt Hannah to discuss Cpl Langridge’s mental health and previous suicide attempts. He asked Capt Hannah about Cpl Langridge’s previous suicide attempts he had become aware of, including the June 2007 attempt, an overdose of medication, attempts to hang himself at his residence and the suicide attempt in February 2008, which took place while Cpl Langridge was at the Royal Alexandra Hospital. Capt Hannah stated he reviewed Cpl Langridge’s file after his death. He noted all the suicide attempts were documented in the file, and MCpl Ritco “hit, certainly, the highlights.”^{Footnote 1368} He added there were other incidents in the file, which may also have been suicide attempts, but it was difficult to say with certainty because they were not necessarily as straightforward or overt as those referred to by MCpl Ritco.

323. Capt Hannah’s opinion about Cpl Langridge’s mental health situation over the previous year was that a person would never be in a chronic or constant state of “being suicidal,” and it was not an ongoing illness that could be labelled.^{Footnote 1369} Instead, suicidality was situational and varied from day to day depending on factors such as mental health issues, life changes and drugs and alcohol. Capt Hannah stated he would not classify a patient as suicidal over a long period of time unless they exhibited daily suicidal thoughts or behaviours, although Cpl Langridge was “absolutely” at higher risk of suicidality than other patients.^{Footnote 1370} Capt Hannah noted it was “certainly on the public record” Cpl Langridge was living at the LDSH duty centre because he was perceived to be at a heightened risk for suicide and required additional supervision.^{Footnote 1371}

324. Earlier in the investigation, MCpl Ritco had initiated a request from the base clinic for Cpl Langridge’s medical records pertaining to his mental health and received the file,^{Footnote 1372} and he sought Capt Hannah’s assistance in interpreting the records in the context of the 2008 investigation. After interpreting various clinical terms and personality disorder diagnoses included in Cpl Langridge’s mental health records, Capt Hannah was asked about Cpl Langridge’s discharge from the Alberta Hospital at Edmonton (AHE) in March 2008. MCpl Ritco was seeking information about the period between his discharge and his being subject to the conditions. Capt Hannah did not know where Cpl Langridge lived after his discharge but remembered he began living within the LDSH lines on March 7^th, 2008.^{Footnote 1373} Capt Hannah told MCpl Ritco, based on the medical records, Cpl Langridge attended Care Delivery Unit C (“CDU(C)”) on March 7, 2008, at the insistence of his Base Addictions Counsellor (BAC) after continued problems with drinking and drug use and complaints from Ms. A about harassment. Cpl Langridge accepted there was a problem and asked to be sent to the AHE. However, the AHE was unable to take him, and Cpl Langridge was unwilling to go to the Royal Alexandra Hospital instead. He denied being suicidal, but:

That not being good enough, we offered him an opportunity for him to live in the LdSH, where he could be – have someone that could keep a close eye on him. He wanted extra supervision, he wanted someone to keep an eye on him. LdSH agreed to that, and so he was allowed to move in.^{Footnote 1374}

325. MCpl Ritco asked Capt Hannah if Cpl Langridge had been on a suicide watch before March 7, 2008. Capt Hannah said he “had no idea” and stated Cpl Langridge was under the care of base medical personnel, but did not reside at the base medical clinic as it did not function as a hospital.^{Footnote 1375} Capt Hannah explained he simply did not know if there was a suicide watch between Cpl Langridge’s discharge from the AHE and March 7, 2008.^{Footnote 1376} Capt Hannah stated he was consulted by the LDSH as to Cpl Langridge’s conditions on March 7, 2008, which he said were instituted to provide Cpl Langridge with “structure” and “support.”^{Footnote 1377} At the time, Cpl Langridge had not indicated he was suicidal, but was asking for extra support, so the decision was made to provide him with that support “and this was a plan that he accepted and agreed to, and was willing to do.”^{Footnote 1378} Capt Hannah advised MCpl Ritco the LDSH did not force Cpl Langridge to reside within the duty centre. Instead, his behaviour was to be closely monitored, with people keeping an eye on him in a structured environment. According to Capt Hannah, the LDSH was responsible for administering his medication, including reminding him of the times for taking his medication.^{Footnote 1379}

326. Capt Hannah did not believe Cpl Langridge was suicidal on March 14, 2008, the day before his death. Cpl Langridge attended the base clinic for a prescription renewal and reported no particular difficulties. When asked by MCpl Ritco why Cpl Langridge was attempting suicide, Capt Hannah speculated Cpl Langridge was repeatedly acting out as a result of borderline personality traits in order to be the centre of attention and:

[…] at some point, some people get frustrated that people stop making them the centre of attention, and -- or pay them too much attention, and take away their privileges in society, and in that case, then, I think -- my opinion – some people will say, ‘Fine. I'll show you. I really will kill myself.’, and they do.^{Footnote 1380}

327. Capt Hannah also speculated Cpl Langridge might have committed suicide because it was the day of another soldier’s funeral “and someone else was the centre of attention that day, not him.”^{Footnote 1381} He also supposed Cpl Langridge had been drinking or using cocaine that day. Finally, he also guessed the cause could have been a combination of all of the above. Capt Hannah concluded, no matter the reason, the LDSH “went above and beyond the call of duty and really tried to accommodate the member in a way that was unique, and I think very flexible and supportive […].”^{Footnote 1382} Finally, Capt Hannah advised MCpl Ritco, as far as he knew, the arrangements had been made for Cpl Langridge to go to residential substance abuse treatment if he had been able to adhere to the structure given to him, and he “absolutely” would have gone.^{Footnote 1383}

MCpl Ritco’s conclusions about the suicide watch

328. It was clear from the witness evidence set out above that some form of watch was planned for Cpl Langridge, although information about the purpose of the watch was contradictory. Sgt Hiscock,^{Footnote 1384} Cpl Rohmer,^{Footnote 1385} Cpl Hurlburt,^{Footnote 1386} MCpl Fitzpatrick,^{Footnote 1387} and MCpl Bowden^{Footnote 1388} each reported to MCpl Ritco that a suicide watch was either planned or conducted for Cpl Langridge. Although Sgt Hiscock was equivocal as to whether the planned watch was a suicide watch, he appeared to have wavered only after an intervention by CWO Ross.^{Footnote 1389} MCpls Bowden and Fitzpatrick each reported having been directly involved in the process of planning the watch on behalf of CWO Ross. Additionally, some witnesses indicated suicide watches were not unknown in the CF and had even been conducted for Cpl Langridge at various times of crisis, including in March 2008.^{Footnote 1390}

329. MCpl Ritco indicated he concluded Cpl Langridge was not under a suicide watch at the time of his death, accepting the assertions made by CWO Ross and Capt Hannah as to what was planned for Cpl Langridge and what was ultimately done. As MCpl Ritco testified:

“[…] because of all the mixed information I was getting whether he was on one or he wasn’t on one, I had to make a decision on: okay, was he on one or wasn’t he on one? So I spoke with the person that would – ultimately that directed it, and that was Chief Ross. He said [...] it wasn’t a suicide watch, so I took it at face value that it wasn’t a suicide watch.”^{Footnote 1391}

330. Despite this apparently categorical statement, MCpl Ritco’s testimony on this question was ultimately somewhat equivocal. On his second day of testimony, he said he was actually unable to reach a conclusion whether Cpl Langridge was “on ‘suicide watch’ or ‘defaulters’” despite having noted on his IP at the time this issue was “completed.”^{Footnote 1392} MCpl Ritco also stated he was not able to reach any conclusions as to the purpose of the conditions to which Cpl Langridge was subject in the last days of his life, nor answer the question whether Cpl Langridge voluntarily submitted to them.^{Footnote 1393}

Misunderstanding Negligence

331. Given the narrow understanding of negligence in the 2008 investigation as essentially requiring evidence of a failed suicide watch,^{Footnote 1394} and given MCpl Ritco’s conclusion a suicide watch was not being carried out at the time of Cpl Langridge’s death (or more precisely, given his inability to conclude one was being carried out), it is not surprising MCpl Ritco testified he encountered no evidence of CF negligence in the course of his investigation.^{Footnote 1395} This conclusion appeared to satisfy his superiors. WO Tourout testified, if evidence arose to substantiate the suggestion Cpl Langridge may have been the subject of a suicide watch when he died, then there might have been reason to consider the possibility of negligence on someone’s part. Because the suicide watch was never confirmed, there was no need for a negligence investigation.^{Footnote 1396} Similarly, MWO Watson testified he was satisfied enough investigation had been done to come to a conclusion on the issue and warrant closing the file,^{Footnote 1397} asserting once the question of the suicide watch was resolved, “we’re done.”^{Footnote 1398}

332. The CFNIS members fundamentally misunderstood the concept of negligence. Investigators and supervisors mistakenly viewed the suicide watch as a necessary precondition to a finding of negligence. They defined both “suicide watch” and “negligence” very restrictively. Even so, MCpl Ritco was unable to answer the very question the subjects identified as being singularly relevant: whether there was a suicide watch being conducted when Cpl Langridge took his own life. More importantly, MCpl Ritco did not consider whether, based on the evidence, other sorts of conduct might have constituted negligence, nor what potentially negligent acts and omissions by the LDSH or by base medical personnel might have looked like.

333. MCpl Ritco did not seem to understand how such negligent acts or omissions could even hypothetically have resulted in Cpl Langridge’s death, meaning he had little conception of how this question could be investigated or even what to look for. Conceiving a botched suicide watch to be the only possible grounds for a negligence investigation, the CFNIS investigators still failed to investigate the matter thoroughly or properly while ultimately leaving other critical questions about the watch and about potential CF negligence unanswered.

334. Critical questions concerning potential negligent acts and omissions by members of the LDSH and base medical personnel were not even contemplated, let alone asked or investigated. MCpl Ritco testified he was mindful evidence of potential negligence might arise, and testified he would have appropriately noted this evidence and if it did, would have ensured he or someone else at the CFNIS investigated the matter. However, this was simply not possible without an informed understanding of the possible duties of care by the CF or its members towards Cpl Langridge, and what potential acts or omissions by LDSH members and base medical personnel might have constituted a breach of such duties.

335. The investigators should have been looking to answer the question whether the CF as a whole, but in particular members of the LDSH and base medical personnel, had a duty to keep Cpl Langridge safe from harm.^{Footnote 1399} Even if it were determined there was no general duty of care for the military to keep its members safe, there still would have been a question as to whether, in Cpl Langridge’s particular circumstances, a specific duty may have arisen for the military to keep him safe.^{Footnote 1400}

336. In simple terms, investigating possible negligence would have required the CFNIS investigators to consider two scenarios, the first being negligence by omission: whether the CF failed to take reasonable steps to keep Cpl Langridge safe in the circumstances.^{Footnote 1401} The second scenario would have been negligence by commission: whether the CF took any steps that created a danger to Cpl Langridge’s safety.^{Footnote 1402}

337. Aside from the question of whether Cpl Langridge was under a suicide watch, there are unanswered questions about whether a suicide watch was planned and/or put in place in all but name and whether Cpl Langridge’s conditions constituted a de facto suicide watch. If such a watch was planned but not carried out, was the decision not to mount a suicide watch reasonable in the circumstances? This would also require answering questions such as, “what sort of watch was being planned, if not a suicide watch?” as well as whether a duty existed to put measures in place, which would protect Cpl Langridge from harm, whether explicitly called a “suicide watch” or not.

338. Even accepting the claims made by LDSH members that Cpl Langridge was not under a suicide watch and was not on the defaulters list or otherwise being disciplined, important questions arise such as why Cpl Langridge was required to sleep in the defaulters room and obey other conditions in March 2008 if not for his safety. If safety was a factor in the development of the conditions, were the conditions reasonable for that purpose? If they were not developed for purposes of safety, did the “structure” they imposed on Cpl Langridge cause or contribute to his death? Were the conditions negligently executed or administered in some way that put Cpl Langridge at risk of harm? These questions seem never to have been considered let alone pursued.

What was missed: Interviews not conducted

339. Key witnesses with information highly relevant to the negligence issue were never approached for interviews. In some cases, such as with Mrs. Fynes and Ms. A, it was decided by MCpl Ritco’s superiors interviews were unnecessary despite the fact they would clearly have possessed intimate knowledge of Cpl Langridge.^{Footnote 1403}

Failure to interview Ms. A

340. MCpl Ritco did not interview Ms. A, Cpl Langridge’s common-law spouse, in the course of his investigation, although she was initially identified in his IP as a witness who should be interviewed.^{Footnote 1404} When asked about this decision, he testified she “[…] was in the back of my mind to be interviewed, but, as the investigation carried on, at the end of the investigation it was deemed that it was irrelevant to interview her because it was a suicide.”^{Footnote 1405}

341. Ms. A had a great deal of information about Cpl Langridge’s final weeks. In a statutory declaration in support of an application for survivor benefits made in July 2009, she described important aspects of her relationship with Cpl Langridge and Cpl Langridge’s last weeks.^{Footnote 1406} Had Cpl Ritco interviewed her, he would have almost certainly obtained information highly relevant to the 2008 Investigation, which very likely may have warranted further investigation into potentially negligent actions.

342. Ms. A attested in her statutory declaration, Cpl Langridge’s certification was reviewed after his 30-day stay between February 5 and March 5, 2008, at the AHE. According to the declaration, Cpl Langridge’s doctor asked that he remain at the hospital for another 30 days, and Cpl Langridge himself wanted to stay. She attested he was finally making progress in the hospital and was frightened of leaving, but the CF requested his release into its care for two weeks of close supervision, after which he would be eligible to attend another rehabilitation centre. According to Ms. A, Cpl Langridge was told the time at base was mandatory if the military was going to continue to assist with his treatment.^{Footnote 1407} Ms. A went on to say Cpl Langridge accepted the CF’s offer of help:

On March 5, 2008 Stuart began living on the base and the military advised me that he would be safe. They ensured [sic] me that Stuart would be under constant supervision, which they referred to as “suicide watch”. They promised that Stuart would attend Addictions Counseling on a daily basis, and Alcoholics Anonymous Meetings as often as possible. During this time, Stuart and I spent as much time together as possible. I would visit him on base, and other times he would leave the base to visit me (either with permission or by evading his caregivers).

Stuart and I remained committed to each other over the last two weeks of his life. Until sadly, against the military’s promises, he was left alone in his room on the base.^{Footnote 1408}

343. Ms. A reaffirmed this version of events in her testimony during the Commission hearings.^{Footnote 1409} She testified Cpl Langridge slowly made progress and began to regain optimism and make plans for the future while he was at the AHE in February/March 2008. According to Ms. A, Cpl Langridge felt safe at the AHE and wanted to stay. His hope was to remain at the AHE until he could be flown to a residential substance abuse treatment centre.^{Footnote 1410} He told her he did not feel he could “screw up” or “fall off the wagon” there, as he was eventually refused grounds privileges due to past abuses and “wasn’t really allowed to go outside even,”^{Footnote 1411} developments which were corroborated in his medical records.^{Footnote 1412}

344. However, he later informed her he had been told to return to base at the end of his 30-day certificate, where he would stay “under full supervision,” being watched constantly.^{Footnote 1413} She testified Cpl Langridge called her and told her he was scared to leave the hospital and did not want to go the night before he was to return to the base. She explained they considered their options, but the expense of addiction (or substance abuse) treatment meant they had little choice but to acquiesce. Cpl Langridge then told her he trusted the LDSH to keep him safe.^{Footnote 1414}

345. Ms. A testified she learned from Cpl Langridge himself his return to base was mandatory and this was confirmed to her by Cpl Langridge’s addictions counsellors or a base psychologist.^{Footnote 1415} She testified the assurance Cpl Langridge would be subject to a suicide watch came from Cpl Langridge’s addictions counsellors and possibly also in a conversation with Capt Lubiniecki. After the passage of time, she could no longer recall if the term “suicide watch” was used explicitly, but she testified her understanding from the conversations she had was Cpl Langridge would be watched by someone 24 hours a day.^{Footnote 1416} Ms. A also testified she was told Cpl Langridge would be looked after and she was not to worry.^{Footnote 1417}

346. These allegations are unproven, but they are serious enough that anyone investigating the possibility of negligent actions related to Cpl Langridge’s death would immediately appreciate their importance. MCpl Ritco readily acknowledged during his testimony this information would have been useful to the 2008 investigation.^{Footnote 1418}

347. MCpl Ritco testified the decision not to interview Ms. A was made following discussions with WO Tourout. His notes record WO Tourout believed “[…] really there was no reason to speak with the common-law [spouse].”^{Footnote 1419} MCpl Ritco could not recall the basis of this decision, but he believed it was made because the view at the time was that the investigators possessed sufficient information.

348. WO Tourout testified he deemed it unnecessary to interview Ms. A because it was believed they required no more than what was contained in Cpl Langridge’s medical file.^{Footnote 1420} When presented with the information in Ms. A’s declaration, he acknowledged it was information not available to the investigators through any other means. Nevertheless, he was dismissive of Ms. A’s account, explaining it was not supported by the medical documents that had been obtained. This explanation does not appear well-founded because, to substantiate such accounts, it would first have been necessary for the investigators and their superiors to know the allegations even existed. They did not because they had never spoken to Ms. A.

349. WO Tourout subsequently acknowledged no documents pertaining to Cpl Langridge’s hospitalization in February/March 2008 had actually been requested.^{Footnote 1421} Regardless, WO Tourout also dismissed Ms. A’s allegations that Cpl Langridge was effectively ordered out of the hospital by the LDSH, that his close supervision was planned from even before his discharge, and that Ms. A was assured Cpl Langridge would be protected by a suicide watch.^{Footnote 1422}

350. It seemed the failure to seek information from this witness was being justified by the fact no other details about the allegations were obtained; however, this resulted from the failure to investigate the issue. With apparent reluctance, WO Tourout conceded in his testimony that had he been aware of Ms. A’s allegations, he would have expected Sgt Ritco to follow up and investigate them in order to determine whether or not they were true.^{Footnote 1423}

351. MWO Watson testified he did not see the relevance to the 2008 investigation, or to the suicide watch question specifically, of interviewing Ms. A.^{Footnote 1424} When MWO Watson was presented with Ms. A’s allegations, he was surprisingly dismissive of their significance. In particular, he did not believe the allegation that Ms. A was promised Cpl Langridge would be under a suicide watch could be true because she also said he was able to leave the base on his own or by evading his caregivers. If he were under suicide watch, he would not be permitted to leave.^{Footnote 1425} This objection seems to miss the point entirely. It ignores the possibility Cpl Langridge may have been subject to a botched or inadequate suicide watch, or that a suicide watch was planned and promised but, perhaps negligently, was not implemented. These were precisely the issues that needed to be pursued in a negligence investigation.

Failure to Interview Mrs. Fynes

352. Mrs. Fynes was also never interviewed. MCpl Ritco testified it was an oversight not to include the Fynes in his IP, but stated, “[…] they were still in the back of mind that I potentially could have interviewed them.”^{Footnote 1426} As with Ms. A, the decision not to interview the Fynes was made by MCpl Ritco’s superiors.^{Footnote 1427} The Fynes did make their own efforts to call MCpl Ritco. MCpl Ritco attempted to return the call made to him by Mr. Fynes and ended up speaking with Mrs. Fynes. Otherwise she would never have been contacted. When they did speak, Mrs. Fynes made several allegations about Cpl Langridge being poorly treated by the civilian and military medical systems before he died.^{Footnote 1428} MCpl Ritco testified he did not recall ever discussing with WO Tourout the possibility of formally interviewing Mrs. Fynes as a result of this call and testified the allegations did not alert him to any further issues requiring follow-up or investigation.^{Footnote 1429}

353. The Commission heard testimony from Mrs. Fynes stating she too was told by base medical personnel in the last days of Cpl Langridge’s life in March 2008 he would be placed under a “suicide watch,” and like Ms. A, was also told she was not to worry.^{Footnote 1430} When she asked what the watch entailed, she was told it would be “eyes-on, 24/7” observation and Cpl Langridge was being kept at the duty centre in order for this to be facilitated. She testified she was also told “no news was good news,” and if anything changed or the watch was removed, she would be contacted. Like Ms. A, Mrs. Fynes alleged the source of the assurance Cpl Langridge would be looked after was one of Cpl Langridge’s addictions counsellors. Mrs. Fynes specifically identified the counsellor as Dennis Strilchuk.^{Footnote 1431}

354. WO Tourout did not have a strong recollection about the decision not to interview Mrs. Fynes, but he testified the decision was again likely made because Cpl Langridge’s medical records appeared sufficient to provide background information. He did not recall ever discussing the possibility of interviewing Mr. Strilchuk with MCpl Ritco.^{Footnote 1432} When MWO Watson was presented with Mrs. Fynes’ allegations, he testified he did not consider them relevant to the investigation. He testified her information would only be relevant if she was given information contradictory to what the CFNIS received from the same sources (for example, if CWO Ross had told her something contradictory to what he had told the CFNIS about a watch).^{Footnote 1433} Surprisingly, MWO Watson appeared unprepared to accept that any information Mrs. Fynes may have been given by a different source about a suicide watch would be relevant to the investigation:

MS COUTLÉE: Okay. And if she received the information from a different source, someone you did not speak to, would that have been relevant?

CWO (RET'D) WATSON: Again, they formed the opinion through their investigative steps that he was not on suicide watch. So they were confident in that matter and they didn't pursue it any further.

MS COUTLÉE: So the fact that Mrs. Fynes may have been told that he was, you don't consider that to be relevant.

CWO (RET'D) WATSON: No.^{Footnote 1434}

355. This defensive posture is troubling, particularly given MCpl Ritco’s equivocation in his testimony as to his ability to reach conclusions about even the most fundamental question of whether there was a suicide watch or not. It is difficult to understand the view that, once the investigators had concluded there was no suicide watch mounted, there was no need to pursue the allegation that one had been promised.^{Footnote 1435}

356. When he was asked whether it would have been important to interview Mr. Strilchuk to determine where this information came from had the CFNIS investigators been aware of it at the time of the 2008 investigation, MWO Watson conceded it possibly would have been.^{Footnote 1436} However, he doubted any such information would have led the investigation in a different direction because “[w]e still would have found evidence to support the fact that there was no suicide watch regardless of what this individual said to Mrs. Fynes.”^{Footnote 1437}

Failure to interview Lt Dunn

357. Other lost opportunities included the failure to interview Lt Dunn, the duty officer for March 14, 2008, who, according to Sgt Hiscock, had briefed him about Cpl Langridge being under a “suicide watch” on the morning of March 15, 2008. MCpl Ritco failed to identify Lt Dunn despite having obtained Cpl Langridge’s last sign-in sheet, which identified the duty officer as “L.D.”^{Footnote 1438} MCpl Ritco did ask Cpl Hurlburt if he knew who the outgoing duty officer was, but Cpl Hurlburt stated he did not know.^{Footnote 1439} The issue was not raised with later witnesses or investigated further. When Lt Dunn appeared before the Commission, he testified he had been given a quick briefing during the handover from the outgoing duty officer on March 14, 2008, in which he was instructed about his duties with respect to Cpl Langridge.^{Footnote 1440}

358. Lt Dunn testified he was made aware of the conditions to which Cpl Langridge was subject, and “I knew he was at risk for suicide and that we had to watch him, that he had to check in with me at least once every one or two hours and that I had to make sure he took his medication and that he was actually sleeping in the defaulters’ room.”^{Footnote 1441} His understanding of the conditions was Cpl Langridge was at risk of committing suicide and he was to be monitored in the effort to prevent this, although he wasn’t sure if the term “suicide watch” was ever used.^{Footnote 1442}

Failure to interview Cpl Langridge’s close friends

359. The CFNIS investigators did not investigate the matter of who had ordered the first suicide watch purportedly conducted for Cpl Langridge when he was in hospital in June 2007. The CFNIS investigators interviewed Cpl Langridge’s friend, Cpl Rohmer, and he discussed the suicide attempt with them. He also mentioned Cpl Hillier was present at this time and – significantly – had been in regular contact with the Regiment while they were at hospital with Cpl Langridge.^{Footnote 1443} The investigators also learned Cpl Rohmer had drifted away from Cpl Langridge.^{Footnote 1444} Having gained all this information, they nevertheless did not interview Cpl Hillier, who Cpl Rohmer described as Cpl Langridge’s “best friend.”^{Footnote 1445} As a consequence, they gained no information about Cpl Hillier’s role in what was apparently a suicide watch conducted with the Regiment’s knowledge and approval after one of Cpl Langridge’s previous suicide attempts.

360. When asked about the June 2007 watch, Cpl Hillier testified he reported the suicide attempt to the LDSH chain of command the night of the incident and remained the better part of two days at the hospital with Cpl Langridge, periodically providing information to the LDSH.^{Footnote 1446} Although Cpl Hillier testified he believed the watch was not a suicide watch, he also testified he received a text indicating the LDSH was preparing to send members to relieve him and Cpl Rohmer at the hospital.^{Footnote 1447} He also testified knowledge of Cpl Langridge’s suicide attempt was widely circulated throughout the Regiment.

361. The CFNIS investigators also did not interview other close friends of Cpl Langridge to determine if they had information relevant to the investigation, such as Kirk Lackie, who testified he subsequently attempted without success to contact the investigators through the MP Garrison in order to provide them with information about Cpl Langridge. At the hearing, Mr. Lackie testified the LDSH took steps to keep Cpl Langridge under watch in March 2008.^{Footnote 1448} MCpl Ritco testified he had never heard Mr. Lackie’s name before.^{Footnote 1449} The information from these witnesses, had it been obtained, might have alerted the investigators to the possibility Cpl Langridge’s suicidal ideation was widely known and some structured watches may have even been undertaken by the LDSH in response.

Failure to interview members of the LDSH Chain of Command

362. MCpl Ritco did not question information provided to him by the members he interviewed within the LDSH chain of command. As a consequence, the investigators chose not to contact high-ranking officers for interviews. Yet these were the officers who made certain decisions regarding Cpl Langridge.

363. After Capt Lubiniecki’s interview on March 17, 2008, MCpl Ritco did not interview any other members of the LDSH chain of command, such as LCol Pascal Demers, Maj Earl Jared, or Maj Trevor Cadieu. The only other interview of a senior LDSH member was MCpl Ritco’s interview of CWO Ross. He stated he would have conducted such interviews, but they were not necessary because he trusted the Adjutant, Capt Lubiniecki, spoke for the entire chain of command. MCpl Ritco testified his assumption was based on his 15 years of experience within the CF.^{Footnote 1450} He added, “I have to take [his] word for it, right, sir?”^{Footnote 1451}

364. A senior member of the chain of command, Maj Jared, who was never interviewed by the CFNIS, was the OC of the LDSH HQ Squadron in March 2008. Cpl Langridge came under his supervision in 2007 following his transfer to that squadron after a failed drug test. Along with CWO Ross and Capt Hannah, he played a significant role in determining what would happen to Cpl Langridge in March 2008. MCpl Ritco had several interactions with Maj Jared in the spring of 2008 concerning Cpl Langridge’s personal effects, owing to Maj Jared’s role as a member of the Committee of Adjustment dealing with Cpl Langridge’s service estate, but did not interview him about the investigation.^{Footnote 1452}

365. Had MCpl Ritco interviewed Maj Jared in 2008, he would very likely have obtained information inconsistent with what he had been previously told by CWO Ross. The version of events, as recounted in Maj Jared’s testimony, contradicts some of the information CWO Ross provided to MCpl Ritco in May 2008. The Commission finds it difficult to reconcile these two versions.

366. In May 2008, CWO Ross originally told MCpl Ritco he had devised the conditions with input from Capt Hannah. CWO Ross provided MCpl Ritco with an email chain indicating, on the afternoon of March 7, 2008, he sent an email message to Maj Jared and Capt Lubiniecki containing “direction and restrictions,” “control measures,” and medical employment limitations constituting the conditions Cpl Langridge would be required to abide by.^{Footnote 1453} CWO Ross forwarded that message to Capt Hannah on March 10, to which the doctor replied, “Outstanding, thanks.”^{Footnote 1454}

367. However, Maj Jared testified CWO Ross came into his office with a different draft email message about the new conditions earlier on March 7, 2008. His recollection was the CF medical system intended to release Cpl Langridge to the LDSH and CWO Ross had consulted with either Capt Hannah or Mr. Strilchuk, giving rise to the requirement Cpl Langridge had to comply with the treatment plan, including “remaining under the supervision of the LDSH.”^{Footnote 1455} To Maj Jared, this meant additional supervisory measures because it was taken for granted the CF already supervises its soldiers. Indeed, Maj Jared testified:

The initial conditions that were proposed to me, I believe, involved CF members watching Corporal Langridge constantly with the intent of preventing him from committing suicide. I did not agree with the measures or the draft document that was put in front of me, and I discussed the measures with the regimental sergeant major, Mr. Ross. The resulting measures are as you see here […].^{Footnote 1456}

368. Maj Jared confirmed he understood what CWO Ross originally proposed was a suicide watch.^{Footnote 1457} In contrast to CWO Ross’ assertion a suicide watch was never intended and he had only considered planning for a 24/7 watch “if it came to that” in the face of unknown medical requirements for Cpl Langridge,^{Footnote 1458} Maj Jared’s testimony was CWO Ross had himself proposed a suicide watch over Cpl Langridge, and it was only because Maj Jared disagreed with the proposal that the watch was scrapped. Whether or not these two versions of events can be reconciled, at the very least they raise significant questions about the conclusions reached by the CFNIS members concerning the suicide watch issue.

369. CWO Ross did not mention Maj Jared at any point in his interview with MCpl Ritco about a suicide watch, a “24/7 watch” or about the final conditions. His interview appears to imply: CWO Ross himself decided not to conduct any manner of watch over Cpl Langridge; the conditions were imposed for structure and not for medical reasons; and CWO Ross did not initially have any knowledge Cpl Langridge was suicidal before Cpl Langridge’s March 11 admission to the Royal Alexandra Hospital.^{Footnote 1459} Having been confronted with Maj Jared’s testimony during his own appearance before the Commission, CWO Ross surmised Maj Jared “[…] could have very well been aware of my initial course of action of putting together a possible 24 and 7 watch [...]”^{Footnote 1460} Beyond that, CWO Ross testified he did not remember the content of the discussions he had with Maj Jared about a watch over Cpl Langridge or about the conditions ultimately imposed.^{Footnote 1461}

370. CWO Ross testified the conditions were the product of his discussions with Capt Hannah but would not have been written in isolation from Maj Jared or Capt Lubiniecki. He reiterated, his view of the purpose of the conditions changed following “[…] the continued discussions that I had with Dr. Hannah as to what exactly they wanted, what the long-term goal, if you will, if you want to call it that, what was the purpose of it, what was the intent, and it certainly changed my focus and my direction that led me to those conditions.”^{Footnote 1462}

371. In his testimony, CWO Ross initially affirmed his 2008 statement the 24/7 watch was not intended to be a suicide watch.^{Footnote 1463} He insisted the 24/7 watch was “very quickly dropped” and was not intended to prevent Cpl Langridge from harming himself.^{Footnote 1464} In further questioning, however, CWO Ross was taken back to the initial request for a 24/7 watch, and he was asked to confirm such a watch would have been functionally a suicide watch with the goal of preventing Cpl Langridge from harming himself. He then conceded, initially at least, it “was a possible course of action that we may have had to taken [sic],”^{Footnote 1465} and added “[h]ad we had to do that, yes, that’s what we would have had to do.”^{Footnote 1466} CWO Ross also testified, having reviewed his 2008 CFNIS interview, nothing in that interview struck him as inaccurate or requiring a change.^{Footnote 1467}

372. Had MCpl Ritco interviewed Maj Jared in 2008, he may well have been led to consider at least the possibility one or more witnesses were incorrect about the arrangements planned and ultimately made during Cpl Langridge’s last days. Such information would have required the CFNIS members to consider a much more probing investigation of the available witnesses. MWO Watson testified he did not know why Maj Jared was never interviewed. He was not aware Maj Jared was involved in determining whether a suicide watch would be conducted or what the nature of the conditions should be.^{Footnote 1468} He testified he did not consider Maj Jared’s evidence relevant, stating it seemed to him Maj Jared simply disagreed with CWO Ross’s “final direction,” and dismissively stated, “That’s his opinion --.”^{Footnote 1469}

Failure to interview key medical personnel

373. The base medical personnel interviewed by the CFNIS members were not Cpl Langridge’s treating physicians. MCpl Ritco testified Capt Hannah informed him he was not Cpl Langridge’s treating physician when he sought his assistance to help understand the medical records he received in response to his request for Cpl Langridge’s mental health file. Capt Hannah said his interaction with Cpl Langridge had been “very brief,” and Capt Hannah did not believe it had anything to do with Cpl Langridge’s suicide.^{Footnote 1470} In fact, Capt Hannah only saw Cpl Langridge once, and only for about an hour, on March 7, 2008.^{Footnote 1471}

374. MCpl Ritco was asked if he gave any thought to interviewing Cpl Langridge’s treating physicians. MCpl Ritco responded:

When Dr. Hannah's name was given -- I forget the doctor that says that that's the person you should speak with -- I assumed that, being the Base Surgeon or Acting Base Surgeon, he or she would have an insight on the patient. So when I went to speak with him, I had full intentions or I was under the impression that he knew full well the conversation I was going to have with him and was up to speed on Corporal Langridge.^{Footnote 1472}

375. Despite Capt Hannah’s unfamiliarity with Cpl Langridge, MCpl Ritco testified he felt the information Capt Hannah provided to him about Cpl Langridge’s circumstances was sufficient, evidently trusting Capt Hannah’s position of authority. MCpl Ritco spoke with only one other doctor, Dr. Robin Lamoureux, who saw Cpl Langridge briefly for a prescription renewal the day before his suicide. MCpl Ritco testified he did not find the interview sufficient to give him any insights into Cpl Langridge’s state of mind prior to his death because Dr. Lamoureux’s interaction with Cpl Langridge was very brief.^{Footnote 1473} MCpl Ritco did not interview any of Cpl Langridge’s base addictions counsellors, such as Mr. Strilchuk or the mental health team nurses who worked with Cpl Langridge.

376. MCpl Ritco also did not interview any of the civilian doctors who treated Cpl Langridge. Such interviews could have included: Dr. Bernard Sowa, who was the attending physician at the AHE when Cpl Langridge was committed for 30 days between February 5 and March 5, 2008; Dr. Jack Chu, who was the attending physician for several of Cpl Langridge’s admissions at Royal Alexandra Hospital after suicide threats in 2007 and early 2008; and Dr. David Block, who was the attending physician for Cpl Langridge’s two-day admission to the Royal Alexandra Hospital just days before his death.^{Footnote 1474}

377. Dr. Sowa testified about Cpl Langridge’s state of mind, providing details about his treatment and progress the witnesses MCpl Ritco interviewed simply could not provide. He had ordered “close observation” for Cpl Langridge repeatedly throughout his AHE hospitalization.^{Footnote 1475} This was a precaution ordered when staff were “particularly concerned about a patient” who was “particularly acutely suicidal” or exhibiting sudden, unstable changes in behaviour. It meant Cpl Langridge was not permitted to leave the unit and a nurse was required to check on him every 15 minutes to ensure he was physically unharmed and emotionally well.^{Footnote 1476}

378. Dr. Sowa testified Cpl Langridge admitted to having attempted suicide in late February 2008.^{Footnote 1477} On March 4 and 5, 2008, Cpl Langridge exhibited great anxiety about returning to base. Looking at the notes recorded by the AHE nursing staff, Dr. Sowa explained he understood this as the source of the anxiety. He testified, “Clearly, he wasn't happy about going back to the base, and he was apprehensive as to what kind of plans they had for him. From my understanding, they wanted him there to attend drug rehab programs […].”^{Footnote 1478} Dr. Sowa testified Cpl. Langridge seemed to be less anxious after speaking with “Leo” at the base to learn more about the situation and this was likely because “[…] he was assured he wouldn't be resuming his normal military duties, whatever they were, so that was my understanding of that. And it looks like at that point, there was also a consideration that it might be Ontario rather than BC where he would be going for his treatment, drug rehab treatment.”^{Footnote 1479}

379. Dr. Sowa worked extensively with Cpl Langridge during his stay at the AHE and testified he believed Cpl Langridge would have responded negatively to the treatment he received at the base upon his return. He believed the conditions actually put into place for Cpl Langridge would have been “highly provocative” to him, and Cpl Langridge would see the conditions as “extremely punitive.”^{Footnote 1480} He also testified the conditions were contradictory. On the one hand they provided for Cpl Langridge to be kept in a room where he could be observed, – suggesting to Dr. Sowa there was consensus Cpl Langridge might harm himself – yet, on the other hand, they imposed normal workdays upon him. He believed this suggested “fuzziness” about where Cpl Langridge was situated in terms of his recovery and about what needed to be done. Dr. Sowa added he would have exercised great caution with a patient who was being discharged, in terms of resuming work, and would have urged a gradual return only, even if that individual (unlike Cpl Langridge) had been particularly keen to do so.^{Footnote 1481}

380. Had the CFNIS sought Dr. Sowa’s evidence, serious questions might have arisen about Cpl Langridge’s stability upon his return to base. There was also evidence available, which strongly indicated a suicide watch was being planned for Cpl Langridge upon his return. Had the matter been pursued with medical witnesses who were actually involved in the events, there seems little doubt issues about the understanding of the LDSH chain of command and medical communities concerning the need to ensure Cpl Langridge’s safety would have come to the forefront.

381. At the very least, further investigation was warranted. Instead, the statements made by Capt Lubiniecki, CWO Ross, and Capt Hannah became MCpl Ritco’s conclusions. The CFNIS members accepted this evidence without critical analysis and did not follow up on the assertions made in any meaningful way. The apparent deference of the CFNIS members meant logical, critical questions went unasked and relevant issues remained unexplored.^{Footnote 1482}

382. MWO Watson testified he did not have any concerns about the fact the investigators relied on the denials made by CWO Ross and Capt Hannah about the suicide watch. He explained if, after the interviews, evidence came to light Capt Hannah and CWO Ross had deceived the investigators, the investigation would then focus on them.^{Footnote 1483} With respect to whether there had been any independent confirmation Cpl Langridge was not on a suicide watch, MWO Watson testified he believed this had been obtained.

The subjects’ explanations

383. Even based on the evidence compiled by the CFNIS investigators, it would seem there was reason to go beyond the accounts given by CWO Ross, Capt Lubiniecki, and Capt Hannah during the 2008 investigation. MCpl Ritco had amassed contradictory evidence about the possible suicide watch even before seeking the assistance of CWO Ross and Capt Hannah to put the question to rest. WO Tourout testified he was not concerned the two persons who would “clearly” be implicated in allegations of negligence concerning the suicide watch were the only two interviewed about it.^{Footnote 1484} He stated, “[…] we had no reason to believe otherwise. [...] There was no other evidence to suggest that they were lying.”^{Footnote 1485} This assertion is unsatisfactory because failing to conduct the due diligence expected in the investigation is simply not the same as finding no evidence.

384. In cross-examination, MWO Watson was asked by his counsel to explain the standard for deciding how many witnesses should be interviewed and how much information should be tracked down in an investigation – essentially, “how far do you go as investigators?”^{Footnote 1486} He explained the standard was to “[…] interview enough people, and it's irrelevant to me whether it's two people or one hundred and two people, how many they interview until they're satisfied that their investigation is complete and they have all the information they require.”^{Footnote 1487}

385. When asked if there was an expectation the CFNIS investigators would “interview every possible person out there who might have information to bear on the issue,” MWO Watson replied timeliness and the relative value to the investigation of the information to be obtained from a given witness were important considerations.^{Footnote 1488} While this may generally be true, the issue is whether the interviews conducted were sufficient to allow CFNIS investigators to conclude they had enough reliable information to terminate the investigation of potential negligence, let alone the suicide watch issue. The long list of witnesses with potentially relevant information who were never interviewed – and those for whom it was decided no interview was necessary – appears to belie any such assertion.

386. The failure to interview Ms. A, Mrs. Fynes, Dr. Sowa, and Mr. Strilchuk is particularly striking given the information they may have been able to give the CFNIS about Cpl Langridge’s last days and the treatment he received. The failure to interview CF personnel such as Maj Jared, Lt Dunn, and Cpl Hillier meant information about suicide prevention efforts planned before and during March 2008 was left undiscovered.

Contradictions and Inconsistencies

387. Although MCpl Ritco, it appears, ultimately concluded there was no suicide watch in place at the time of Cpl Langridge’s death, it was clear from the evidence he gathered some form of watch had been planned for Cpl Langridge. Information about the purpose of the watch and the subsequent conditions was inconsistent. Some witnesses stated Cpl Langridge was to be watched, but not for the purpose of preventing him from committing suicide. Some witnesses told the CFNIS Cpl Langridge was under a suicide watch in substance if not in name. Some witnesses went further and indicated, not only were suicide watches known within the CF, but they had been expressly conducted for Cpl Langridge in March 2008 or after prior attempts at suicide.

Apparent inconsistencies in Sgt Hiscock’s accounts of the arrangements for Cpl Langridge

388. One of these unexplored inconsistencies involved Sgt Hiscock’s references as to what was arranged for Cpl Langridge. Sgt Hiscock provided conflicting statements regarding the nature of the supervision provided for Cpl Langridge. On the day of Cpl Langridge’s death, MCpl Christina Mahoney, an MP member,^{Footnote 1489} recorded Sgt Hiscock’s statement in her MP notebook following the discovery of Cpl Langridge’s body. She reported Sgt Hiscock said, “Cpl LANGRIDGE was on suicide watch and had been sleeping at the Unit lines since approx one week.”^{Footnote 1490} Sgt Hiscock added in this account that Cpl Langridge was required to report in to the Unit every two hours and, following a missed check-in, Cpl Hurlburt was sent to find him, resulting in the discovery of his body.

389. During his interview with MCpl Ritco, Sgt Hiscock first stated he was told he was conducting a suicide watch, although he believed it would not have been a suicide watch by his understanding of the term. When asked to describe what Cpl Langridge’s situation was, if not a suicide watch, Sgt Hiscock replied it was more “a structured program [...] like an extra duty thing so we could just keep an eye on the guy and help him.”^{Footnote 1491} Sgt Hiscock could not explain why Cpl Langridge would be subject to the conditions if not for fear that he would harm himself.^{Footnote 1492} MCpl Ritco did not probe further. Later in the interview, Sgt Hiscock revealed he met with CWO Ross the day before his interview and was essentially told the watch was not a suicide watch, but intended for “structure.”^{Footnote 1493}

390. According to Sgt Hiscock, CWO Ross explained to him Cpl Langridge’s conditions were developed in conjunction with his mental health care providers to provide him with structure while preserving his dignity. Sgt Hiscock suggested to MCpl Ritco the conditions were a discreet attempt to avoid conducting a formal suicide watch, “so that [Cpl Langridge] could still do stuff without having, like I say, a guy standing there watching you, you know, take a crap.”^{Footnote 1494}

391. When asked to explain what his understanding of Cpl Langridge’s situation was after the meeting with CWO Ross, Sgt Hiscock stated he believed Cpl Langridge was under a suicide watch, “but put the little quotation marks around it.”^{Footnote 1495} He added Cpl Langridge was not a defaulter and felt Cpl Langridge was “not really on suicide watch” because he was not being watched constantly. Sgt Hiscock also suggested “imposed restrictions” might be an appropriate term to classify Cpl Langridge’s situation. In his typed summary of the interview, MCpl Ritco noted: “Sgt HISCOCK was under the impression Cpl LANGRIDGE was not a defaulter, nor on suicide watch, that the conditions where [sic] in place to give Cpl LANGRIDGE a controlled structure program to follow. Sgt HISCOCK further related this information came from the RSM the day prior.”^{Footnote 1496} MCpl Ritco did not ask Sgt Hiscock about the statement he gave to MCpl Mahoney. He did not inquire why Sgt Hiscock’s statement had changed.^{Footnote 1497}

392. When MCpl Ritco interviewed CWO Ross on May 23, 2008,^{Footnote 1498} he did not inquire into the issue of CWO Ross’s meeting with Sgt Hiscock the day before his CFNIS interview.^{Footnote 1499} MCpl Ritco did not ask CWO Ross about the reasons for this intervention and evidently did not find it significant. When MCpl Ritco was asked during his testimony what he made of the fact Sgt Hiscock’s statement changed after his meeting with CWO Ross, he only replied “I didn't – nothing there, sir.”^{Footnote 1500}

393. MCpl Ritco’s supervisors also did not see any issues with the inconsistent information about a suicide watch. WO Tourout testified the issue of Sgt Hiscock changing his account was of “more relevance” to MCpl Ritco than to him.^{Footnote 1501} Like MCpl Ritco, moreover, WO Tourout appeared to exhibit considerable deference to the chain of command, to the extent he implied rank entailed credibility. In particular, WO Tourout explained he was unconcerned about Sgt Hiscock changing his statement regarding the suicide watch after CWO Ross met with him because “[Sgt Hiscock] had no reason not to believe [CWO Ross]. People will believe one thing until they are told whether or not it’s correct or incorrect. If Sergeant Hiscock believed that initially, [it was a suicide watch], and he was told later by Chief Ross that it wasn’t, then he would accept the change, unless there was proof otherwise.”^{Footnote 1502}

394. Similarly, when he was taken through Sgt Hiscock’s conflicting statements, MWO Watson testified, “I think it would be appropriate to ask MCpl Mahoney if that's actually what was said.”^{Footnote 1503} MWO Watson dismissed any concerns over the inconsistent accounts, as he was satisfied MCpl Ritco’s investigation did not uncover any evidence of a suicide watch.^{Footnote 1504}

The December 2007 suicide watch

395. Sgt Hiscock’s testimony at the Commission revealed more than the narrow scope of his CFNIS interview in March 2008. As Sgt Hiscock recalled, he learned in December 2007 members of the LDSH were arranging a suicide watch for Cpl Langridge. Sgt Hiscock testified he was approached by WO Boudar and told a 24/7 suicide watch for Cpl Langridge was necessary. He and WO Boudar attempted to come up with a list of names of people willing to take Cpl Langridge home with them and watch him over the holidays.^{Footnote 1505} The watch was required until Cpl Langridge’s next meeting with his counsellor. He believed it would be roughly a week. Cpl Rodney Bartlett volunteered to watch Cpl Langridge.

396. The Commission was able to call Cpl Bartlett, who was a friend of Cpl Langridge, as a witness. Due to the passage of time, Cpl Bartlett’s recollection of these events was not strong, deepening the consequences of the failure of the CFNIS members to investigate the matter thoroughly. He believed the watch took place in the winter, as Sgt Hiscock said, but for only one night, and suggested it might have been in February 2008^{Footnote 1506} – possibly after Cpl Langridge’s discharge from the RAH on February 4, 2008. Cpl Bartlett testified he was instructed to watch Cpl Langridge, to prevent him from leaving his house, and to prevent him from harming himself.^{Footnote 1507} Cpl Bartlett was “fully aware that it was a suicide watch,” and reported back to WO Boudar (his superior in HQ squadron) about it.^{Footnote 1508} Cpl Bartlett also testified he was aware of a suicide watch list “floating around the regiment” at another point – he believed it was before the watch he conducted, because he recalled being unable to participate. He did not know what happened with this list.^{Footnote 1509}

Questions Never Asked or Never Followed Up

397. Apart from the fundamental conceptual failures, another of the principal deficiencies in the 2008 investigation of the negligence issue was the failure to obtain relevant and important information. The existence of such information was evident from information already obtained. Yet, CFNIS members failed to follow up on questions and allegations brought to their attention.

Previous suicide attempts

398. After speaking to Capt Lubiniecki, MCpl Ritco knew at least some members of the LDSH chain of command were aware of Cpl Langridge’s June 2007 and February 2008 suicide attempts. It would have been appropriate at this point for MCpl Ritco to probe further into the Regiment’s knowledge of Cpl Langridge’s past suicidal behaviour in order to evaluate the assertions the conditions were put in place purely for structure and the claim no suicide watch had been planned for Cpl Langridge.

399. MCpl Ritco failed to ask any questions of any other witnesses, including CWO Ross, as to their knowledge of previous suicide attempts. In his testimony at the Commission hearings, CWO Ross confirmed he was aware of multiple suicide attempts. He testified he knew of the June 2007 suicide attempt.^{Footnote 1510} He was also aware of an incident in October 2007 in which Cpl Langridge appeared to have made another suicide attempt by way of an overdose of medication.^{Footnote 1511} Had MCpl Ritco explored this issue with the LDSH witnesses, he might have become aware of the need to investigate what was known about the risks to Cpl Langridge and to reconcile this with what was actually done for him.

The allegation of inadequate care

400. The CFNIS investigators did not follow up on the allegation,^{Footnote 1512} made by Mrs. Fynes in the spring of 2008, that Cpl Langridge received inadequate care from the military and civilian health care units. Mrs. Fynes also informed MCpl Ritco she was greatly troubled by Cpl Langridge’s treatment in hospital, and believed he was improperly released from hospital in February 2008 while he was in a suicidal state. While Cpl Langridge’s treatment in the civilian medical system would clearly have been beyond the jurisidiction of the CFNIS to investigate, MCpl Ritco testified Mrs. Fynes’ allegations about the medical care provided by the military did not alert him to anything he felt needed to be followed up in the 2008 investigation,^{Footnote 1513} although he denied this meant her information was irrelevant to him:

What I'm saying is [...] that at the time when I spoke with Ms Fynes, when she mentioned that I was dealing with a sudden death. [...] So it was my back of my mind, but did it have a lot of relevance? No, because I was dealing with a sudden death. I wanted to find out: Was it foul play? Did Corporal Langridge die at the hands of somebody else or was it a suicide or other means -- or other things?^{Footnote 1514}

401. MCpl Ritco possessed information, which made it readily apparent^{Footnote 1515} Cpl Langridge had been admitted to both the Alberta Hospital at Edmonton and the Royal Alexandra Hospital shortly before his death (including an admission to the RAH just days before his suicide). The records would have yielded significant information about Cpl Langridge’s stability and state of mind in this period, but MCpl Ritco did not request any medical records pertaining to those admissions despite Mrs. Fynes’ complaint about inadequate care by the military medical system, and despite information from Capt Lubiniecki about these hospital admissions. He assumed these records would have been included in his request for Cpl Langridge’s medical file from base mental health services.^{Footnote 1516} Due to that assumption, he testified, it never occurred to him to ask for further records.^{Footnote 1517} He conceded it would have been helpful to his investigation to obtain these medical records.

Lack of details on Cpl Langridge’s final days

402. There are critical gaps in what is actually known about Cpl Langridge’s last days. The CFNIS investigators seem not to have tried to fill in those gaps, despite the clear relevance to the conditions Cpl Langridge faced upon his discharge from the hospital, plans to ensure his safety and stability, and the intention of the conditions arranged two days after his release from hospital. CWO Ross and Capt Hannah spoke of developing the conditions on March 7, 2008, but were unaware of Cpl Langridge’s living arrangements and any conditions he was living under before. CWO Ross told MCpl Ritco he was not certain but did not believe Cpl Langridge was out of hospital before that date,^{Footnote 1518} and when Cpl Langridge first came to the LDSH he “started right into” the conditions.^{Footnote 1519} MCpl Ritco actually attempted to clarify the timing, because he understood the “suicide watch list” incident took place at some point before the conditions were imposed on Cpl Langridge, and CWO Ross agreed his release must have occurred some time before the conditions were put in place. He stated he believed the hospital release, the suicide watch email, and the conditions all fell very close together and possibly occurred on the same day.^{Footnote 1520} CWO Ross was unable to provide further information. However, CWO Ross also mentioned the arrangements were made because Cpl Langridge had nowhere else to go. He heard a rumour Cpl Langridge was sleeping in his vehicle, but explained he only learned of this after the barracks room had been arranged.^{Footnote 1521}

403. The medical records MCpl Ritco obtained provided the timeline for Cpl Langridge’s discharge from the AHE, but the CFNIS members never determined what happened to Cpl Langridge between the time of his discharge from AHE on March 5, 2008, and the imposition of the conditions on March 7, 2008, including where Cpl Langridge was living.^{Footnote 1522} MCpl Ritco testified each witness had a version of where he was living and why he ended up in the defaulters room.^{Footnote 1523} As a result, he never did learn what actually transpired:

[…] Like I said, sir, I kept getting mixed -- I was told that at one point in time he was living in his vehicle – depending on who you spoke with. Hence, the reason that I was speaking with his unit to try and figure out exactly where he was living to find out what he was doing up to the days prior. […] Like I said, I got information that he was living in his vehicle. Then I got told that, no, it wasn't, that he was staying in the defaulters'. Then there was information that he was actually residing in his room.

To this day I don't know, sir.^{Footnote 1524}

404. Had MCpl Ritco interviewed Ms. A, he might have learned Cpl Langridge and Ms. A were discussing his living arrangements before his discharge from the AHE. In her testimony, Ms. A disputed the contention Cpl Langridge had been assigned a room at the duty centre because he had nowhere else to go before he went to residential substance abuse treatment.^{Footnote 1525} The townhouse they had rented was gone but, according to Ms. A, they had hoped to live together at Ms. A’s new residence, and Ms. A then learned Cpl Langridge was required to live on the base:

They told me that they had given him a room in the barracks, in the shacks, but that he was to spend most of his time behind the duty desk and that if he missed anything or misbehaved at all, which I think might have taken place by the second day, he ended up sleeping in the bed behind the duty desk in Lord Strathcona’s Horse Building.^{Footnote 1526}

405. Maj Jared, OC of Cpl Langridge’s squadron, also had no knowledge of what happened to Cpl Langridge between March 5 and March 7, 2008. He did not think Cpl Langridge had been discharged from the AHE before March 7, 2008, and knew nothing about any release or other arrangements before this date.^{Footnote 1527} His understanding was the defaulters room was arranged for Cpl Langridge on March 7, 2008, because he had nowhere else to stay and the defaulters room was the most expeditious arrangement that could be made on a Friday afternoon.^{Footnote 1528} He also testified he thought Cpl Langridge was under the care of the military medical system upon returning to base, and if Cpl Langridge had been released from the AHE before March 7, 2008, then he must have been at the base clinic.^{Footnote 1529}

406. However, Capt Hannah and the primary care nurse, Charlene Ferdinand, said there was no place for Cpl Langridge to live within the military medical system as there were no in-patient beds, and they could only provide treatment during the daytime.^{Footnote 1530}

407. The investigation of potential negligence should have included efforts to sort out the disagreement on where Cpl Langridge resided or what conditions he was living under between his release and the imposition of the March 7, 2008 conditions. The inconsistent information raises questions regarding how the LDSH planned to receive and treat Cpl Langridge on his return from the hospital. The records suggest a room in the barracks was arranged for Cpl Langridge on March 4, 2008.^{Footnote 1531} Despite this, where Cpl Langridge actually resided between March 5 and March 7, 2008, remains unclear.

408. MCpl Fitzpatrick told MCpl Ritco he had been instructed by CWO Ross to have a room in the “shacks” (the barracks block) available for Cpl Langridge upon his discharge from hospital in March 2008, as he would be residing there for the time being.^{Footnote 1532} However, MCpl Fitzpatrick also told MCpl Ritco (and testified) Cpl Langridge slept in the defaulters room from the first night of his release.^{Footnote 1533} Capt Hannah’s notes of the morning of March 7, 2008, suggest Cpl Langridge was already residing in the defaulters room before March 7, 2008, referring to already existing arrangements: “Member directed by Unit to live in company lines to enhance supervision. [Member] upset with this plan.”^{Footnote 1534}When asked about this, CWO Ross acknowledged this strongly suggested Cpl Langridge was already residing in the defaulters room.^{Footnote 1535}

409. The evidence obtained by the CFNIS investigators suggested the LDSH and base medical personnel made certain arrangements for Cpl Langridge’s return and those arrangements were quickly changed. Things may not have gone as planned. This should have raised questions about Cpl Langridge’s stability and safety at the time, and the purpose or appropriateness of any measures put into place. Due to the failure to pursue such questions, we simply do not know what happened, or why, or what the impact on Cpl Langridge could have been.

Other issues not investigated or followed up

410. The narrow understanding of negligence and a suicide watch meant the CFNIS investigators were not prepared to look further and consider the possibility a deficient watch was arranged, which was potentially a negligent act, or no watch was arranged when one should have been, which was potentially a negligent omission. As a consequence of failing to conduct key interviews, the CFNIS investigators did not discover and thus failed to investigate whether any assurances were given to Cpl Langridge’s parents or common-law spouse that he was being kept safe and/or was under a suicide watch. Additionally, the CFNIS members failed to follow up on MCpl Bowden’s statement Cpl Langridge had been under previous suicide watches,^{Footnote 1536} and this watch was already underway when it was cancelled.^{Footnote 1537} This information gains even greater significance following the testimony of Mr. Lackie, who was never interviewed by the CFNIS, who stated a “partner” reportedly accompanied Cpl Langridge from the duty centre during activities like meals as part of a “suicide watch.”^{Footnote 1538} Pursuing these questions would have been highly relevant for determining what was planned in response to Cpl Langridge’s suicide attempts and what was known by the chain of command about his mental state. This, in turn, would have enabled the investigators to understand how a duty of care towards Cpl Langridge, if one existed, was understood and being discharged.

Were the conditions a de facto suicide watch?

411. The contention that the conditions by which Cpl Langridge was required to abide for the last week of his life were put into place purely for structure and support, demanded further scrutiny. Beyond testifying his mind was “always open” during his investigation, MCpl Ritco testified he did not recall whether he contemplated investigating the true purpose of the conditions, or whether he ever formed any hypothesis on the matter.^{Footnote 1539}

412. Rigid definitions of what would constitute a suicide watch, or might have been negligent conduct, impeded the investigation of negligence. The LDSH leadership generally gave evidence it would be difficult and onerous to place Cpl Langridge under a suicide watch that restricted his freedoms, and thus they did the best they could under those circumstances. WO Tourout had his own understanding of what a suicide watch looked like and, because of this, discounted the possibility the CFNIS investigators should have examined the actions taken concerning Cpl Langridge instead.

413. WO Tourout testified he understood the relatively liberal and voluntary nature of the conditions to mean they could not constitute some manner of suicide watch.^{Footnote 1540} He gave the example of Cpl Langridge being able to leave LDSH lines, and even the base, with permission. He testified this would never be allowed under a strict suicide watch. WO Tourout noted Cpl Langridge successfully committed suicide while living under the conditions, and used this to infer there was never a suicide watch, because, under a suicide watch, “there is little or no chance that a person is going to be successful in the commission of suicide.”^{Footnote 1541} This is a circular understanding of a suicide watch, and it ignores the fact a suicide watch can only prevent the commission of suicide if it is executed properly, that is, non-negligently. This again was precisely part of the issues the CFNIS should have pursued in a negligence investigation.

Were the conditions for structure and support?

414. MCpl Ritco failed to ask why, if the conditions were for structure and support as claimed, they included measures such as requiring Cpl Langridge to sleep in the defaulters’ room and to keep the door open at all times, as well as to make timed check-ins.^{Footnote 1542} MCpl Ritco was never able to answer the question he put to Sgt Hiscock: “If they didn’t think he was going to hurt himself, why even put these conditions on him?”^{Footnote 1543} MCpl Ritco testified, “I never did found out [sic] the reason why he was on conditions if the – if they believed that he wasn’t going to hurt himself, no, sir.”^{Footnote 1544}

415. This was a question investigators should have pursued thoroughly, given the conflicting, and possibly self-serving, answers given during the 2008 investigation.

416. When MCpl Ritco interviewed CWO Ross, he asked him if there was any other purpose to the conditions other than gaining structure in support of going to substance abuse treatment. CWO Ross simply said “uh-uh.”^{Footnote 1545} However, the conditions were created with members of the LDSH chain of command having some awareness of Cpl Langridge’s medical condition, previous hospitalization, and previous suicide attempts, and witnesses testified the purpose of the conditions was at least in part to ensure Cpl Langridge’s safety.

417. LCol Demers testified he understood conditions, such as residing in the defaulters’ room and checking in every two hours, were meant to provide structure for Cpl Langridge, but also “[…] to try to prevent another suicide attempt like the one in June where he had driven away. We knew that if he was away for over two hours that there was a possibility that he was off trying that same type of thing again […].”^{Footnote 1546}

418. During the 2008 CFNIS interview, upon reviewing his notes, Capt Hannah told MCpl Ritco, Cpl Langridge had attended the CDU(C) at the insistence of his BAC and reported numerous problems with substance abuse and harassment, and Cpl Langridge informed Capt Hannah he needed “close supervision to protect himself and his ex-girlfriend, and he asked to be referred to Alberta Hospital.”^{Footnote 1547}

419. Capt Hannah was asked about his 2008 statement that, because the AHE was “full,” and because Cpl Langridge refused to go to the RAH and denied suicidality, he offered Cpl Langridge “an opportunity for him to live at the LDSH where he could be – have someone that could keep a close eye on him.”^{Footnote 1548} The statement suggests the purpose for having Cpl Langridge live at the LDSH was to give him the close supervision he requested and ensure he was being watched. Capt Hannah agreed the reason Cpl Langridge sought close supervision at that time was because he felt he was a risk to himself and possibly Ms. A.^{Footnote 1549} Capt Hannah denied the aim was to prevent Cpl Langridge from harming himself, but acknowledged, again, Cpl Langridge was at a higher risk of suicide, and it was a “good idea” to have someone keep an eye on him.^{Footnote 1550} Capt Hannah also testified suicidal ideation comes and goes and “[a] person may be suicidal in one instance and not suicidal in another. Suicidality is a difficult thing to pin down sometimes.”^{Footnote 1551} In fact, in justifying the need to give Cpl Langridge conditions for structure and support prior to going to residential treatment, Capt Hannah described Cpl Langridge as “unstable and suicidal and having acute problems.”^{Footnote 1552}

420. The evidence makes it clear there was a widespread awareness within the LDSH and medical community that Cpl Langridge needed to be kept safe. Because the conditions were put in place with that knowledge, the underlying intention and the sufficiency of the conditions to prevent him from harming himself were live issues.

421. During the 2008 interview, Capt Hannah told MCpl Ritco Cpl Langridge was assigned to the defaulters’ room in order to receive “extra supervision.”^{Footnote 1553} When asked what he understood this to mean in terms of Cpl Langridge’s risk of suicide, MCpl Ritco testified, “Well, from his statement here, [...] I take this is that he was staying at the LDSH [...] because he was a higher – higher risk than normal people that are out on the street,” meaning “something to do with [...] suicidal tendencies and attempted suicides.”^{Footnote 1554} Indeed, Capt Hannah told MCpl Ritco in the CFNIS interview, “it’s certainly on the public record” Cpl Langridge was living at LDSH because he was perceived to be at a heightened risk of suicide.^{Footnote 1555} MCpl Ritco disagreed with the suggestion this meant Cpl Langridge was being given extra supervision because he was at a higher risk of suicide, however, and testified, “I don’t take the suicide. I take that he needs extra supervision.”^{Footnote 1556} Though MCpl Ritco was, at the time, unable to determine the purpose of any extra supervision, in his testimony when pressed, he conceded he now believed Capt Hannah was speaking about suicidal risk as the impetus for the conditions.^{Footnote 1557}

422. In his testimony Maj Jared denied the final version of the conditions was intended to ensure Cpl Langridge’s safety, but he also testified at least one of the measures was specifically intended to prevent Cpl Langridge from harming himself – specifically, by a drug overdose:

[…] and there is a correction made with respect to medication. I will say these conditions were imposed on Corporal Langridge as a result of some of the recent experience we had within the regiment, including an individual -- I believe the term was "confined to barracks" within the same room that Corporal Langridge would be staying in -- overdosing on his own medication, which is why included in this documentation, you will see comments about the member's medication. Because we had an individual in that room overdosing on it, the medication would be held by the duty officer. The duty officer would not be responsible to decide on the dosage for the member, but the member would then request the medication from the duty officer and take the dosage as appropriate.^{Footnote 1558}

The purpose of the watch conditions

423. Evidence appears to indicate members of the LDSH chain of command foresaw Cpl Langridge might try to harm himself and were aware of the need to implement some measures to prevent that harm. The potential implication is there was recognition of a wider duty to protect Cpl Langridge, and the conditions were developed, at least in part, with the risk of harm in mind. The failure of the CFNIS members to follow leads and recognize relevant evidence meant they did not undertake any examination of this issue.

424. Despite the fact there was evidence the conditions were developed with the input of members of the LDSH chain of command and medical personnel,^{Footnote 1559} and witnesses such as Capt Volstad and LCol Demers^{Footnote 1560} testified the conditions were vetted by CF legal advisors, there was scant evidence both at the time and during the hearings as to the purpose of the conditions. Had the purpose been investigated in 2008 when memories were fresher, more substantial information might have been obtained. CWO Ross was unable to explain why the condition, as written, required the door be kept open at all times, except that it may have been his “initial thought” when first contemplating close supervision for Cpl Langridge.^{Footnote 1561} Capt Lubiniecki testified he could not explain the reason for the “open door” policy.^{Footnote 1562} Maj Jared testified he believed the door was to be kept open in order to allow Cpl Langridge to “interact with the duty staff,” and it was a “minor” supervisory measure.^{Footnote 1563}

425. The evidence is vague in terms of explaining what this requirement was meant to do, if not what was clearly implied, which was Cpl Langridge was understood to be at risk of harming himself and, believing themselves unable to confine him or guard him at all times, the members of the Regiment devised the requirement to prevent or minimize the harm Cpl Langridge could do to himself while within Regimental lines.

426. Similarly, the 2100 hrs curfew would seem to suggest an attempt to limit Cpl Langridge’s time away from the close supervision possible within the duty centre without actually detaining him. The evidence about this condition was only explored during the hearings and did not wholly explain the purpose of the condition. CWO Ross testified the 2100 hrs curfew was imposed to limit Cpl Langridge’s exposure to drugs and alcohol.^{Footnote 1564} Capt Lubiniecki believed this requirement would prevent Cpl Langridge from being able to go to establishments that served alcohol, but conceded this did not stop Cpl Langridge from going out for a drink prior to 2100 hrs.^{Footnote 1565}

427. The origins of the conditions – the intention to prevent a very unstable and frequently suicidal soldier from harming himself – have to be taken into consideration when interpreting the requirements imposed on Cpl Langridge. This is not to say the conditions had a single purpose. But requiring a soldier to check in regularly, to reside in a highly public area, to keep the door to his room open, and to ask for his daily dosages of medication to prevent overdose attempts, may be evidence of a purpose above and beyond offering him “structure and support” alone. Rather, it may be there was real concern Cpl Langridge was unstable and was going to harm himself. As LCol Demers testified, with an actual suicide watch taken off the table, these “highly unusual” conditions were seen as necessary:

We have never done anything like this before, but it was the best that we could come up [with] between the unit and the doctor to try to provide some kind of control measures in an attempt to assist Cpl Langridge.

It was uncomfortable in a sense that we had never done this type of thing before. It’s a restriction of his freedoms, but we saw what could happen when he had too much freedom, if you will.^{Footnote 1566}

428. WO Tourout was asked if he ever came to a conclusion about the purpose of the conditions placed on Cpl Langridge if they were not because the LDSH believed he would harm himself. WO Tourout endorsed the view Cpl Langridge had actively sought structure and wanted to be under the conditions in order to go on to further treatment.^{Footnote 1567} In his opinion, the conditions could not simply be related to Cpl Langridge being suicidal because the military “had no reason to believe at that point and there were no indications from the hospital that he was suicidal at that point. So, he wasn't -- the conditions were in relation to structure and not to keep him alive.”^{Footnote 1568} WO Tourout reached this conclusion despite Cpl Langridge’s 30-day certification for being a risk to himself, which had ended only days previously, and despite Mr. Strilchuk’s complaint about the need for close supervision because Cpl Langridge was “totally non-compliant” with the restrictions he contracted to prior to March 7, 2008.

429. WO Tourout considered Mr. Strilchuk’s observation Cpl Langridge had to be sent back to the LDSH for close supervision to mean “monitoring”; specifically, Cpl Langridge would be sent to the defaulters’ room “so he could be monitored, observed, not 24 hours a day.”^{Footnote 1569} He was unable to say what Cpl Langridge would have been monitored and observed for, beyond speculating having something to do with restraining Cpl Langridge from abusing alcohol or drugs. Even on this he was uncertain:

Well, it would have been -- then that would have been between a doctor -- I'm not sure what their intention was. Their intention was, from our understanding, was to provide him a structure. So, the structure would have been in close supervision, reporting in every... and be sure he takes his medication. Would that have prevented him from abusing, no, because he was still away for two hours at a time.

MR. FREIMAN: Exactly. And if we're looking for the reasons for the conditions, what would the reason be for having him report every two hours?

MWO TOUROUT: Just so to maintain some -- to give him some -- he knows -- to see if he can deal with timings. [M]ilitary, our world revolves around timings, from basic training right to retirement, we have to be somewhere at a certain time of the day and if you're not, then that's not in accordance with military -- the way the military runs. So, the best way to ensure – to see if someone's acceptable with conditions or of structure is to see if they can make timings, so [...].^{Footnote 1570}

430. WO Tourout testified it was likely Cpl Langridge was required to live at the LDSH under supervision because of his drug use while in hospital. On the other hand, he acknowledged it would have been impossible to prevent Cpl Langridge from abusing substances because of the two-hour interval between check-ins.^{Footnote 1571} The difference between the rationale and the execution of such monitoring and structure may raise an implication of potential negligence in the design of the conditions and/or the manner in which they were administered.

431. Based on the evidence gathered during the 2008 investigation and the Commission’s hearings, it appears one of the purposes of the conditions may have been to provide Cpl Langridge extra supervision and prevent him from harming himself, while satisfying the concerns voiced by officers and legal advisors about mounting an explicit suicide watch.

432. CWO Ross testified he did not believe there would have been any legal obstacles to imposing the conditions because they were not imposed as a form of discipline.^{Footnote 1572} This reinforces the possibility the conditions were seen by those involved in designing and implementing them as the path of least resistance to meet the goal of keeping Cpl Langridge safe.

433. The characterization of the conditions by CF members as being purely for structure does not appear to fit well with the conditions themselves as well as with evidence obtained by the CFNIS investigators or readily available to them. The conditions included measures to supervise Cpl Langridge to prevent him from harming himself. He was required to live at the duty centre, where staff were present 24 hours per day, and he was required to keep his door open to allow them to monitor him. Moreover, the evidence demonstrates, the duty officers for March 14 and 15, 2008, were under the clear impression they were to watch Cpl Langridge because he was at risk of committing suicide. It is difficult to reconcile the conclusions reached about the conditions with these observations.

Were the conditions suitable for their intended purpose?

434. Related to the complainants’ allegation the CFNIS members did not investigate potential acts of criminal negligence or service offences is the possibility the conditions were inadequate for their intended purpose. The CFNIS investigators did not investigate the adequacy of the conditions, and they did not investigate whether imposing such conditions in the absence of disciplinary proceedings constituted the service offence of abuse of a subordinate.

435. MCpl Ritco testified he did not investigate whether the conditions were suitable for giving Cpl Langridge structure and demonstrating he was capable of going on to residential substance abuse treatment.^{Footnote 1573} Sgt Bigelow testified the issue of whether Langridge’s conditions were suitable to either protect or assist him should have been investigated. However, he was unaware whether this was done.^{Footnote 1574}

436. This leads to the question of whether the design and administration of the conditions may itself have been negligent and, as a result, may have contributed to Cpl Langridge’s death. There is evidence to suggest, whatever the stated purpose of the conditions, they were at least in part intended to ensure Cpl Langridge’s safety. Even if the conditions were adequate for this purpose, they would only be effective if Cpl Langridge’s compliance and his progress could be monitored. Because of a limited focus, the CFNIS members were unaware of how the conditions were to be enforced. They did not investigate the extent to which those ensuring Cpl Langridge followed the conditions were familiar with the nature and purpose of the conditions or the implications of inadequately supervising him.

437. CWO Ross informed MCpl Ritco all duty staff were provided with a copy of the written conditions.^{Footnote 1575} The duty staff were also told they must log all of the times Cpl Langridge left the building, the times at which he checked in with the duty officer, and the times at which he returned.

438. MCpl Ritco asked a number of personnel responsible for ensuring Cpl Langridge abided by his conditions whether they were aware of these conditions and knew what they were supposed to do. Although several answered they were not aware, he did not investigate further or reach conclusions about the matter.^{Footnote 1576}

439. The effectiveness of the conditions as a means of protecting and supervising Cpl Langridge seems also to be put in question by apparently contradictory understandings of how they were to be followed. The evidence uncovered during the 2008 investigation, or what would have been available to the CFNIS investigators, made these contradictions apparent and raised the possibility the administration of the conditions was inadequate.

Administration of the check-in condition

440. One such issue had to do with Cpl Langridge’s regular check-ins. CWO Ross told MCpl Ritco, Cpl Langridge had to come to the duty centre every two hours to check in, and he repeated this in his testimony^{Footnote 1577} Many other witnesses indicated the check-ins could be done by telephone. Capt Hannah testified, “he could do that by phone as long as he informed whoever was on the other end of the line where he was.”^{Footnote 1578} Maj Jared testified his recollection was Cpl Langridge could have checked in every two hours by telephone.^{Footnote 1579} Lt Dunn testified his understanding, as a duty officer at the time, was Cpl Langridge could check in by telephone.^{Footnote 1580} Capt Lubiniecki did not recall the arrangements, but he testified he believed the conditions called for Cpl Langridge to phone in on a scheduled basis “just to confirm that everything was well.”^{Footnote 1581}

441. If Cpl Langridge could check in with the duty desk by telephone every two hours, this meant his movements were not being effectively monitored. He could be anywhere and doing anything, especially if he called from a mobile phone. The CFNIS investigators did not determine if the phone number Cpl Langridge left as a contact number was a mobile phone number or a landline. Sgt Hiscock testified the number Cpl Langridge left at the duty desk was for his mobile phone, and it was this number he called repeatedly on March 15, 2008, when Cpl Langridge failed to check in.^{Footnote 1582} He also testified the only way he knew where Cpl Langridge was located was by what was written on the sign-in sheet. Maj Jared also believed Cpl Langridge could leave a mobile phone number.^{Footnote 1583} He acknowledged this meant the LDSH could never really know where Cpl Langridge was or what he was doing, but testified that, if there were duties to assign to him, the number provided still meant they had a way to reach him.

442. Significantly, only the sign-in sheet for the day of Cpl Langridge’s death was ever obtained by the CFNIS investigators. The investigators did not determine what happened to the sign-in sheets for the eight prior days Cpl Langridge spent under the conditions.^{Footnote 1584} They were never found, and their conspicuous absence was unexplained. Additionally, the CFNIS members did not investigate whether it was sufficient to simply accept Cpl Langridge’s repeated check-in reports that he spent nearly the entirety of his last day in the shacks “doing laundry.”^{Footnote 1585} Sgt Hiscock testified Cpl Langridge signed in personally each time after 0905 hrs on March 15, 2008. He assumed Cpl Langridge was in the shacks doing laundry.^{Footnote 1586} During his CFNIS interview, Sgt Hiscock stated he was told Cpl Langridge was going to the barracks to do laundry on March 15, 2008, but it was not Cpl Langridge who provided him with that information. In his testimony, Sgt Hiscock no longer recalled who gave him that information. He acknowledged, in hindsight, it was unusual Cpl Langridge would spend so much time doing laundry and admitted he should have questioned him. However, because that was a particularly busy Saturday for the Regiment, and because Cpl Langridge was still checking in, it was not high on the list of competing priorities.^{Footnote 1587}

The administration of other conditions

443. Other aspects of the effort to monitor and enforce the conditions were also unclear, and again, would have warranted investigation in connection with possible negligence. While the purpose of keeping the door to the defaulters’ room open at all times was to monitor Cpl Langridge’s well-being, the CFNIS investigators did not determine whether or not the door was actually kept open.

444. The CFNIS investigators also did not ascertain whether Cpl Langridge took his medication as directed. The information the CFNIS investigators obtained in 2008 showed Cpl Langridge’s prescription medications were intended to treat depression, anxiety and insomnia.^{Footnote 1588} Failing to take them might have affected his state of mind.^{Footnote 1589} Sgt Bigelow testified his understanding was the duty personnel were not verifying Cpl Langridge was taking his medication, and he was responsible for this on his own.^{Footnote 1590} CWO Ross testified this to be the case as well.^{Footnote 1591} Witnesses, such as Lt Dunn, testified they understood they did have to ensure Cpl Langridge took his medication.^{Footnote 1592} Capt Hannah did not testify whether Cpl Langridge’s compliance with his prescribed medications was in any way monitored or enforced, but, during his CFNIS interview, he told MCpl Ritco the LDSH was responsible for ensuring Cpl Langridge took his medication appropriately and on time.^{Footnote 1593}

Controlling access to alcohol and illicit substances

445. The conditions required Cpl Langridge to abstain from alcohol and narcotics. There was no realistic way to ensure his compliance, particularly in light of the problems in monitoring his movements. The CFNIS investigators were told by Capt Hannah in 2008 that Cpl Langridge’s substance abuse was likely inducing mood disorders, which led to suicidal behaviour, and his periodic binging triggered suicide attempts.^{Footnote 1594} Without attempting to draw conclusions about Cpl Langridge’s state of mind or the reasons for his suicide attempts and his ultimate suicide, it is nevertheless clear the CFNIS investigators had cause to investigate whether Cpl Langridge was appropriately supervised. Cpl Langridge’s safety was possibly at risk in the absence of such supervision. CWO Ross acknowledged in his testimony there was no way to monitor Cpl Langridge’s compliance concerning drugs, but argued the duty staff would have detected the smell of alcoholic beverages and notified him if Cpl Langridge had been drinking.

446. Ms. A testified Cpl Langridge was able to leave the base on multiple occasions, sometimes by sneaking out, and was consuming alcohol. This contrasts with the assurance she testified was given to her by Cpl Langridge’s addiction counsellors, “he was never alone and therefore there wasn’t any time for him to be doing drugs or drinking or trying to hurt himself.”^{Footnote 1595} Not having interviewed Ms. A, the investigators were unaware of this evidence.

447. Despite the obvious difficulties in preventing Cpl Langridge from accessing alcohol and illicit substances with the relative freedom he enjoyed at the LDSH, Capt Hannah testified it was actually better for Cpl Langridge to be back at the base than in hospital. Looking back at the incident on March 7, 2008, when Cpl Langridge requested to be sent to the AHE, Capt Hannah testified he felt Cpl Langridge was upset with the requirement to live in company lines because “he didn’t like to be told what to do,” and speculated the LDSH wanted to impose more stringent rules:

Corporal Langridge -- it hasn't been really stated -- while he was at the Alberta hospital previously, had been using cocaine while he was in the hospital. I would wonder whether or not he felt that it would be less obvious, he could get away with using cocaine while he was in the hospital, where it would be very difficult to do that in the Strathconas. Perhaps it was a method to avoid that type of having people around. I don't know, to be honest.

Q. Would it be difficult for him to use cocaine while he was with the Strathconas?

A. I think it would be. His behaviour would certainly change. There are people around. He's in uniform. There would really be no opportunity to -- it would be very awkward to go out to the smoking area or use cocaine in a place like that, where in an anonymous place like a hospital where he's not wearing the uniform, it would be much easier to do it. There would certainly be more people around the Strathconas who knew him and knew what he was doing, much like if he lived in a small town. Everyone is going to know who you are as opposed to if you live in downtown Ottawa. No one knows or cares who you are, and you become an anonymous face.^{Footnote 1596} [Emphasis added]

448. This might have been an unsound assumption, and would be particularly troubling if it played any role in the determination of where Cpl Langridge would be safest and most stable or what supervision was appropriate. The medical records and the testimony of Dr. Sowa indicate, when it became clear Cpl Langridge was accessing narcotics while at the AHE, his grounds privileges were revoked. This caused him considerable frustration, but in general the AHE had a much greater ability to restrict his movements than the LDSH, particularly when he became unstable, because, despite having originally admitted himself to the AHE on a voluntary basis, Cpl Langridge was placed under a 30-day certificate for the duration of his stay. In fact, Capt Hannah conceded in his testimony it would have been impossible to prevent Cpl Langridge from using narcotics under the conditions imposed at LDSH.^{Footnote 1597}

449. The evidence above casts doubt on the effectiveness of the conditions as a mechanism for protecting Cpl Langridge from harm. This raises the possibility the conditions were negligently put into effect, negligently administered, or both, and the further possibility such potential negligence contributed to Cpl Langridge’s suicide.

450. Taking Cpl Langridge out of hospital for the purpose of preventing him from accessing drugs and alcohol may imply the CF and base medical personnel undertook to do better. At the AHE, Cpl Langridge could be controlled and observed to a much higher degree, and yet was able to find ways to access drugs unless medical personnel restricted his freedom of movement. With a stated focus on substance abuse prevention and stabilization,^{Footnote 1598} the conditions imposed by the Regiment were in some ways strict, but if the purpose was actually to do better than the civilian medical system, they were unsuccessful.^{Footnote 1599} If Cpl Langridge was required to abstain from abusing substances but provided ample opportunity to access those substances without his movements being meaningfully monitored or controlled, that may be another indication of possible negligence.

The condition to reside in the defaulters’ room

451. Another issue in the design and administration of the conditions raised by the evidence was the requirement for Cpl Langridge to reside in the defaulters’ room. Capt Hannah testified Cpl Langridge was assigned to the defaulters’ room for several reasons – first, because he had no other place to live.^{Footnote 1600} However, before his discharge from the AHE, arrangements had been made for Cpl Langridge to reside in barracks. Capt Hannah testified the value of keeping Cpl Langridge in the defaulters’ room was also the reassurance of constant company:

If you're sleeping in your Jeep or you're in a hotel room by yourself, you have nobody to talk to. If it's 3:00 in the morning and you feel like killing yourself, who do you phone? Do you phone somebody and wake them up and get them out of bed? I would argue that most people are reluctant to pick up their phone and call people at 3:00 in the morning, recognizing that they are most likely sleeping where, at the Strathconas with the Duty Officer there awake and on duty 24 hours a day, he had access. I think that recognizing suicidal behaviour comes and goes, absolutely.^{Footnote 1601}

452. This was a mistaken perception. Duty personnel may all be asleep during the night; they have beds in a room beside the defaulters’ room in the duty centre; and there was no requirement one member present had to be awake at any given time.^{Footnote 1602} This might prompt questions whether keeping Cpl Langridge in the defaulters’ room at night served the purpose of keeping him safe.

453. Capt Hannah testified if Cpl Langridge felt suicidal at any point, he would be “in a place with people around him that know him and care about him, and if he has a question, there is someone available at all times.”^{Footnote 1603} The notion Cpl Langridge would be in the company of people who cared about him – or were even friends – at the duty centre was mistaken. No matter the good intentions and professionalism of the duty centre staff, the evidence demonstrated duty officers like Lt Dunn were not friends with Cpl Langridge.^{Footnote 1604}

454. Sgt Hiscock admitted he was contemptuous to Cpl Langridge the day he died.^{Footnote 1605} He testified he made an assumption Cpl Langridge was faking a claim of having PTSD for personal gain. When Cpl Langridge talked to Sgt Hiscock about his medication and having bad dreams, Sgt Hiscock testified he responded by rolling his eyes, sighing, and saying “Oh, here’s another one.”^{Footnote 1606} Sgt Hiscock testified he would still have made derisive comments and reacted negatively, even knowing what he does now.^{Footnote 1607}

455. Cpl Langridge’s troubles were widely known, and it is not clear he would have felt cared for in a public area frequented by soldiers, some of whom considered him “a waste of oxygen.”^{Footnote 1608} The CFNIS investigators possessed some information about the scrutiny, skepticism, and even hostility Cpl Langridge faced in March 2008, and it was an open question whether residing at the duty centre had a positive or negative impact on his safety and supervision.

456. In the same way as a failed suicide watch might raise issues of negligence, even if the conditions did not amount to a “suicide watch” but were nevertheless intended to prevent Cpl Langridge from harming himself, it seems relevant to ask whether they were adequate for that purpose given his fate. If not, were they so inadequate for the purpose of keeping Cpl Langridge safe as to constitute negligence?

457. The evidence indicates the conditions may have been insufficient for their intended purpose and may have been poorly administered. They may have been incapable of providing Cpl Langridge with structure and may have been inadequate to prevent him from harming himself. Monitoring and enforcement of the conditions appear to have been lax; personnel appear to have been unclear as to what was required; and there is evidence Cpl Langridge was not always compliant. Because he could check in by telephone from essentially any location, Cpl Langridge seems to have been given ample time on his own, for practical purposes unaccountable and unsupervised, to come to harm. He was still able to access alcohol and drugs, and his health and state of mind during his intense and unstable final days seemed to go unnoticed and without comment. If there was a duty to keep Cpl Langridge safe, or if the CF assumed such a duty, these would all be relevant matters in assessing possible negligence.

Did the conditions contribute to Cpl Langridge’s death?

458. The CFNIS investigators viewed the existence of a suicide watch as essential to any finding negligence played a role in Cpl Langridge’s death. Consequently, WO Tourout did not believe the conditions were relevant to possible negligence. He accepted the assertion by CWO Ross and Capt Lubiniecki the conditions were for structure and relied on this definition to distinguish the conditions from a failed suicide watch. In his view, because the conditions gave Cpl Langridge some time to himself, they were different from a suicide watch.^{Footnote 1609} According to MWO Watson’s testimony, the following issues related to the conditions were irrelevant to the investigation:

whether Langridge agreed to the conditions put on him;
what the purpose of the conditions was;
whether the requirement Langridge had to sleep with the door open was a sign the conditions were a form of suicide watch;
whether there was a plan to send Langridge to treatment in Ontario;
whether there was a plan to release Langridge from the military if he failed to comply with his conditions;
whether and how the conditions were being enforced; and
whether the conditions themselves could have contributed to Langridge committing suicide.^{Footnote 1610}

459. What should have been evident to the CFNIS investigators, based on the information obtained during the 2008 Investigation, was that Cpl Langridge was unstable, was reacting poorly to the conditions, had requested changes to the conditions, and those requests were denied. There was evidence available to the CFNIS investigators suggesting the conditions were not voluntary, and Cpl Langridge was required to return to the base to abide by the conditions and prove himself before he would be authorized to go on to treatment.

460. On March 11, 2008, Cpl Langridge reported active suicidal thoughts regarding the prospect of going back to work. Regardless of what the appropriate response by the LDSH or the base medical community should have been, the impact of the conditions on Cpl Langridge was relevant. MCpl Ritco testified he did not pursue the matter of Cpl Langridge’s suicidal statements 4 days before his death. He testified the main relevance of this incident was that it “just shows that Corporal Langridge was dealing with issues.”^{Footnote 1611} Sgt Bigelow was asked if he and MCpl Ritco investigated whether this specific suicidal ideation changed anything in terms of the potential legal limitations or obligations on the Unit with respect to a possible suicide watch. He replied they did not.^{Footnote 1612} This position meant CFNIS members did not consider the possibility the conditions may have constituted negligence contributing to Cpl Langridge’s death.

Did Cpl Langridge agree to the conditions voluntarily?

461. The CFNIS members did not investigate in depth whether Cpl Langridge voluntarily agreed to the conditions imposed on him in March 2008. This matters because if Cpl Langridge found the conditions intolerable, the flexibility of the conditions and the potential consequences for disobeying them might have had significant repercussions with respect to his stability and state of mind. MCpl Ritco received conflicting information about whether Cpl Langridge voluntarily agreed to the conditions. Capt Lubiniecki testified he had no role in the formulation of Cpl Langridge’s conditions. However, he testified his understanding was Cpl Langridge had voluntarily submitted to the conditions and the requirement to reside at the duty centre.^{Footnote 1613} After Cpl Langridge’s death, Capt Lubiniecki sent a Significant Incident Report to Ottawa HQ indicating Cpl Langridge “was residing in the regimental duty centre under his own admittance in conjunction with regimental direction.”^{Footnote 1614} He could not recall how he obtained this information.^{Footnote 1615}

462. The notes taken at Capt Lubiniecki’s 2008 CFNIS interview make reference to the fact he spoke to Capt Hannah about Cpl Langridge’s request to live in the shacks rather than in the duty centre and Cpl Langridge’s attempt to convince Capt Lubiniecki there was no need to “come in” (possibly a reference to the reporting-in period). Sgt Bigelow wrote, “Agreed with steps unit taking on forcing Cpl Langridge committed to taking course.”^{Footnote 1616} The word “forcing” is potentially significant as it may suggest Cpl Langridge was being compelled into doing something linked to his ability to participate in the substance abuse treatment he sought. Little is known about the request or its context. At the time of Capt Lubiniecki’s testimony, the Commission had not obtained Sgt Bigelow’s notebook, which was unfortunately never scanned into the SAMPIS system. The summary of the interview in SAMPIS, prepared by Sgt Bigelow, did not refer to this passage.^{Footnote 1617} As a consequence, Capt Lubiniecki was not asked to testify about this incident. This passage raises obvious questions.

463. CWO Ross’ evidence was he and Cpl Langridge had a lengthy discussion about the conditions. He recalled, at the end of the conversation, Cpl Langridge “was very happy about it. He thanked me stating that he needed some structure, he wanted to be a good soldier, he wanted to get on with things, and he seemed very, very compliant with it.”^{Footnote 1618} CWO Ross testified he would not have imposed the conditions if Cpl Langridge had been unwilling.

464. On the other hand, when Cpl Langridge subsequently requested a change to the conditions and made it clear he was extremely unhappy under them, CWO Ross refused.

465. CWO Ross testified he did not feel enough time had elapsed for Cpl Langridge to “prove” to him, “’I’m complying with everything you are asking me to do. I have shown you that over a period of time. I’m now asking for some additional leeway.’”^{Footnote 1619} Regardless if these constraints were initially voluntary, this requirement may be relevant to the issue of their possible impact on Cpl Langridge’s state of mind on a going forward basis.

466. Additionally, the consequences Cpl Langridge faced for failing to comply with the conditions could have been serious. CWO Ross stated in his CFNIS interview, the conditions had the force of orders and Cpl Langridge could have been charged with a service offence or deemed AWOL for failing to obey them. He testified, “There is [sic] consequences to any soldier who does not follow direction.”^{Footnote 1620} Again, this could have been relevant to understanding Cpl Langridge’s state of mind. Failing to abide by conditions he found onerous and intolerable could have resulted potentially in serious disciplinary action.

Compliance with conditions as a prerequisite for substance abuse treatment

467. There is also evidence Cpl Langridge was told he would not be eligible for drug treatment unless he agreed to the imposition of conditions. This may have meant Cpl Langridge was in a nearly impossible situation – his treatment was predicated on making progress he may not have been capable of without that treatment itself, or something analogous to it.

468. Ms. A testified Cpl Langridge was told, at the time of his AHE release, returning to the base was mandatory if the CF was going to send him for further substance abuse treatment. CWO Ross testified he believed compliance with the conditions would have played a “very large part” in the final decision, and it was his understanding, until Cpl Langridge demonstrated compliance with the conditions, the medical side was unwilling to send him.^{Footnote 1621}

469. Capt Lubiniecki informed MCpl Ritco during his CFNIS interview the medical community would not incur the expense to send Cpl Langridge to residential substance abuse treatment without him demonstrating he could comply with the conditions. He also testified his understanding was the medical personnel did not support Cpl Langridge attending a second course until he proved he could attend scheduled AA meetings.^{Footnote 1622}

470. Capt Hannah testified compliance with the conditions was never a prerequisite for Cpl Langridge being sent to the rehabilitation program.^{Footnote 1623} He testified he recognized people struggling with addictions typically misbehaved, and it would be circular to expect individuals who needed treatment to prove they could straighten themselves out. He also testified he told Cpl Langridge on March 7, 2008, he needed “to behave himself. He needs to smarten up, stop using alcohol, stop using drugs.” ^{Footnote 1624} When asked about a base clinic record stating, “Discharged from Alberta Hospital today for a trial of good behaviour to see if capable of going to addiction treatment centre,”^{Footnote 1625} Capt Hannah initially rejected the word “precondition” in reference to the treatment.^{Footnote 1626} He testified the treatment centre was not a place to send someone who “is incredibly unstable and suicidal and having acute problems.”^{Footnote 1627} A person would need to be at least somewhat stable and cooperative and capable of sitting down to “have a civilized conversation with someone who may have a different opinion than he will […]” before doing so.^{Footnote 1628} Capt Hannah endorsed this more qualified version of “precondition,” adding “[…] you don’t have to be perfect – don’t get me wrong – but you need to kind of at least show that you can follow some routine […].” He explained sending someone to treatment was very expensive. He believed the cost was in the tens of thousands of dollars. He acknowledged, “in a sense,” Cpl Langridge’s treatment was conditional on his good behaviour, but denied this meant there was a condition that “You must behave. Otherwise, we will never send you to treatment.” ^{Footnote 1629}

471. As with many aspects of the evidence about the suicide watch and conditions, this may raise questions. If Cpl Langridge was not stable enough to go to treatment, and if he was suicidal, non-compliant and unable to follow routines, why was he brought back from the AHE? Why would he be subject to voluntary conditions in an environment ill-equipped to handle him, under the authority of doctors who could not provide him 24-hour care, and with military members unwilling to supervise him constantly?

472. Capt Hannah’s testimony highlights the conundrum. He testified he told Cpl Langridge he could not go to the treatment program until he demonstrated he could follow some rules. If Cpl Langridge was unable to demonstrate this, and was instead “struggling” and “acutely ill,” Capt Hannah told him, then “[…] we really can’t send you to a treatment program that doesn’t have the facilities to deal with that. We will have to do something else […]”^{Footnote 1630} specifically, sending Cpl Langridge to the AHE or RAH, “in the direct care of a psychiatrist.”^{Footnote 1631} Either Cpl Langridge was well enough to go to treatment by being able to meet the conditions, or he was not well enough and could not satisfy the conditions, and would likely have to return to a hospital equipped to handle him. This not only seems like the essence of a precondition to treatment, but also appears to rely on the assumption Cpl Langridge was well enough to be taken out of the hospital in the first place.

The impact of the conditions on Cpl Langridge

473. It is clear Cpl Langridge loathed the conditions, but the CFNIS investigators did not examine the significance of his request for a loosening of the restrictions upon him, including a reduction in the frequency of reporting. MCpl Ritco testified the matter had relevance in terms of “[…] just trying to find out what was going on. So it did have some relevance. But [...] did it have an impact on my outcome of my investigation? No.”^{Footnote 1632} There was also no investigation into the possibility the denial of his request for a revision to the conditions triggered a further decline in his condition.

474. Sgt Bigelow’s notes provide some details about Capt Lubiniecki’s 2008 CFNIS interview and refer to Cpl Langridge’s request to adjust the conditions. During the interview, Capt Lubiniecki recounted Cpl Langridge had requested his check-in interval be increased from two hours to three hours.^{Footnote 1633} Capt Lubiniecki informed Cpl Langridge he would lessen the requirements if Cpl Langridge could prove himself. Cpl Langridge was expected to prove himself over the weekend (presumably the weekend of March 15 and 16, 2008, given the conditions had only been imposed the Friday of the weekend before). According to Sgt Bigelow’s notes, Capt Lubiniecki gave a note to a MCpl Banks to pass to Cpl Langridge. This was placed on Cpl Langridge’s pillow. The Commission knows little about the request because it was only documented in Sgt Bigelow’s notebook.

Cpl Langridge’s workload

475. Another condition with which Cpl Langridge seems to have struggled concerns the workload expected of him. CWO Ross testified, under the conditions, he would have assigned Cpl Langridge “very meaningful jobs, all things that any soldier would probably have to do at some point or another.” This would include taking out garbage, cleaning out oil pans underneath the LDSH vehicles, and cleaning and polishing trophies.^{Footnote 1634} He did not recall what he actually assigned Cpl Langridge to do, although there is evidence Cpl Langridge was assigned similar duties even before the conditions were imposed.^{Footnote 1635}

476. There was also evidence Cpl Langridge was required to work between 0800 hrs and 1630 hrs, which would have been half an hour longer than normal. CWO Ross told MCpl Ritco in his 2008 interview, “[t]he only thing I asked him to do was to work a half-an-hour beyond everybody else. Half-an-hour beyond everybody else. […] Just because I wanted to do that, to be quite honest.”^{Footnote 1636} This appears to indicate this was done essentially on a whim. When asked about this, CWO Ross testified this was done to make Cpl Langridge available in case any work came up at the last minute, which the RSM required to be done before the end of the day.^{Footnote 1637} He testified there “was some talk” about the fact Cpl Langridge had only been working three half days per week^{Footnote 1638} prior to this, but he did not know all the details.^{Footnote 1639} CWO Ross justified this dramatic change in working conditions by stating he assumed medical personnel would have objected to this requirement if they had had any concerns about its suitability.

477. There was evidence Cpl Langridge was suffering from chest pains and panic attacks triggered by work even before the conditions were imposed.^{Footnote 1640} There was also evidence Cpl Langridge reacted extremely poorly to the work requirements under the conditions and may have had suicidal thoughts as a result.^{Footnote 1641} This raised the possibility Cpl Langridge actually found the imposed work expectations devastating.

478. Capt Hannah testified he had no idea what Cpl Langridge’s work hours were before the conditions were imposed.^{Footnote 1642} He believed there was no intention to assign Cpl Langridge extra work hours but, on being presented evidence Cpl Langridge had been working reduced hours before his hospitalization, Capt Hannah was unconcerned. He disputed Cpl Langridge was actually required to work full days under the conditions. He contended Cpl Langridge spent most of his time attending appointments, and his duties could have been “anything” depending on the RSM’s instructions and “could include doing nothing, presumably.”^{Footnote 1643} He agreed he would have had an issue had Cpl Langridge been ordered to work five days a week, eight and a half hours a day. He would have contacted Capt Lubiniecki about it. Capt Hannah testified he did not believe this was the case.^{Footnote 1644}

479. The duty centre sign-in sheets were never recovered. These might have cast some light on what a weekday looked like for Cpl Langridge during the last week of his life. In particular, his duties, appointments, supervision and workload might have been laid out for the investigators. However, all they could discern from the evidence was how Cpl Langridge spent his last Saturday. Considering the conditions were imposed on a Friday afternoon, and Cpl Langridge was requesting a change to the conditions and urgently seeking admission to hospital by the following Tuesday, there was at least some cause to ask what the weekdays might have had in store and whether Cpl Langridge’s work week may have precipitated a further decline in his condition.

480. Medical records obtained by MCpl Ritco from the base CDU(C)^{Footnote 1645} note Cpl Langridge attended the CDU(C) on March 11, 2008, in a state of crisis. He complained he had gone two nights without sleep and was working during the day when he was formerly on half days, and he had to report in every two hours after work. Cpl Langridge was described as tearful and anxious, and the note recorded, upon realizing he would be forced back to work that day, he said “he would rather kill himself than go back to work.”^{Footnote 1646} On this basis, Cpl Langridge was referred to the RAH and remained there between March 11 and 13, 2008. This appears to be the incident reported to CWO Ross by medical personnel and described in the transcript of his 2008 CFNIS interview.

481. Capt Hannah testified he felt the fact Dr. Robert Turner, who wrote the notes, sent Cpl Langridge to the hospital because he was suicidal was an appropriate response.^{Footnote 1647} He testified that “only three days later, [Cpl Langridge] was doing quite well and was happy with the situation.”^{Footnote 1648} According to him, the fact Cpl Langridge was upset one day and not upset another day did not mean “[…] that the whole thing was a terrible idea or that he was unhappy all the time […] He certainly said to [Dr. Robin Lamoureux] that he was doing fine.”^{Footnote 1649} Capt Hannah pointed to Cpl Langridge’s attendance at the CDU(C) on March 14 for a prescription renewal as “very clearly imply[ing]” he believed he needed the prescription and did not intend to kill himself at that point.^{Footnote 1650} Capt Hannah suggested Cpl Langridge’s instability stemmed from being in withdrawal from cocaine, likening the effects to the upset and irrationality of quitting smoking.

482. MWO Watson testified it “[c]ould have been”^{Footnote 1651} relevant to the investigation that Cpl Langridge sought a relaxation of the conditions and his request had been denied. The evidence indicated a seemingly distraught Cpl Langridge stated he found the conditions unbearable and a return to work worse than death. However, MWO Watson testified the records made by Dr. Turner on March 11, 2008, were “relevant,” in that the investigators took copies of them, but he felt it was not significant for the question of whether the conditions could have contributed to Cpl Langridge’s suicide. He explained the fact Cpl Langridge was later discharged from the hospital (having first mistakenly testified Dr. Turner himself had released Cpl Langridge after noting these concerns) indicated the physicians were not concerned he would harm himself, meaning Cpl Langridge’s frustration with the conditions was not relevant to his suicide.

483. MWO Watson did not know why Dr. Turner was not interviewed.^{Footnote 1652}

484. On the whole, the CFNIS members failed to recognize or act on evidence of actions undertaken by LDSH personnel and base medical personnel that might potentially have created dangers to Cpl Langridge or exacerbated existing dangers. The conditions may not have been adequate to prevent Cpl Langridge from harming himself. The conditions apparently seemed intolerable to Cpl Langridge. The failure to take appropriate measures to ensure his safety in light of such an extreme reaction might also potentially have been implicated in his death.

Was a suicide watch planned?

485. The CFNIS interviews of MCpl Fitzpatrick, MCpl Bowden, and CWO Ross all suggested a watch was planned upon Cpl Langridge’s release from the AHE. Members such as MCpl Bowden provided evidence suicide watches did occur within the CF, and she testified she was specifically asked to put together a list of personnel able to conduct a suicide watch for Cpl Langridge before CWO Ross cancelled it.^{Footnote 1653} MCpl Bowden told the CFNIS investigators the watch was already underway, with a member accompanying Cpl Langridge in the room behind the duty desk, before it was cancelled.^{Footnote 1654} She also stated Cpl Langridge had previously been the subject of a suicide watch.^{Footnote 1655}

486. MCpl Ritco told the Commission, after conducting all of his interviews he concluded, “that there was a watch being set up -- personnel to watch Corporal Langridge, if need be, 24/7.”^{Footnote 1656} This conclusion does not appear in his Concluding Remarks^{Footnote 1657} or anywhere else in the investigation report. MCpl Ritco also testified he was unable to determine whether this meant a suicide watch was planned.^{Footnote 1658} CWO Ross told MCpl Ritco the planned watch was a 24-hour a day watch, for an unnamed purpose different from a suicide watch.^{Footnote 1659} MCpl Ritco testified he “took it as there wasn’t a suicide watch”^{Footnote 1660} and accepted these assertions to be conclusive.^{Footnote 1661}

487. MCpl Ritco relied on an assertion that does not seem capable of withstanding much scrutiny. The obvious question was never posed. If the watch was not a suicide watch, what was it for? Further, if it was a suicide watch, why was it cancelled, and was the cancellation reasonable in the circumstances? Each question about the suicide watch raised further questions, or should have. It is concerning MCpl Ritco appears to have simply left these matters dangling.

488. MCpl Ritco testified he was unable to come to any conclusions as to the purpose of the 24/7 watch. He could not understand why there would be a constant watch planned if Cpl Langridge were not suicidal, and it was never explained to him.^{Footnote 1662} The paradox ought to have been revealing in and of itself as the difficulty of answering that question emphasizes the implausibility of its very premise.

489. One answer best fits the evidence obtained by or readily available to the CFNIS investigators. Simply put, a plan had been devised to watch Cpl Langridge to prevent him from harming himself.

The purpose of the planned watch

490. MCpl Ritco did not determine why Cpl Langridge was required to reside in the defaulters’ room – possibly as early as March 5, 2008, the day of his discharge from hospital – if he was not on defaulters or not under some form of a suicide watch.

491. CWO Ross’ contention he was legally prevented from conducting a suicide watch raised additional questions. What was the basis for CWO Ross’ belief? How could it be reconciled with evidence of other suicide watches being organized? And, under which circumstances could such a constraint change? MCpl Ritco did not investigate the assertion the Regiment was not legally able to conduct a suicide watch without explicit direction from a physician. Answering this question would have given the CFNIS members a better understanding of what the LDSH could have done regarding Cpl Langridge, and the potential consequences of taking certain actions. All these questions appear relevant to the issue of negligence.

492. On a related theme, MCpl Ritco failed to inquire why a watch was not conducted after Cpl Langridge’s attendance at sick parade the week he died. If, as was suggested to MCpl Ritco, the bar against mounting a suicide watch was the need for medical staff to tell the Regiment Cpl Langridge was suicidal, why was it not mounted once the medical staff informed CWO Ross that Cpl Langridge was actively expressing suicidal thoughts?^{Footnote 1663} What duties should such information have triggered in the circumstances?

493. MCpl Ritco was asked why he concluded this aspect of the investigation despite being unable to determine the matter. He testified:

Since I spoke with Chief Warrant Officer Ross at the very end of my investigation, there was basically -- he confirmed that with all the rumours that he was on a suicide watch, he wasn't on a suicide watch; he was in defaulters, he wasn't in defaulters, that's the reason why we went to go speak with Chief Warrant Officer Ross as the discipline person in LdSH, get it right from him what exactly was going on.

So, to answer your question, yeah, basically when we were done speaking with him that I was led to believe that there was no suicide watch, that people were being arranged should Stuart need to be watched, but he said there wasn't a suicide watch and that there was no defaulters.

MR. FREIMAN: Okay. I appreciate you said, "led to believe", but you're an investigator, sir, so one of the things you need to is to draw conclusions.

SGT RITCO: Absolutely.

MR. FREIMAN: Not just being led to believe. So, when you heard that, you heard there might have been a watch but it wasn't a suicide watch, what kind of a watch could it have been if it wasn't a suicide watch?

SGT RITCO: I don't know, sir, but you'd have to ask Chief Warrant Officer Ross that.

MR. FREIMAN: Did you?^{Footnote 1664}

494. MCpl Ritco did ask CWO Ross the purpose of the 24/7 watch, but when CWO Ross told him it was not considered a suicide watch, he did not inquire what other purpose there might have been.^{Footnote 1665} Regarding why he did not ask this fundamental question of CWO Ross, MCpl Ritco provided a candid answer:

I was dealing with a sudden death investigation, sir. I can't think of all the questions. I mean looking at it back now, with all the issues with the suicide watch and the defaulters, maybe it should have been a question I asked. At the time I didn't feel it was relevant – […] – or I didn't feel that I needed to ask it.^{Footnote 1666}[Emphasis added]

495. When questioned about this during his testimony before the Commission, CWO Ross acknowledged, generally, the purpose of a 24/7 watch is for the protection of the individual being watched.^{Footnote 1667} He also admitted there was very little difference between the 24/7 watch he proposed and a suicide watch.^{Footnote 1668} CWO Ross even conceded the possibility MCpl Fitzpatrick heard the term “suicide watch” from him directly and this caused it to be used throughout the Regiment.^{Footnote 1669}

496. During his testimony, CWO Ross was presented with a patient update report from Mr. Strilchuk dated March 7, 2008.^{Footnote 1670} In it, Mr. Strilchuk wrote Cpl Langridge had just returned from a 30-day stay at the AHE, and he had contracted to many restrictions but was “totally non-compliant.”^{Footnote 1671} He was so non-compliant, he “had to be sent to his unit for close supervision.”^{Footnote 1672} Mr. Strilchuk called for employment restrictions prohibiting Cpl Langridge from weapons and from driving, and indicated he required close supervision and monitoring.

497. CWO Ross acknowledged the recommendation for “close supervision” could refer to a 24/7 watch or something similar.^{Footnote 1673} He did not believe it was possible to do so without a disciplinary or medical reason for such a watch, but agreed it could have been done had the base clinic requested a 24/7 watch. The limiting factor would be the fact LDSH personnel were “not really trained for that.”^{Footnote 1674}

498. CWO Ross was then presented with the notes of Capt Hannah’s medical restrictions for Cpl Langridge, also recorded on March 7, 2008.^{Footnote 1675} In it, Capt Hannah directed a three-day period of “supervision @ LDSH.”^{Footnote 1676} CWO Ross was asked if it was his understanding Capt Hannah was directing three days’ worth of supervision and if it was on that basis he devised the suicide watch plan, which was subsequently rejected by Maj Jared. CWO Ross testified he could not recall what he had discussed with Maj Jared.^{Footnote 1677} He denied this conversation caused him to change his mind about the watch and reiterated the change was the result of ongoing discussions with Capt Hannah.

Evidence about the CF and “suicide watches”

499. There is evidence a “suicide watch” is not an officially recognized concept within the CF. Maj Jared testified suicide watches were not an unknown concept but “did not exist” within the Regiment.^{Footnote 1678} On the other hand, many members understood such watches to have been employed in practice. In addition to MCpl Bowden and Sgt Hiscock, Lt Dunn testified he was told to watch Cpl Langridge, and the purpose of doing so was to prevent his suicide.^{Footnote 1679} Maj Cadieu testified he had been involved in and indeed sat on several suicide watches over the years, describing it as a period of 24/7 observation (effectively a guard ensuring constant supervision) when a member credibly threatens harm to himself or herself.^{Footnote 1680} More to the point, when Cpl Langridge was discharged from the RAH in February 2008, Maj Cadieu sent an email message to the LDSH leadership to advise them he was released to his own residence and a friend (likely Cpl Bartlett)^{Footnote 1681} offered to spend the evening with him. Maj Cadieu specifically mentioned the possibility of conducting a “watch”:

BPT [presumably “be prepared to”] provide soldiers to ‘watch’ Cpl Langridge only if directed by the CO/RSM/Adjt, after consultation with the HSS community. This is not reqr [required] at this time.^{Footnote 1682}

500. The recipients of this message included Maj Jared, LCol Demers, CWO Ross, Capt Lubiniecki, Capt W.R. Hubbard, and MWO Mulhern. It is not known what if anything was said in reply.

501. Even Capt Lubiniecki, who denied the use of suicide watches within the CF, acknowledged watches of different kinds could be applied to soldiers for multiple reasons, including watching over a member for their health or safety.^{Footnote 1683} His primary objection to the notion of the CF mounting suicide watches seemed to be the implication the medical community might release persons from their care, having assessed them as not being a danger to themselves, while at the same time requesting a suicide watch for them.^{Footnote 1684} CWO Ross testified, while he had never had to organize a suicide watch, he knew doing so within the CF was a possibility.^{Footnote 1685} This might happen where, for example, an individual was to be watched at the MP cells but, because of a shortage of available MP staff, the Unit would provide the watch instead. He testified it might also happen in a hospital situation where there was a shortage of staff, so members would conduct the watch.^{Footnote 1686}

Earlier suicide watches

502. Beyond the evidence suicide watches were not an unknown phenomenon within the CF, there was also evidence available to the investigators suicide watches had been discussed concerning Cpl Langridge in March 2008 and during previous incidents in the last months of his life. Had the CFNIS members interviewed witnesses such as Ms. Ferdinand, a primary care nurse at the base CDU(C) in 2008, they would have learned she had been told in March 2008 a “safety plan” would be put in place regarding Cpl Langridge upon his release from the AHE, and he would be “watched.”^{Footnote 1687} In fact, she had been part of repeated discussions about the proper level of care and supervision for Cpl Langridge to ensure his safety.

503. Cpl Langridge’s decision to remove himself from residential substance abuse treatment in January 2008 was something of a crisis. Don Perkins, a BAC, approached Ms. Ferdinand on January 11, 2008, to inform her Cpl Langridge had left the Edgewood program and was refusing to come to the base clinic for an assessment.^{Footnote 1688} Mr. Perkins was extremely concerned about Cpl Langridge’s health because he had attempted suicide before and Mr. Perkins believed he was at risk again. Ms. Ferdinand contacted Capt Lubiniecki to inform him of what had happened and that, having left treatment early, Cpl Langridge was therefore AWOL. She testified her recollection was she told Capt Lubiniecki, Cpl Langridge was at risk of suicide at that time.^{Footnote 1689} According to Ms. Ferdinand, Capt Lubiniecki was initially unable to reach Cpl Langridge but eventually succeeded. Capt Lubiniecki informed her Cpl Langridge was stable and had promised he would not harm himself over the weekend.^{Footnote 1690} Ms. Ferdinand disagreed with Capt Lubiniecki’s actions and urged him to bring Cpl Langridge back to the base with MPs, but he did not feel this was necessary. Capt Lubiniecki did not recall having this discussion and had no notes about it, but he did not dispute it had occurred.^{Footnote 1691}

504. On the night of January 31, 2008, Cpl Langridge put a noose around his neck in an attempt to hang himself at home.^{Footnote 1692} Ms. Ferdinand testified, following Cpl Langridge’s ensuing hospitalization at the RAH on February 1-4 2008, she was contacted by Dr. Chu and notified both of Cpl Langridge’s impending discharge, as well as the fact he had attempted suicide while in their care.^{Footnote 1693} This meant Cpl Langridge, who was obviously experiencing distress which put him in danger of further attempts to harm himself, was being released back to the CF.

505. Ms. Ferdinand was frustrated with the fact the civilian hospital would only keep patients for 48 to 72 hours for assessment after being admitted. She was concerned about Cpl Langridge’s discharge given he did not seem stable, but she was told he was being discharged because he was not suicidal at that moment in time.^{Footnote 1694} Ms. Ferdinand discussed the impending discharge with Capt Hubbard, the Padre for the Regiment, and Mr. Strilchuk on February 4, 2008.^{Footnote 1695} No one felt Cpl Langridge should have been discharged, and she testified the base clinic was simply not set up to provide the 24-hour type of care Cpl Langridge required.^{Footnote 1696} Her notes indicated they believed a watch was necessary because, in their view, Cpl Langridge was not stable.^{Footnote 1697} According to Ms. Ferdinand, if Cpl Langridge had had family in the area, the team would have sought someone to assist with ensuring his safety. For someone like Cpl Langridge, they would have had no choice but to involve the Regiment in a suicide watch.^{Footnote 1698}

506. A physician would have to decide such a watch was necessary. Ms. Ferdinand testified she was unaware of what happened to Cpl Langridge when he was discharged on February 4, 2008, but she learned from Capt Hubbard on February 5, 2008, the watch was unnecessary because Cpl Langridge had gone to the AHE for an assessment and was being admitted.^{Footnote 1699} She informed Capt Lubiniecki and the acting base surgeon of the development. In light of Maj Cadieu’s February 4 email, it is apparent at least some members of the chain of command knew of a proposed watch – and arguably a proposed suicide watch – and the reason it was obviated.

The March 2008 watch

507. Ms. Ferdinand was contacted by the hospital when Cpl Langridge was about to be discharged from the AHE in March 2008.^{Footnote 1700} She testified she was involved in the coordination between the base counsellors, physicians and the LDSH about what would be done with Cpl Langridge while he was at the base. Cpl Langridge’s safety was a concern, and she recalled Capt Hannah had contacted Capt Lubiniecki to ensure a “safety plan” was in place. He was preparing a set of limitations while the LDSH made arrangements to carry out the plan. She believed this referred to a watch to be conducted by the LDSH.^{Footnote 1701}

508. On the morning of March 7, 2008, Cpl Langridge attended the Care Delivery Unit. Capt Hannah’s notes record Cpl Langridge was upset and “not following BAC plan.”^{Footnote 1702} At this point, Capt Hannah developed the medical employment restrictions to be sent to CWO Ross. Ms. Ferdinand testified she telephoned Capt Lubiniecki on March 7, 2008. He sent her an email later that morning indicating he was currently on leave, but was copying CWO Ross and Capt Craig Volstad on the message and provided her with their contact information.^{Footnote 1703}

509. In the afternoon of March 7, 2008, Capt Volstad replied to Capt Lubiniecki’s email message to say arrangements had been made to “watch” Cpl Langridge over the weekend using phone calls and check-in times.^{Footnote 1704} Capt Hannah informed Ms. Ferdinand the matter had been taken care of, but she did not learn of the conditions or any of the arrangements made.^{Footnote 1705} Capt Volstad, who was not interviewed by the CFNIS in 2008, testified he understood the purpose of the watch was to protect Cpl Langridge from harming himself and from using illicit substances.^{Footnote 1706} He testified his recollection was other members sought legal advice and medical advice as to the best way to proceed.^{Footnote 1707} Capt Volstad’s email to Capt Lubiniecki (sent at 1446 hrs on March 7, 2008)^{Footnote 1708} was sent about an hour before CWO Ross emailed the final version of the conditions to Maj Jared and Capt Lubiniecki (at 1535 hours).^{Footnote 1709} Capt Volstad did not recall why so much time passed. It is possible during this interval CWO Ross and Maj Jared were discussing the final version of the conditions. Capt Volstad testified he did not consider the conditions imposed to be part of a “trial of good behaviour.” His interpretation at the time was “it was 100 percent to protect the soldier.”^{Footnote 1710}

510. Maj Jared’s testimony provides further insight into what happened that afternoon. When CWO Ross presented Maj Jared with the initial version of the conditions to be imposed on Cpl Langridge on March 7, 2008, (which included “CF members watching Cpl Langridge constantly with the intent of preventing him from committing suicide”^{Footnote 1711}), Maj Jared testified he rejected this arrangement because of two major concerns.^{Footnote 1712} First, an around-the-clock watch would be overly intrusive on Cpl Langridge. Additionally, he was worried the LDSH crewmen assigned would not be capable of successfully conducting a suicide watch, and the LDSH would be “[…] accepting a certain amount of liability of having medically untrained armoured soldiers being responsible for what could be perceived as close or intensive medical care of a member.”^{Footnote 1713}

511. While CWO Ross later told the investigators the Regiment would not legally have been able to conduct a suicide watch, Maj Jared testified his concern was not about the legal authority to conduct such a watch. Instead, he sought legal advice about potential liability. He subsequently instructed CWO Ross not to proceed, and in his discussions with CWO Ross, the conditions ultimately imposed upon Cpl Langridge were put into place.

512. Maj Jared testified he was uncertain about the basis upon which to conduct a suicide watch because there was no regulation, QR&O, CFAO, or DAOD referring to suicide watches.^{Footnote 1714} He also doubted armour crewmen were trained for such a task, and that the medical side should have been responsible for any such watch. However, he testified he did not dispute it would have been possible operationally to carry out the arrangements CWO Ross originally made – which is, to have soldiers conduct a constant watch over Cpl Langridge within Regimental lines to prevent him from harming himself without having to actually confine him in a prison.^{Footnote 1715}

513. The evidence obtained during the Commission hearings from witnesses the CFNIS members did not interview and sources the CFNIS members did not pursue, demonstrates there is a great deal of ambiguity and nuance in any assertion “there was no suicide watch.” To be fair to the witnesses, the evidence does not indicate an intention on the part of any witness to be deceptive or misleading at the time of the 2008 investigation or during their testimony at the Commission hearings. Nevertheless, the evidence overwhelmingly supports the conclusion something resembling a suicide watch was at least planned by members of the LDSH upon Cpl Langridge’s return from hospital. Steps may even have been taken towards conducting a watch, although MCpl Bowden’s statement the watch was already underway when cancelled, remains unconfirmed. Members of the base medical staff had recommended Cpl Langridge receive additional supervision. The only identified purpose for the proposed watch was to prevent Cpl Langridge from harming himself.

514. MCpl Ritco conceded in his testimony the evidence from the Unit indicated a plan was made to organize a watch of some sort for Cpl Langridge – a watch would be maintained 24 hours per day, and 7 days per week if necessary.^{Footnote 1716} He acknowledged the evidence was consistent in establishing plans were being made in case it became necessary up until the point when CWO Ross was alleged by MCpl Fitzpatrick to have cancelled the watch.^{Footnote 1717} In these circumstances, there is reason to doubt the basis for a conclusion there was no suicide watch.

515. There may well have been possible legal or administrative impediments to conducting such a watch. It could be Cpl Langridge’s objections to the scrutiny and constraints of a suicide watch played a role in its cancellation, but this would hardly end the matter for the CFNIS investigators. It is also possible the decision was made without him. To begin, there was information in the possession of the CFNIS members, or readily available to them, indicating individuals within the LDSH chain of command and base medical personnel understood Cpl Langridge to be at risk of harming himself. There was information measures to protect him were being planned. Had the CFNIS interviewed members further up the LDSH chain of command regarding the suicide watch, the CFNIS would presumably have learned one of the key reasons for calling off the suicide watch was a concern about legal liability. Because of the way the CFNIS investigation was conceptualized and conducted, many opportunities to resolve ambiguities and contradictions were put aside, minimized, forgotten about, or dismissed.

Should Cpl Langridge have been on a suicide watch?

516. From the perspective of an investigator looking into the possibility of potentially negligent acts or omissions, the natural next question ought to have been whether the refusal to mount a watch in these circumstances could potentially be negligent. When asked about whether any part of the investigation examined the decision of whether to mount a suicide watch and the reasons for that decision, MWO Watson testified he saw no need to investigate this.^{Footnote 1718} MWO Watson subsequently admitted in his testimony he actually did not recall information about this issue coming to his attention. He also testified he would have asked his own superiors for direction had such information been obtained,^{Footnote 1719} rather than dismissing it outright. Unfortunately, because of the failure to seek out further details about the proposed suicide watch, that information was never found.

517. If the conditions were intended to prevent Cpl Langridge from harming himself, their failure and the failure to mount a competent suicide watch might well have been evidence of negligence. If one concludes there were no efforts at preventing Cpl Langridge from harming himself, a question that arises is “Should Cpl Langridge have been subjected to a suicide watch?” This question was never seriously considered by the investigators. A failure to conduct a watch where one was required might potentially constitute negligent performance of a duty.

518. Had the CFNIS members better understood the concepts of negligence and duty of care, they might have recognized evidence potentially relevant to the possible creation of a duty on the part of the CF to protect Cpl Langridge from harming himself. This included Cpl Langridge’s discharge from a hospital, where he was apparently safe and under considerable oversight and monitoring, to a military environment where he had more freedom, was at greater risk, and was under greater pressure and stigma. The interviews conducted by the CFNIS disclosed Cpl Langridge’s prior suicide attempts were “common knowledge” at the Regiment. The investigation confirmed senior staff were aware of them.^{Footnote 1720} The investigators also knew Cpl Langridge was actively expressing suicidal intentions three or four days prior to his death and was hospitalized.^{Footnote 1721} Despite this, the CFNIS investigators did not ask whether, even if there was no suicide watch, there was still an obligation on the CF to put measures in place for Cpl Langridge’s safety. They did not consider the possibility it may have been negligent for LDSH to fail to put a competent suicide watch into place. MCpl Ritco,^{Footnote 1722} WO Tourout,^{Footnote 1723} MWO Watson,^{Footnote 1724} and Maj Frei^{Footnote 1725} all indicated in their testimonies they believed this question was outside the scope of the investigation. MCpl Ritco testified, “That’s not what I was investigating, sir.”^{Footnote 1726}

519. Sgt Bigelow testified he expected the question of whether a suicide watch was necessary would have come out in the investigation, as it was relevant to the negligence issue, but it was not at the forefront.^{Footnote 1727} WO Tourout, although he recognized questions about negligence would have been raised if a watch was required and was not conducted, testified the question of whether a watch was in fact required or necessary would not have occurred to him.^{Footnote 1728} He dismissed the issue as not being a matter for the CFNIS to investigate.^{Footnote 1729} Because of the conclusion there was no suicide watch, WO Tourout considered it unnecessary to investigate whether one should have been organized based on what the LDSH knew at the time. He acknowledged the evidence demonstrated the chain of command were aware of Cpl Langridge’s previous suicide attempts.^{Footnote 1730} However, in his view, it was a matter for a BOI.^{Footnote 1731} This brings the matter full circle to the fact the issue of possible negligence was artificially confined by the investigators to simply determining whether or not a suicide watch was in place at the time of Cpl Langridge’s death.

520. MWO Watson testified the question of whether Cpl Langridge should have been under a suicide watch was outside the scope of the 2008 Sudden Death Investigation. He acknowledged this could have been the topic of a separate investigation had investigators brought to his attention that a watch should have been conducted.^{Footnote 1732} Again, this reasoning becomes circular, because evidence of whether a watch should have been conducted was not sought by the investigators or even acknowledged as a possible avenue for investigation. A further consequence of the failure to understand correctly or to address comprehensively the issue of negligence in the 2008 investigation was the fact CFNIS members involved in the 2010 Investigation, who were to look specifically into the issue of potential criminal or service offences arising out of negligence by the CF, also did not themselves ask any of the relevant questions, apparently assuming they had all been resolved in 2008.^{Footnote 1733}

521. Some personnel within the base mental health team, including Ms. Ferdinand and Mr. Strilchuk, recommended Cpl Langridge be subject to close monitoring or to a suicide watch within the Regiment. It has already been noted they and Capt Hubbard believed a watch was necessary on February 4, 2008, and the CFNIS investigators had notes about this in their possession. The CFNIS members also knew that on March 7, 2008, Mr. Strilchuk recommended Cpl Langridge be subject to close supervision and monitoring, and also recommended work limitations and a prohibition on weapons and driving. Mr. Strilchuk was unable to testify at the Commission hearings owing to ill health, but his affidavit evidence makes it clear he was seriously concerned about Cpl Langridge’s mental state on March 7, 2008. As a result, he sought to have Cpl Langridge taken to a safe place where he would be constantly monitored and accompanied by one or two members who were to be with him at all times.^{Footnote 1734} There are difficulties with details in Mr. Strilchuk’s affidavit.^{Footnote 1735} Mr. Strilchuk was never interviewed by the CFNIS, meaning his evidence was not obtained at a time when memories were fresher, and his allegations could have been duly investigated.

522. A distraught Cpl Rohmer told MCpl Ritco during his 2008 interview he believed Cpl Langridge should have been under a suicide watch in light of his higher risk of suicide and the fact the Regiment was aware he was suicidal and had made previous attempts. WO Tourout was asked if this was the starting point of a complaint that the LDSH had an obligation to do something about it, knowing what it knew about Cpl Langridge. He denied it was a complaint, merely an opinion held by Cpl Rohmer. In his view, it could not have been the foundation of a complaint because the “totality of the evidence in the report” was “far, far apart” from that opinion.^{Footnote 1736}

Awareness of previous suicide attempts and ongoing risks

523. The issue of whether the LDSH chain of command was aware of Cpl Langridge’s previous suicide attempts would have been relevant to the question of whether the CF thereby came under a duty of care to Cpl Langridge to protect him from harming himself. The existence of such a duty and a failure to discharge that duty could be a foundational element of negligence.^{Footnote 1737}

524. There was evidence the LDSH chain of command was well aware of a number of Cpl Langridge’s suicide attempts. LCol Demers testified he would not have expected to be briefed by medical staff about Cpl Langridge’s suicidal ideation,^{Footnote 1738} but CWO Ross, for one, was aware of most of Cpl Langridge’s suicide attempts, including his explicit suicidal remarks of March 11, 2008.

525. One incident that the evidence makes clear must have been known by at least some of the members of the LDSH chain of command occurred in October 2007, when Cpl Langridge attempted suicide through an overdose of medication. It was discovered when CWO Ross dispatched Sgt Anick Murrin, the Regimental Sherriff who was under his command,^{Footnote 1739} to attend at Cpl Langridge’s residence when he failed to report to duty.

526. Ms. A testified she went to the base and sought help from the LDSH, telling them Cpl Langridge had “[…] swallowed two whole bottles of pills which, as far as I am aware, were full of his prescription medications […].”^{Footnote 1740} Sgt Murrin testified, in late October 2007 she was asked to attend Cpl Langridge’s residence because he did not report that morning and because Ms. A contacted the LDSH and asked them to check on him.^{Footnote 1741} After Ms. A provided a key to the residence, Sgt Murrin attended the townhouse with two regimental police members.^{Footnote 1742} A knock on the front door led to no response. She sent the regimental police around to the back door but again received no answer, so she used the house key to enter the dwelling.^{Footnote 1743} Sgt Murrin eventually found Cpl Langridge asleep and difficult to rouse in a bedroom on the second floor. She shouted Cpl Langridge’s name, and this finally woke him.^{Footnote 1744} Cpl Langridge was compliant and got out of bed to use the washroom, but was so drowsy, upon his return he fell back into bed and went to sleep. Sgt Murrin called the base medical clinic for advice, and they told her to call 911 and bring him to a civilian hospital. She did so, and the responding paramedics took him to the hospital along with his medication bottles.^{Footnote 1745} Sgt Murrin then phoned the RSM, CWO Ross, and gave him an update before returning to base.

527. CWO Ross testified he could not remember the specific conversation he had with Sgt Murrin about the incident, but it would have been normal for the sergeant to report back to him about what took place. When asked if that situation would have led to a heightened awareness something was wrong with Cpl Langridge, CWO Ross replied, “There certainly would be a cause for alarm, I would assume, yes.”^{Footnote 1746}

528. MCpl Ritco learned about this incident from Sgt Murrin in April 2008^{Footnote 1747} but did not appear to appreciate its significance because Sgt Murrin could not recall the date it took place and denied it was a suicide attempt. In fact, Cpl Langridge was admitted to the short stay mental health unit of the Royal Alexandra Hospital on a Form 1 certificate under the Alberta Mental Health Act because of his overdose attempt, with the emergency department estimating he had swallowed 60 to 70 tablets of his prescription medication.^{Footnote 1748} Records from the hospital indicate the Regiment was contacted during his hospitalization, and in an “official military conversation” about Cpl Langridge’s potential discipline, the physicians were advised neither an arrest nor any charges were pending against Cpl Langridge at that time.^{Footnote 1749}

529. MCpl Ritco evidently did not link what he was told by Sgt Murrin with the suicide attempt documented in his May 2008 review of Cpl Langridge’s medical file. There, he noted, on “28/29 Oct 07, [Cpl Langridge] attempted suicide by overdoze [sic] (seroquil) [sic] with 9-10 beers, while at home, because girlfriend broke up with him, admitted to Royal Alexandra Hospital, no suicide or homicidal thoughts when released on 30 Oct 07.”^{Footnote 1750} MCpl Ritco asked no questions about this or other such incidents of personnel with knowledge of it, specifically members of the chain of command.

530. There were other indications members of the chain of command were aware of at least some of Cpl Langridge’s previous suicide attempts. Capt Hubbard, the LDSH padre, testified Ms. A contacted the duty centre in early February 2008 because Cpl Langridge attempted to hang himself in their townhouse and had been taken to the hospital.^{Footnote 1751} Capt Hubbard was on call and notified the chaplain chain of command of the attempt. The base chain of command and LDSH chain of command subsequently learned of the attempt,^{Footnote 1752} and Capt Hubbard testified he recalled speaking to Capt Lubiniecki, Maj Jared, and Maj Cadieu about the suicide attempt after they learned of the incident.

531. Capt Lubiniecki testified he was unaware Cpl Langridge had been admitted to hospital because of a suicide attempt.^{Footnote 1753} LCol Demers also testified he had no recollection of being informed of this incident.^{Footnote 1754} However, Cpl Langridge attempted suicide again while admitted to the RAH, and Capt Lubiniecki testified he was informed about this further attempt by Capt Hubbard when it happened. The disclosure required some convincing of Capt Hubbard by Capt Lubiniecki, as the former understandably had Cpl Langridge’s confidentiality to consider. Capt Hubbard testified it was very important to Cpl Langridge to live without the shame and stigma of his condition, as this was viewed harshly in the military community.^{Footnote 1755}

532. The evidence makes it clear that members of the LDSH chain of command were aware of at least the following incidents of suicide attempts or suicidal ideation:

When Cpl Langridge attempted suicide in June 2007, it was reported to the LDSH chain of command and an SI was conducted regarding those events;^{Footnote 1756}
When Cpl Langridge attempted suicide in October 2007, CWO Ross dispatched MPs to attend Cpl Langridge’s house, and they found him overdosed on medication. He was taken to a civilian hospital, and this was reported back to CWO Ross;^{Footnote 1757}
When Cpl Langridge left Edgewood in January 2008, members of the medical community were greatly concerned about Cpl Langridge’s risk of suicide and communicated this concern to Capt Lubiniecki, who reportedly contracted with Cpl Langridge not to harm himself;^{Footnote 1758}
When Cpl Langridge attempted suicide by hanging in early February 2008, there is evidence Capt Lubiniecki, Maj Jared and Maj Cadieu were informed of this by the Padre, Capt Hubbard;^{Footnote 1759}
Cpl Langridge subsequently attempted suicide again while in a civilian hospital, and Capt Lubiniecki acknowledged being told of this attempt by Capt Hubbard;^{Footnote 1760}
Upon Cpl Langridge’s release from hospital on February 4, 2008, Maj Cadieu sent an email to Maj Jared, LCol Demers, CWO Ross, Capt Lubiniecki, Capt Hubbard and MWO Mulhern indicating it may be necessary to set up a “watch” for him;^{Footnote 1761}
When Cpl Langridge expressed suicidal ideation in March 2008, this was reported to CWO Ross by base medical personnel, and he was aware Cpl Langridge was sent to a civilian hospital.^{Footnote 1762}

The Ultimate Question

533. CWO Ross informed the CFNIS investigators the LDSH could not “legally” put Cpl Langridge under a 24/7 watch unless the medical community said he was suicidal. The CFNIS investigators did not examine this issue. Further, once CWO Ross told MCpl Ritco a doctor had called him and said Cpl Langridge was claiming to be suicidal, the issue of whether this changed the legality of a suicide watch was not investigated.^{Footnote 1763} Regardless, Maj Jared’s testimony that a suicide watch was considered and rejected for Cpl Langridge on March 7, 2008, indicates Cpl Langridge’s stability and propensity for self-harm were active concerns for both the LDSH and the base medical community.

534. It is outside the mandate of the Commission to conclude Cpl Langridge should have been on a suicide watch when he died. But the evidence was there for the CFNIS investigators to examine this question in the context of possible negligence on the part of the CF. It is uncertain whether, in this case, a finding that a watch was not conducted when it ought to have been would support a charge of an offence under the Criminal Code or a service offence under the Code of Service Discipline^{Footnote 1764} in this case. However, this question and the issues discussed earlier were all matters a focused investigation should have pursued, even if the conclusion would have been charges were not warranted. The failure to even consider these questions is disconcerting.

535. The failure to identify the relevant issues and to develop a competent IP made it inevitable the investigative team would also fail to comprehend the significance of the available evidence, to pursue further evidence or to interview clearly relevant witnesses. All of this compounded an already inadequate investigative effort into some of the most essential aspects of the 2008 investigation.

536. Because the investigators did not turn their mind or properly investigate conduct possibly pointing to negligence in this case, they never got to the stage of assessing the elements of any potential criminal or service offences arising from such possible negligence. As set out elsewhere in this report, all such possible offences include elements of a duty and a failure to discharge that duty.^{Footnote 1765} They also all require that the conduct involved in failing to discharge the duty must be below a certain standard. The standard in the case of both the criminal and the service offences potentially applicable on the facts for the conduct to be “negligent” is high compared to civil negligence. For criminal negligence, the culpable conduct must be of a “marked and substantial departure”^{Footnote 1766} from the standard of care expected of a reasonably prudent person in the circumstances. For the service offence of negligent performance of a military duty, the standard of responsibility requires a marked departure and is based on an objective assessment of what a reasonable person of the rank and in all the circumstances of the accused would have done.^{Footnote 1767}

537. In both cases, as for all criminal or service offences, there is also a mental element or “mens rea” which, in the case of negligent conduct resulting in death, requires that the accused either recognize a serious risk to life and safety and they ran that risk anyway, or gave no thought to the risk.^{Footnote 1768}

538. The Commission is aware it may very well be the offences could not have been proven, even if some of the conduct could have been considered to be negligent, in light of the high threshold of culpable conduct that would be required in this case for either criminal negligence or negligent performance of a military duty. However, because the CFNIS members never investigated the actual conduct that required investigation, they never got to this stage of the analysis. The Commission’s comments about the failure to investigate the relevant conduct and issues should not be taken to imply the ultimate standard to be applied in deciding whether to lay charges should have been any lower than the usual standard applicable. Rather, the Commission’s view is simply that the information the CFNIS investigators possessed or had the means of obtaining made it clear that there was much more that ought to have been investigated, and to have been investigated to a much greater extent, before any possibility of CF negligence in the death of Cpl Langridge could have been ruled out.

4.1.3 The Investigation Plan

The Purpose of the Investigation Plan: To-do List or Conceptual Tool?

539. Through the course of this hearing, the Commission heard varying explanations from CFNIS members as to the purpose of an Investigation Plan (IP). Maj Frei was the DCO CFNIS at the time of the 2008 sudden death investigation and Acting Commanding Officer (A/CO) when that investigation was concluded. At the close of this hearing, Maj Frei was the CO CFNIS.^{Footnote 1769} He offered the following statement to describe the purpose of an IP:

From my perspective the real value in the investigation plan is forcing the lead investigator to take the time to think through what it is he's investigating, to understand the elements of the offence that's involved; to put some thought into how he is going or she is going to conduct the investigation. The fact that we [document it] and ensure that a supervisor reviews it simply captures those steps in SAMPIS but, like any other plan in the military, there is a common saying within the military that no plan survives first contact. It's the same with investigations.^{Footnote 1770} [Emphasis added]

540. The IP, if employed as described by Maj Frei, encourages an investigator to assess an investigation critically on an ongoing basis, to formulate the questions that must be answered in order to conclude the investigation, and to develop a plan as to how to investigate each issue in order to reach relevant conclusions. The Commission agrees with Maj Frei’s characterization and understands this process to be the purpose, and the value, of the IP.

541. Conversely, MCpl Ritco, Sgt Bigelow and WO Tourout each described the IP as a form of “to do” list.^{Footnote 1771} MCpl Ritco testified an IP serves to remind him of the steps to take in the course of the investigation and to inform his case manager of what steps he is taking.^{Footnote 1772} Sgt Bigelow offered a more general definition, stating the IP is “just ideas of what [the lead investigator] wants to do.”^{Footnote 1773} WO Tourout explained the IP is broader than the investigation itself, including anything else that comes up in the course of the investigation.^{Footnote 1774}

542. Having reviewed the IP and resulting investigation in this case, the Commission finds using the IP simply as a “to do” list impoverishes the investigation. Rather than focusing on what questions need to be answered, the checklist model of the IP is simply a laundry list of topics, steps and memos to self. It does not promote an understanding or critical analysis of the state of the case and does not encourage the investigator to assess the merits of the evidence in order to answer the questions under investigation.

Planning and Organization

543. On the whole, an outside observer looking at the IP for the 2008 investigation would have great difficulty ascertaining what the investigators planned to do and why, what remained to be done, what insights they gained, and what new avenues of inquiry they identified. The IP, drafted and revised on March 17 and 31, 2008, respectively, and approved by MCpl Ritco’s case manager, WO Tourout, on March 18 and April 1, 2008, reads:

Tasking

MCpl RITCO is tasked to investigate the death of Cpl LANGRIDGE and compile the findings in this report. [...]
Interviews [March 17, 2008]

Cpl BRUCE-HAYES (Duty MP) (Completed 16 Mar 08);

Cpl BROADBENT (Duty MP); (not required)

Capt LUBINIECKI (LDSH ADTJ); (Completed 17 Mar 08);

Cpl HURLBURT (LDSH Duty Cpl); (Completed 19 Mar 08);

Sgt HISCOCK (LDSH Duty Sgt); (Completed 18 Mar 08); and

Cpl HARE (resides in Rm F312). (Completed by Base MPs)

Plan
CFNIS WR will investigate the following in order to gather information/evidence pertaining to this file:

current residence of Cpl LANGRIDGE; (Completed)

was Cpl LANGRIDGE on “suicide watch” or “defaulters”; (Completed)

any documentation pertaining to a “suicide watch”; (Completed)

any documentation pertaining to “defaulters”; (Completed)

person(s) who notified media and all related information; (Completed)

personnel from LDSH tasked to handle the personal effects of Cpl LANGRIDGE; (Completed)

confirmation of girlfriend or common law wife; (Completed 17 Mar 08)

obtain medical records from UMS in favor of Cpl LANGRIDGE; (Completed)

identity and whereabouts of next of kin; (Completed 17 Mar 08)

turnover of personnel [sic] effects to proper personnel; (Completed 20 Mar 08)

documentation from ambulance emergency services; (not required)

description of medication and what side effects it may cause if any; (Completed)

possible negligent actions on behalf of CF, resulting in possible involvement in death; (completed)

attend Alberta Hospital in order to gain information regarding Cpl LANGRIDGE’S committal/release. (information located on CF medical records)

who are Cpl LANGRIDGE’S closest friends; (Completed)

tours, missions, or otherwise taskings; (Completed 17 Mar 08)

problems within unit; (Completed 17 Mar 08)

abuse of alcohol or narcotics; (Completed 17 Mar 08)

medical examiner’s report (return date at least 4 months) (completed)

TIME ESTIMATE: 4 months [...]
INTERVIEWS: [March 31, 2008]

Cpl ROHMER (best friend of deceased) (Completed 18 Mar 08);

MWO MAINVILLE (MWO in charge of personal effects); and (Completed 17 Mar 08)

[Ms. A] (common law); (decided no need to be interviewed)

Plan

Compile 8 (2) (E) for medical records at ASU Edmonton UMS; (Completed 22 Apr 08)

Obtain Edmonton Police Services Reports regarding Cpl LANGRIDGE; (Completed)^{Footnote 1775}

544. The IP is incomplete and incoherent. It includes no information about the goals of the investigation beyond simply collecting information, about the reasons for selecting certain investigative steps or interviews, or about the reasons for subsequently deciding not to pursue them. Seemingly connected issues are not grouped together, whereas unconnected issues are. Actual investigative steps connected to possible charges are listed alongside purely administrative issues. Obvious steps and interviews are missing, while irrelevant or less relevant ones are included.

545. Aside from the administrative matters such as Cpl Langridge’s residence, relationship status, and next-of-kin, the IP appears to propose steps for investigating the cause and manner of Cpl Langridge’s death as well as potential Unit negligence. Completed properly, these planned steps could yield relevant evidence concerning the circumstances of Cpl Langridge’s last days and of his death. However, the IP lacks a conceptual vision as an outline of the investigation. It provides no indication about how these proposed steps were intended to inform and organize the investigation.

546. The goal for the Sudden Death Investigation, as identified by MCpl Ritco in his testimony, was to rule out foul play.^{Footnote 1776} However, many of the obvious steps necessary to determine whether foul play had any part in Cpl Langridge’s death are not included in the IP. Nothing in the IP relates to any of the evidence obtained at the scene,^{Footnote 1777} to the information and facts ascertained from the position and examination of Cpl Langridge's body, the opinions given by the ME investigator, or the tests subsequently conducted by the ME's office. In fact, the IP does not include steps directed towards one of the most important factors in determining foul play: whether someone was in the room with Cpl Langridge at the time of, or immediately prior to, his hanging.

547. Another glaring omission is the failure to make any mention of the suicide note found at the scene. The existence of a suicide note was clearly of high relevance to the determination of whether foul play was involved in the death. Had there been any realistic suspicion of foul play, the note would have had to be tested to confirm its authenticity, but the IP makes no reference to the possible use of the note during the investigation, or even to the note’s existence.

548. The proposed steps in the IP related to medical records, alcohol or drug addiction or work-related issues were all relevant to determine whether suicide was the most likely cause of death. Nevertheless, even here there is little indication the investigators thought through what was being investigated in the manner described by Maj Frei. WO Tourout explained steps 16 (“tours, missions, or otherwise taskings”) and 18 (“abuse of alcohol or narcotics”) were investigated in order to create a background sketch of the deceased; to determine “what may be a contributing factor [to the suicide].”^{Footnote 1778} On the other hand, MCpl Ritco testified he added Cpl Langridge’s abuse of alcohol and narcotics because he was still thinking about the possibility of foul play. He stated:

[...] I just wanted to see what his background was like, to find out if there was some foul play, if there was somebody, like, a suspect; did he attend certain places; did this person -- if it was foul play, was this person at the same location. I am keeping my mind open to everything.^{Footnote 1779}

549. MCpl Ritco testified nothing of significance resulted from his investigation into Cpl Langridge’s history with alcohol and narcotics.^{Footnote 1780} When asked whether anything from his investigation might indicate Cpl Langridge’s problems with alcohol and narcotics were implicated in his death, MCpl Ritco replied, “I can't really answer that, because I don't know why Corporal Langridge killed himself.”^{Footnote 1781} In other words, MCpl Ritco failed to appreciate the relevant question was whether there were serious issues capable of constituting motives for suicide.

550. Similarly, step 17 (“problems within [the] unit”) could potentially identify workplace problems, thus painting a picture of a troubled individual. However, MCpl Ritco testified he was only interested in determining whether Cpl Langridge was “having problems with somebody in his unit, i.e., if it was foul play, or if it turned out to be a homicide, should I be looking in his unit lines. Had he been -- you know, was there somebody after him, or something like that.”^{Footnote 1782} The investigation of whether or not anyone had a reason or intention to harm Cpl Langridge was relevant, but a well-planned and organized investigation would also recognize information about Cpl Langridge’s workplace conduct and interactions over the last months of his life would be relevant to help answer the critical question of whether his behaviour was consistent with an apparent suicide.

551. The same conceptual and analytical problems are apparent when examining the steps relevant to the investigation of possible negligence by the Regiment. Many of the issues listed are indeed relevant, but many other relevant issues are not listed.^{Footnote 1783} The IP creates the impression the CFNIS members did not ask themselves what constitutes negligence and why, or what issues would be relevant in such an investigation. Instead, it appears they only asked whether or not Cpl Langridge was under a suicide watch. Step 14 (“attend Alberta Hospital in order to gain information regarding Cpl Langridge’s committal/release”) was clearly relevant and appropriate. This step was never undertaken, and the IP mistakenly indicates the information was obtained by other means.^{Footnote 1784} In fact, the CF medical records obtained instead of the Alberta Hospital records contained little if any relevant information about this hospitalization.

552. The IP also includes a number of steps not relevant to any aspect of the investigation, further suggesting confusion surrounding its planning and purpose:

Step (5): person(s) who notified the media and all related information;

Step (6): personnel from LDSH tasked to handle the personal effects of Cpl Langridge; and

Step (10): turnover of personnel [sic] effects to proper personnel.^{Footnote 1785}

553. From the file, it appears MCpl Ritco was concerned about the media issues (Step 5) because, on the morning of March 17, he heard an Edmonton radio station announce a soldier had died at CFB Edmonton.^{Footnote 1786} He testified he had included this in his IP because the CFNIS has its own media relations personnel, and he wanted the chain of command to be aware of this in the event the media needed to be notified of anything.^{Footnote 1787} Including this step suggests a lack of focus on the matters at hand. The identities of personnel tasked to handle Cpl Langridge’s personal effects (Step 6) and the turnover of his effects (Step 10) are similarly irrelevant to the investigation. The inclusion of such “notes to self” with no relation to the investigation is a direct reflection of the IP as an unsorted “to-do list,” rather than a conceptual tool.

554. The investigative steps also include a number of witness interviews. In general, the witnesses listed were appropriate. Each could reasonably be expected to have relevant knowledge regarding the circumstances of Cpl Langridge’s death. The exception is the interview of MWO Remi Mainville. It addressed issues related to the disposal of Cpl Langridge’s personal effects, which was not an investigative issue at all.^{Footnote 1788}

555. However, the witness list is incomplete and lacks important details. The IP provides no indication of the possible purpose of the planned interviews. The process used to select the witnesses does not appear to be based on a systematic analysis of the information required or the persons most likely to possess such information.

556. Potentially important witnesses with relevant information were discounted or not included at all. Cpl Langridge’s common-law spouse, Ms. A, was initially listed as a witness, but an interview was later deemed unnecessary, and the IP offers no explanation of why the decision to discount a witness with potentially relevant information was made. Cpl Rohmer, who had been one of Cpl Langridge’s closest friends, was selected as a witness but, during the interview, the investigators learned Cpl Rohmer and Cpl Langridge had been estranged for most of the previous year.^{Footnote 1789} MCpl Ritco testified Cpl Rohmer had “nothing relevant” to offer to the investigation.^{Footnote 1790} While this view was not wholly accurate in light of the valuable information Cpl Rohmer did provide,^{Footnote 1791} it is surprising the investigators made no effort to find closer friends to interview. The list should have been updated to reflect witnesses who might provide information the investigators still required.

557. In addition, many obviously relevant witnesses were never listed. The most striking omissions are Cpl Langridge’s parents, Mr. and Mrs. Fynes. They could be expected to have valuable information related to his past history and mental state. The evidence in this hearing has revealed it was MCpl Ritco’s case manager and perhaps the Detachment MWO who provided a directive indicating it was not necessary to interview the Fynes.^{Footnote 1792} The list of witnesses in the IP was drafted before this directive was issued on April 15, 2008. MCpl Ritco testified, prior to that date, it was “in the back of [my] mind that I potentially could have interviewed [the Fynes].”^{Footnote 1793} It is difficult to understand why they were never listed in the IP, while Ms. A, whom MCpl Ritco was also told not to interview,^{Footnote 1794} was and remained listed in the IP. The only explanation MCpl Ritco could offer for the omission was it was due to an oversight on his part.^{Footnote 1795}

558. Similarly, members of Cpl Langridge’s chain of command were not listed as possible witnesses. Considering the nature of the issues being investigated, particularly in relation to the suicide watch, it seems many of these individuals might have had information relevant to the investigation. MCpl Ritco testified he considered interviewing witnesses from Cpl Langridge’s chain of command, including his OC, Maj Jared, his DCO, Maj Cadieu, and his CO, LCol Demers.^{Footnote 1796} However, no explanation was provided as to why they were never listed in the IP, even as other witnesses who had been identified but not interviewed were listed.

559. The lack of clarity in the IP might be explained by MCpl Ritco’s inexperience, but this does not excuse his superiors’ lack of guidance. Throughout the investigation, none of the CFNIS WR supervisors intervened to correct misconceptions and gaps in the planning of the investigation or provide additional guidance about the purpose of the investigation. WO Tourout reviewed and approved the IP without making any changes.^{Footnote 1797} MWO Watson did not even look at the IP or provide any direction about the planning of the investigation.^{Footnote 1798}

The “Completed” Steps

560. The investigative steps and proposed interviews listed in the IP are followed by one of three statements: (1) completed; (2) completed, with a date; or (3) a statement the step was unnecessary or would not be pursued. The use of “completed” in the IP was explained by MWO Watson in his testimony as meaning “the investigator added here that he’s looked into it and it’s done,” and the question has been answered.^{Footnote 1799} The Commission agrees with MWO Watson’s view that this is the proper usage. The purpose of the IP is to assist investigators in creating a path to reach conclusions, and marking a step as “completed” should indicate the step has been taken and an answer to the question has been obtained. However, this is not the manner in which MCpl Ritco used the term.

561. It appears when a step was marked as “completed” in the IP, it did not mean the investigator had reached a final conclusion about the question being investigated. Rather, it meant he was not going to pursue the issue any further. The IP is replete with examples. MCpl Ritco marked as “completed” the first step in the IP, identifying Cpl Langridge’s residence.^{Footnote 1800} Nevertheless, MCpl Ritco testified he received conflicting information and never determined the actual address.^{Footnote 1801} He agreed this first question was never answered.^{Footnote 1802} The second step in the IP, identifying whether Cpl Langridge was under a suicide watch or on defaulters, is also marked as being “completed.”^{Footnote 1803} However, when asked whether he had come to any conclusion as to whether or not Cpl Langridge was on defaulters, MCpl Ritco testified he had not.^{Footnote 1804} He explained, when he added the notation “completed,” what he really meant was:

[...] that topic that I was trying to or that investigation that I was doing had been completed, that I wasn't able to determine whether he was on a suicide watch or he was on -- well, defaulters, yes, but the suicide watch I was not able to determine that.^{Footnote 1805}

562. Step three, obtaining documentation pertaining to the suicide watch, is also marked “completed.”^{Footnote 1806} The CFNIS did obtain some documents about this issue,^{Footnote 1807} but at least one crucially relevant document – an email directly related to the request for a list of personnel to conduct a watch for Cpl Langridge – was known to the investigators and yet they decided not to obtain it.^{Footnote 1808} This step cannot be said to be “completed” in any ordinary sense of the word.

563. The fourth step in the IP, obtaining any documentation pertaining to defaulters, is also marked as “completed” even though there is no documentary evidence whatsoever in the file pertaining to this issue.^{Footnote 1809} No testimony was heard indicating such documentation existed or indicating steps were taken in an effort to obtain it. The fifth step, identifying the person or persons who notified the media of Cpl Langridge’s death, is similarly marked as being “completed.”^{Footnote 1810} While irrelevant, there is no evidence this matter was pursued or any conclusions were reached with respect to it.

564. The thirteenth step, investigating “possible negligent actions on behalf of [the] CF, resulting in possible involvement in [Cpl Langridge’s] death” is marked “completed” as well.^{Footnote 1811} MCpl Ritco testified he did not actually investigate the issue of potential negligence, but included this step in his IP as a reminder to investigate it if he did find any indication there was negligence.^{Footnote 1812}

Updating and Reviewing the Investigation Plan

565. The Commission heard consistent evidence the IP is a ‘live’ document to be updated and amended as an investigation progresses.^{Footnote 1813} Indeed, considering the purpose of the IP, it should be revisited and updated regularly. The benefits of maintaining a current IP are many. Updating the IP encourages the investigator to actively consider the progress and direction of the investigation. It also encourages the investigator to identify the questions needing to be answered and to assess whether sufficient evidence has been gathered on that point. It promotes reaching timely conclusions, and it allows a case manager to review the progress of a case in a condensed format. It also allows the CFNIS Chain of Command to grasp the purpose and progress of the investigation when conducting a review. Where the matter is reviewed by an external body like the MPCC, a current IP allows for a step-by-step assessment of the conduct of the investigation. This is not to suggest an IP must be updated prior to each new investigative step. The IP is a tool to help in conducting an investigation and should not become a bureaucratic hindrance, particularly where new issues may arise suddenly.

566. The IP was amended at various times through the course of the 2008 investigation. The amendment to note the ME’s report had been obtained suggests the IP was updated as late as May 15, 2008.^{Footnote 1814} Unfortunately, the updates were sporadic and inconsistent. Several new investigative steps and three possible interviews were added on March 31, 2008, after two of the three interviews had already been conducted. Meanwhile, many other interviews were conducted without any mention in the IP before or afterwards. WO Tourout could not explain why amendments were not made to the IP to reflect the interviews conducted.^{Footnote 1815}

567. On the whole, the amendments made to the IP provide no indication of the process by which the investigators may have assessed what they had learned and determined how it would impact on the investigative steps required or not required. Nothing in the IP indicates whether any investigative step taken led to further issues being investigated. There is also no indication regarding which steps turned out to be important and which steps were either unimportant or inconclusive. The overall result was the IP was of little use. The case manager and other supervisors within CFNIS WR could not use the IP to assess whether sufficient steps were being taken to investigate relevant issues or to evaluate any progress made during the investigation. The IP, as written, could also not be used as the basis for any new investigator to discern the purpose or status of the investigation.

4.1.4 The Concluding Remarks

568. At the end of the 2008 investigation late in the spring of 2008, MCpl Ritco was finally able to conclude “[i]t would be absolutely 100 percent that the file is definitely a suicide […] I laid everything out, said, yeah, definitely without a shadow of a doubt, anybody that reviews this file, it’s a suicide.”^{Footnote 1816} He was then in a position to write the Case Summary and Concluding Remarks. MCpl Ritco explained the purpose of the Concluding Remarks is to inform those reviewing the file of the outcome of the investigation and whether or not charges are to be laid following the investigation.^{Footnote 1817}

569. WO Tourout described the Concluding Remarks as stating “what the actual outcome” of an investigation is,^{Footnote 1818} or alternatively, “a brief summation of the investigation.”^{Footnote 1819}

570. MCpl Ritco’s Concluding Remarks state:

On 15 Mar 08, Cpl LANGRIDGE committed suicide by hanging himself with his belt while in his room. This investigation revealed Cpl LANGRIDGE suffered from alcohol and cocaine addiction which caused him to have mental health issues. All these issues combined may have been a factor in Cpl LANGRDIGE’s suicide. This investigation also revealed that the military, in particular LdSH(RC), made several attempts to help Cpl LANGRIDGE in dealing with his problems. This investigation is concluded.^{Footnote 1820} [Emphasis added]

571. When MCpl Ritco wrote this entry on June 2, 2008, he created two copies containing the same text.^{Footnote 1821} The second version was intended to be edited by his case manager, WO Tourout. The practice of CFNIS WR (and perhaps other detachments) at the time was to create two copies of the Concluding Remarks entry in order for supervisors to make changes for grammar, syntax, brevity and clarity while leaving the original entry intact.^{Footnote 1822} Between June 4, 2008 and June 12, 2008, WO Tourout modified the Remarks.^{Footnote 1823} The content of the second version he created is different from the original and presumably reflects WO Tourout’s editorial intent. It reads:

This investigation revealed that Cpl LANGRIDGE suffered from alcohol and cocaine addictions and subsequent mental health problems. Cpl LANGRIDGE had an extensive documented history of medical treatment, provided to him by base and provincial institutions, and several confirmed previous suicide attempts were discovered. Despite the efforts of his Unit to provide structure and support to Cpl LANGRIDGE, the medical examiner’s report confirmed his death to be a suicide as a result of hanging. As no further investigation into this matter is anticipated, this investigation is concluded.^{Footnote 1824} [Emphasis added]

572. Both versions of the Concluding Remarks state Cpl Langridge had alcohol and cocaine addictions and link these addictions to his mental health issues. The two versions of the Remarks also make no direct mention of the issue of potential CF negligence in Cpl Langridge’s death or of the investigation with respect to the suicide watch.^{Footnote 1825} The only remark possibly relevant to potential negligence is the finding that the LDSH offered Cpl Langridge “help,” or “structure and support,” in the face of his struggles with addiction, mental health issues, and suicide attempts.

573. The Concluding Remarks caused great pain for Cpl Langridge’s family. In their complaint to this Commission, the Fynes allege the Remarks “contained findings that were inaccurate, that the investigator was not qualified to make, and that were aimed at attacking Cpl Langridge’s character and exonerating CF members of any wrongdoing or liability.”^{Footnote 1826}

574. In a previous meeting with the CFNIS and during his testimony before the Commission, Mr. Fynes explained the two main problems he saw with the findings. On the one hand, he believed it was inaccurate to state Cpl Langridge’s mental health issues were caused by or subsequent to his addiction issues, and he indicated this was a medical diagnosis the CFNIS members were not qualified to make.^{Footnote 1827} On the other hand, Mr. Fynes believed the comments about the assistance, structure or support provided by Cpl Langridge’s Regiment were both inaccurate and irrelevant editorializing by the investigators.^{Footnote 1828} Mr. Fynes explained it was treatment Cpl Langridge needed, which the Regiment and the CF, in his view, specifically failed to provide.^{Footnote 1829}

575. On the whole, the Fynes believe both versions of the Concluding Remarks contained spurious comments about their son’s struggles and death. They saw them as essentially praising the military for its efforts while setting aside the possibility anyone but Cpl Langridge himself had a blameworthy role in his death.^{Footnote 1830} By emphasizing a link between Cpl Langridge’s addiction issues and his suicide, the Fynes felt the Remarks were “passing blame to the victim,”^{Footnote 1831} and presenting Cpl Langridge as “a drunk and […] a drug addict who made himself sick, and that led to his suicide.”^{Footnote 1832} As Mr. Fynes described it:

[…] there are three things in there: It was suicide, it was his own damn fault, and the Army did everything they could to help [him].

I'm not happy with that.^{Footnote 1833} [Emphasis added]

576. In the Commission’s view, mentioning addiction issues, mental health issues, and previous suicide attempts in the Concluding Remarks was not, in itself, inappropriate. While the CFNIS members would not be qualified to draw conclusions about the actual causes of Cpl Langridge’s suicide, the existence of prior serious problems constitutes circumstantial evidence relevant to confirming suicide as the most likely cause of death. These factors legitimately form part of the aspects to be investigated in a sudden death investigation.^{Footnote 1834}

577. However, the Concluding Remarks here go further and comment on the cause of Cpl Langridge’s mental health issues. There was no evidence to support a finding Cpl Langridge’s mental health issues were “caused” by or were “subsequent” to his addiction issues.^{Footnote 1835} The medical files obtained contained a number of different diagnoses,^{Footnote 1836} and the investigators had not obtained evidence from medical experts qualified to comment on the cause of Cpl Langridge’s condition. The one medical professional interviewed during the investigation, Capt Hannah, did emphasize the addiction issues.^{Footnote 1837} However, not having personally treated Cpl Langridge or seen him more than once for a short visit, Capt Hannah would not have been qualified to draw conclusions about the chronology or cause of Cpl Langridge’s medical conditions.^{Footnote 1838} The CFNIS members were certainly not qualified to draw such conclusions themselves.

578. The comments about the assistance or “structure and support” provided by the Regiment are based on equivocal evidence obtained during the investigation. While there were various measures put in place for Cpl Langridge, the evidence raised questions about their adequacy, their sufficiency or even their potential harmful impact.^{Footnote 1839} These questions were not adequately investigated by the CFNIS members involved.^{Footnote 1840} As such, there was arguably insufficient evidence to draw the conclusions included in the Remarks, which present the measures taken by the Regiment in a positive light.

579. In this respect, the second version of the Concluding Remarks is particularly problematic. Comparing the two versions, it appears the editing done by WO Tourout changed the tone and implication of the Remarks by converting the previous reference regarding the Unit’s efforts to “help” Cpl Langridge into a statement that Cpl Langridge’s suicide occurred despite the Unit’s efforts to “provide structure and support.”^{Footnote 1841} This was clearly not supported by the evidence, as not enough investigation had been done to enable the members to determine whether the measures put in place by the Regiment were capable of providing assistance or whether they, in fact, contributed to making things worse for Cpl Langridge.^{Footnote 1842}

580. The Concluding Remarks were eventually edited by Maj Dandurand to delete the matters complained of by the Fynes.^{Footnote 1843} However, there was no recognition by the CFNIS or its members that the initial Remarks were inaccurate or unsupported by the evidence.^{Footnote 1844} The Fynes continued to complain about the initial Remarks having been included in the report, as they alleged “they spoke to a mind-set that was exculpatory for the military and passing blame to the victim.”^{Footnote 1845}

581. The Commission saw no evidence the findings were aimed at attacking Cpl Langridge’s character or at exonerating the Regiment or the CF.^{Footnote 1846} In fact, the evidence reveals the members had no such intentions.^{Footnote 1847} However, some of the statements in the Remarks were unsupported by the evidence and contained conclusions the members were not qualified to draw. They also did not fairly represent the investigation conducted, particularly with respect to the suicide watch issue.^{Footnote 1848}

4.1.5 Supervision and Recordkeeping

Supervision

582. The 2008 Sudden Death Investigation was headed by a lead investigator who lacked relevant experience in such investigations. The inexperience of the lead investigator was mirrored in the lack of experience in sudden death investigations on the part of his immediate supervisor. While there was supervisory input at various points in the investigation, that input was problematic both in terms of guidance on investigative steps – notably, whom to interview – and in terms of its impact on the records in the investigative file.

Policies respecting supervision

583. The MPPTP dealing with Supervision identifies two crucial supervisory positions: the Case Manager and the Senior MP Advisor.

584. The Case Manager is described by the MPPTP as the:

MP assigned […] to head the overall criminal investigation. This usually includes: direction, correlation of data, assessment of resource/equipment needs, reporting and maintaining information flow, co-ordination of specialty support requirements, and the management of the investigation team members in consultation with the primary investigator. They should possess strong management skills, a thorough understanding of investigative standards and practices, and familiarity with the context in which the investigation is being conducted.^{Footnote 1849}

585. In testimony before the Commission, WO Tourout, who acted as Case Manager for the 2008 Investigation, stated this policy is a general outline, likely based on the major case management model. He testified: “The [case manager] doesn’t head the investigation; the primary investigator will head the investigation. The case manager will oversee.” The remainder of the description, in his view, was appropriate.^{Footnote 1850}

586. The Senior MP Advisor, meanwhile, has a more managerial role. MPPTP policy states the Senior MP Advisor “should be familiar with the basic premise of each ongoing investigation.”^{Footnote 1851} The first responsibility of a Senior MP Advisor on a file is to screen the case. The Advisor is to determine whether a complaint is trivial, frivolous, vexatious, or made in bad faith, and whether it ought to be investigated.

587. Among the responsibilities of MP supervisors is to verify the accuracy and completeness of all reports and investigation files, including the GO file (which is the complete record of SAMPIS text box entries and scanned images generated for an investigation) and the Military Police Investigation Report (‘MPIR’) (which is the disseminated report of the findings of the investigation):

All Military Police reports shall be subjected to rigorous review by the appropriate MP supervisors who have a positive obligation to ensure completion and accuracy of both the reports and the investigations they represent. 100% verification of accuracy is the responsibility at both the Detachment and HQ PM level.^{Footnote 1852} [Emphasis in original]

588. In carrying out this function, it was, at the time, typical for MP supervisors to review and edit the Case Summary (which generally summarizes the steps taken in the course of an investigation and any associated relevant facts) and Concluding Remarks (which summarize the findings and conclusions of an investigation) prior to distribution of a completed MPIR. The “vetted” versions of these documents were distributed with the MPIR, though the original versions remained within SAMPIS.^{Footnote 1853} In terms of the editing process, Maj Frei testified a supervisor should make an identical copy of the original document in a new file, change the author code to reflect her or his own badge number, and then make any amendments.^{Footnote 1854} This is of particular importance, as SAMPIS does not retain a history of changes made to a document. It saves only the latest version.^{Footnote 1855}

589. The role of the Senior MP Advisor is removed from conducting or closely supervising ongoing investigations. When an investigation commences, the Senior MP is responsible for ensuring efficient and consistent procedures are used, and that “all available resources are maximized.” The Senior MP Advisor also assigns a case manager to head the overall investigation.^{Footnote 1856}

Roles and experience of supervisors

590. The two CFNIS members supervising the investigation into Cpl Langridge’s death were WO Tourout and MWO Watson. WO Tourout was the Case Manager, directly overseeing and providing guidance to the investigators.^{Footnote 1857} MWO Watson acted at the time as Senior Advisor, Detachment Warrant Officer^{Footnote 1858} and A/CO CFNIS WR.^{Footnote 1859}

591. WO Tourout was involved in many aspects of the planning and execution of the investigation. After formally tasking MCpl Ritco as the lead investigator,^{Footnote 1860} he reviewed and approved the initial Investigation Plan on March 18, 2008.^{Footnote 1861} He also reviewed and approved the amended Investigation Plan on April 1, 2008.^{Footnote 1862} He testified he interacted with the investigators under his supervision on a daily basis, if required.^{Footnote 1863} MCpl Ritco’s notebook reveals he briefed WO Tourout regularly over the course of his investigation.^{Footnote 1864} WO Tourout was also involved in making the decisions not to interview Mrs. Fynes and Ms. A.^{Footnote 1865} He reviewed and edited all of the investigators’ SAMPIS entries^{Footnote 1866} and reviewed the final investigation file, noting he agreed with the investigative steps taken.^{Footnote 1867}

592. Prior to his involvement in this investigation, WO Tourout had not been involved in any sudden death investigation as an investigator or a supervisor.^{Footnote 1868} He was aware at the time MCpl Ritco also had no sudden death investigation experience.^{Footnote 1869} However, in his view, the fact neither he nor MCpl Ritco had this prior experience was not an issue. WO Tourout stated he had a variety of experience in different types of investigations conducted over the years. He was confident basic level MP training and subsequent courses teach MP members to process crime scenes. He stated investigators apply those principles to crime scene processing across all investigations, adjusting according to specific needs.^{Footnote 1870}

593. MWO Watson was acting as the Duty Officer for CFNIS WR on the day of Cpl Langridge’s death. He received a call from the MP advising him of the death, at which point he contacted Sgt Bigelow. He testified he could have contacted either Sgt Bigelow or MCpl Ritco as both were on duty.^{Footnote 1871} Sgt Bigelow testified he was neither on duty nor on call, but that he was likely contacted due to a shortage of CFNIS members at the time.^{Footnote 1872} MWO Watson provided basic instruction to the investigators, advising them to take their time in processing the scene and not to release the body or anything else until certain the scene had been processed appropriately.^{Footnote 1873}

594. After that point, MWO Watson participated in this investigation mainly as an advisor to WO Tourout and as a liaison with CFNIS HQ. In the course of the investigation, he was consulted by WO Tourout or MCpl Ritco, or both, on some of the issues that arose, including the possibility Cpl Langridge was under a suicide watch at the time of his death^{Footnote 1874} and the question of whether or not Mrs. Fynes ought to be interviewed.^{Footnote 1875} MWO Watson briefed CFNIS HQ on the investigation through File Status Reports.^{Footnote 1876} He also approved the request for a forensic analysis of Cpl Langridge’s phone on May 29, 2008.^{Footnote 1877} MWO Watson testified his review of the investigative file involved only the Initial Complaint, Case Summary, and Concluding Remarks. He testified that, if he had questions with respect to the file, he would have reviewed the individual SAMPIS entries, but he did not recall doing so in this case.^{Footnote 1878}

595. Following the conclusion of the investigation, MWO Watson drafted the cover letter accompanying the MPIR when it was distributed.^{Footnote 1879} He also drafted the Request for Disposal of Evidence, which was sent to LDSH on October 31, 2008.

596. Unlike WO Tourout, MWO Watson had been involved in a number of sudden death investigations prior to Cpl Langridge’s death. The majority of the investigations were while on deployment in theatre in Afghanistan,^{Footnote 1880} though he testified he had been an investigator in three sudden death investigations domestically.^{Footnote 1881} He had never acted as the lead investigator in an investigation of a suicide. As a supervisor, MWO Watson had overseen “numerous sudden death investigations, from accidental to suicides to killed in action (sic).”^{Footnote 1882} However, he testified he was not involved in the day-to-day conduct of investigations and would only become deeply involved in an investigation if it were necessary.^{Footnote 1883}

597. The most experienced member of the team was Sgt Bigelow, who had been part of four to six sudden death investigations while on secondment with the RCMP and at least one suicide investigation with the CFNIS.^{Footnote 1884} However, not only was Sgt Bigelow not the lead investigator, he was not even a member of the investigation cell;^{Footnote 1885} and his involvement in the investigation was limited to processing the scene and attending a number of interviews as a note-taker. MWO Watson was clear the only reason Sgt Bigelow was assigned to the case was “because [the CFNIS] needed assistance with fulfilling of the duty and he was on duty that day” and not because of his prior experience.^{Footnote 1886} By his own account, Sgt Bigelow’s role in the 2008 investigation following the processing of the scene was limited to assisting MCpl Ritco with interviews and providing some preliminary tutelage, rather than supervision.^{Footnote 1887}

598. MWO Watson was aware at the time of the investigation that neither MCpl Ritco nor WO Tourout had any prior sudden death experience. He was not concerned by their inexperience and neither took any measures to compensate for it nor supervised them more closely because of it. He testified there were ample resources for MCpl Ritco and WO Tourout to refer to in the event they required assistance. These resources included himself, the RCMP “K” Division, CFNIS HQ and other CFNIS investigators. MWO Watson was confident that, if the investigative team had questions, he would be called; “I had full confidence in Warrant Officer Tourout as a case manager, in Sergeant Bigelow as assistant to the investigation and to Master Corporal Ritco as the lead investigator. I had full confidence in them.”^{Footnote 1888} Indeed, it was MWO Watson who recruited MCpl Ritco for the CFNIS, citing his tenacity, thoroughness and professionalism as qualities that convinced MWO Watson that MCpl Ritco would be a talented investigator.^{Footnote 1889}

Supervisory input in the conduct of the investigation

599. WO Tourout appears to have been actively involved in guiding the course of the investigation, approving the Investigation Plan and subsequently providing direction to MCpl Ritco. He also appears to have been involved (perhaps along with MWO Watson) in significant decisions about interviews, notably in the instructions to MCpl Ritco not to contact Mrs. Fynes^{Footnote 1890} and not to contact Ms. A.^{Footnote 1891} At the hearing, MWO Watson testified he did not recall being involved in the decision not to interview Mrs. Fynes but did state:

[Cpl Langridge] was a 28-year-old male in the military, and I would not have seen a need to speak to the mother in this situation to further the investigation. […] [T]he background information [investigators] obtained from the medical authorities and his colleagues, in the course of their investigation, and the unit, would have been sufficient.^{Footnote 1892}

600. WO Tourout testified he could not remember the reason for that decision. He did not recall the conversation well, but suggested that the reason they were considering whether or not to contact Mrs. Fynes might have had to do with decisions about Cpl Langridge’s personal effects. Accordingly, the decision was made that Mrs. Fynes needn’t be contacted about this because she was not next of kin.^{Footnote 1893} When asked about the potential value Mrs. Fynes might have had as a witness concerning Cpl Langridge’s background, WO Tourout replied that Cpl Langridge’s medical records were presumed to contain the relevant background information.

601. From MCpl Ritco’s notebook, it appears that WO Tourout made the decision not to interview Ms. A. The notebook for May 2008 records an intention to review medical records, speak with the LDSH RSM (CWO Ross) and Ms. A.^{Footnote 1894} MCpl Ritco briefed WO Tourout about the work he intended. The entry continues:

WO T[ourout] feels there is really no reason to speak [with] common-law as mother states he had problems [and] the medical records states attempts to suicide (sic), however I should review the medical records first and then come up [with] a final decision.^{Footnote 1895}

602. On May 27, 2008, a follow-up entry notes MCpl Ritco briefed WO Tourout. Following a notation concerning the need speak to MWO Wason about Cpl Langridge’s BlackBerry, MCpl Ritco’s entry, then reads: “no reason to speak [with] girlfriend/[common-law].”^{Footnote 1896}

603. WO Tourout testified the decision not to interview Ms. A was made because the investigative team had the medical records, which “were documentation relating to Corporal Langridge’s health, so that was sufficient.”^{Footnote 1897} MCpl Ritco testified it was “irrelevant to interview her because it was a suicide.”^{Footnote 1898} MWO Watson testified he did not recall such a discussion and in any event did not see the relevance of interviewing her.^{Footnote 1899}

604. Given the evident potential importance of both Mrs. Fynes and Ms. A to understanding Cpl Langridge’s situation, the decisions not to contact his mother or interview the person the military recognized as his common law spouse are open to question. As discussed elsewhere in this report, these decisions ran contrary to the expert evidence heard by this Commission with respect to interview practice in sudden death investigations.^{Footnote 1900} Their evidence would also clearly have been relevant to any investigation of negligence. The fact the decisions were made at the supervisory level indicates the issues in the conduct of the investigation were not confined to the investigators on the ground and may have been reflected or even amplified through the guidance offered at the supervisory level.

Supervisory input in the investigative record

605. Supervisors also appear to have had a hands-on role in producing many of the GO file entries.

606. From a review of SAMPIS records for this investigation,^{Footnote 1901} it appears WO Tourout modified nearly every text box entry within the 2008 GO file at some point in the course of the investigation. Nothing in the evidence would suggest his changes went beyond correcting basic grammar and typographical errors. WO Tourout testified the practice at CFNIS WR at the time was to modify a copy of a file’s Concluding Remarks for grammar and brevity, in order to (among other things) avoid over-briefing the chain of command.^{Footnote 1902} It is unclear, however, that this policy extended to the entire GO file. The Commission’s concern is not based on any belief that the changes were substantive or had a nefarious purpose. Rather, notwithstanding the benign nature of such corrections, unattributed changes to the records of an investigation file should be avoided because they may conflict with police disclosure requirements. That conflict could potentially jeopardize an ensuing prosecution even when any changes were made in good faith. Perhaps because of the default set-up of SAMPIS, WO Tourout did not create secondary versions in order to preserve the originals; did not change the authorship to reflect he had edited them; nor otherwise indicate what he had edited.^{Footnote 1903} As SAMPIS does not retain records of changes,^{Footnote 1904} it is difficult to determine who is ultimately responsible for what aspects of the final products in the GO file or the nature of the changes made by WO Tourout.

MPIR documents

607. The MPIR is used to convey the results of an investigation. The investigation “should continue until a clear, comprehensive, and accurate report of all findings can be presented to the appropriate authorities.”^{Footnote 1905} When an MPIR is released to the CF Chain of Command following the conclusion of an investigation, four documents are provided to the distribution list for that investigation: the Initial Complaint; Case Summary; Concluding Remarks; and a cover letter.^{Footnote 1906} The distribution list for the documents related to the 2008 investigation included the CO LDSH, CO CFNIS, and CLS.^{Footnote 1907} CFNIS WR Detachment practice (and evidently the practice of other detachments)^{Footnote 1908} was for two versions of the investigator’s Case Summary and Concluding Remarks to be created.^{Footnote 1909} WO Tourout, MWO Watson and Maj Frei testified the second version of these documents is edited by supervisors for grammar, syntax, brevity, and clarity.^{Footnote 1910}

608. The original version of the Case Summary, drafted by MCpl Ritco on May 30, 2008, generally details the course of the investigation. It begins by describing the processing of the scene and Cpl Langridge’s vehicle. It continues with the interviews and investigative steps taken with respect to the investigation of the sudden death and of the suicide watch issue.^{Footnote 1911} The second version, edited at various times by WO Tourout and MWO Watson, though still bearing MCpl Ritco’s name as the author, is approximately half the length of the original. It omits nearly all details related to the investigation of the suicide watch issue. The effect of these changes is to remove any indication the CFNIS may have been investigating issues relevant to possible negligence by members of the LDSH in relation to Cpl Langridge’s death.

609. With respect to the interview of Capt Lubiniecki, the original Case Summary notes:

On 17 Mar 08, Capt LUBINIECKI (LdSH Adjt) was interviewed by MCpl RITCO, were it was learned that Cpl LANGRIDGE had a lot of medical/mental problems, in which he had been attending treatment centers but did not complete any programs. Capt LUBINIECKI stated that Cpl LANGRIDGE had just been discharged from a hospital in the past couple of days, and had requested to attend a treatment center in On, however due to Cpl LANGRIDGE's track record of not completing any treatment programs, missing AA meeting, and medical appointments, it was decided that Cpl LANGRIDGE needed "conditions" implemented to provide structure for Cpl LANGRIDGE, These conditions also showed that Cpl LANGRIDGE was committed to attending a treatment center in On. Capt LUBINIECKI also provided information that Cpl LANGRIDGE had attempted suicide in past dating as far back as Jun 07. Capt LUBINIECKI in closing made it very clear that Cpl LANGRIDGE had been placed on these conditions for structure only not any form of being on defaulters or on a suicide watch (sic).^{Footnote 1912}

610. The Case Summary was edited by both WO Tourout^{Footnote 1913} and MWO Watson^{Footnote 1914} The edited version, provided to the LDSH Chain of Command, states:

On 17 Mar 08, Capt LUBINIECKI was interviewed by MCpl RITCO where it was learned that Cpl LANGRIDGE had numerous medical/mental problems and had been attending different treatment centers, however had not completed any programs. Capt LUBINIECKI stated that Cpl LANGRIDGE had been discharged from a hospital in the past couple of days and had requested attendance at a treatment center in ON.^{Footnote 1915}

611. Comparing these two versions, the latter omits Capt Lubiniecki’s statements that:

Cpl Langridge’s request to attend an addictions treatment facility was not accepted;
Cpl Langridge failed to attend AA meetings;
Cpl Langridge was living under “conditions” at the Regiment in an effort to prove he was committed to accepting treatment;
Cpl Langridge had attempted suicide in the past; and
Cpl Langridge was not under a suicide watch at the time of his death.

612. These modifications significantly change the focus of the document. Almost all of the omitted issues relate directly to issues connected with possible negligence on the part of LDSH members.^{Footnote 1916}

613. This pattern continues throughout the remainder of the document. MCpl Ritco recorded details in the Case Summary about the interviews of MCpl Fitzpatrick, MCpl Bowden, CWO Ross, and Capt Hannah.^{Footnote 1917} These four interviews dealt mainly with the suicide watch issue.^{Footnote 1918} They are omitted entirely from the edited Case Summary.^{Footnote 1919} The references in the Case Summary written by MCpl Ritco illustrating the LDSH chain of command’s knowledge of Cpl Langridge’s past suicide attempts and active suicidality have also been omitted from the versions edited by his supervisors. All but one of the several references to the suicide watch in MCpl Ritco’s document have been removed. The only statement remaining is attributed to Sgt Hiscock and reads: “Sgt HISCOCK stated that Cpl LANGRIDGE was not on defaulters nor was he on a suicide watch.”^{Footnote 1920} As detailed elsewhere in this report, this statement does not fully reflect what Sgt Hiscock had reported to investigators.^{Footnote 1921}

614. WO Tourout testified the changes made to the Case Summary concerned grammar and sentence structure and that it had been shortened for brevity, including removing references to statements made about the suicide watch. He stated:

It's […] to provide the CO [LDSH] with just enough information, a corrected version to make a decision […] in the event that the CO was going to see or preside over a trial of some sort. […] [I]f there was any indication that we're trying to change something or hide something we would have taken it out of the Case Summary as well and we did not.^{Footnote 1922}

615. He did, however add he did not expect any trial to come out of this case. WO Tourout was asked if the information contained in the edited Case Summary could possibly have suggested to anyone in the chain of command that there were issues that might warrant further examination. While he stated members of the CF chain of command could, if they needed to, order the whole file in order to learn more about the investigation and the issues covered, he conceded that on its face this edited Case Summary would not suggest there was any reason to review the entire file in detail.^{Footnote 1923}

616. MWO Watson testified the records indicated he had made changes to the Case Summary, but he did not recall specifically what he had changed.^{Footnote 1924} Referred to the section respecting Capt Lubiniecki’s interview, he stated the omitted statements were “[i]nformation that really didn’t lead to any level of importance on the part of the reader as far as I’m concerned.”^{Footnote 1925} When asked if it was important to report this information related to Cpl Langridge’s conditions and the suicide watch, both of which were investigated by the CFNIS, he stated: “This is reporting on the suicide. […] [H]ad there been grounds to pursue an investigation on a suicide watch or substantiation that there was, in fact, a suicide watch, then I would suggest some of that information would be important to the reader.”^{Footnote 1926}

617. MWO Watson testified he did not see a need to include the interviews of MCpl Fitzpatrick, MCpl Bowden, CWO Ross, and Capt Hannah. Acknowledging it was clear from early on in the investigation there were no suspicions of foul play, and that the next two to three months were spent investigating the suicide watch, he stated he did not believe the interviews needed to be included in the Case Summary “[b]ecause I think this second summary is factual. It tells what transpired. If there was a reason […] to substantiate another file being opened with regards to [the] suicide watch […] then that information, I think, becomes relevant to include [in] a case summary.”^{Footnote 1927} Overall, MWO Watson was satisfied the second Case Summary was an accurate description of what was learned in the investigation. He testified it is the case manager’s role to ensure the accuracy of the document.^{Footnote 1928}

618. To the extent the 2008 investigation could be seen as simply addressed to the issue of whether Cpl Langridge’s death was a suicide or involved foul play, the revised Case Summary does indeed “tell what transpired.” As a description of the investigative activity on the file, that characterization appears to be less apt. For most of its duration the investigative activity was focused on the suicide watch,^{Footnote 1929} an issue relevant to possible negligence. Whether or not that investigative activity should have been conducted as part of a separate investigation, MCpl Ritco conducted it as part of the sudden death investigation pursuant to an investigation plan which, whatever its shortcomings, was reviewed and approved by his case manager.^{Footnote 1930}

619. The changes made to the Case Summary are much wider than simply editing for grammar, clarity and brevity. The effect of the changes, intended or not, is to remove any basis for a possible inference that part of the investigation was focused on assessing the possibility of negligence on the part of the Regiment. Whatever the motivation, these changes meant the Case Summary provided an incomplete impression of what was investigated.

620. The Concluding Remarks drafted by MCpl Ritco were also edited by WO Tourout.^{Footnote 1931} The content of these changes is explored in some detail in Chapter 4.1.4, Concluding Remarks. In effect, the second version seized upon already questionable speculation in the first version and strengthened it to the point that the Fynes believed the message was that Cpl Langridge was responsible for his own suicide despite the CF’s efforts to provide him with structure and support. As was the practice at the time,^{Footnote 1932} the second version was the only one provided to the LDSH chain of command for review upon the conclusion of the file.^{Footnote 1933}

621. WO Tourout denied any intention to change the content beyond making an effort to reword what MCpl Ritco had said,^{Footnote 1934} but whatever the intention, the second version contained certain findings that are perhaps more problematic than those in the first version.^{Footnote 1935}

622. MWO Watson does not appear to have made any modifications to the Concluding Remarks. His cover letter accompanying the MPIR on distribution, drafted July 1, 2008, reads in part:

Investigation into this incident revealed that Cpl LANGRIDGE had a history of drug addiction and mental disorders that he was receiving treatment for from both military and civilian medical professionals. It was also determined that Cpl LANGRIDGE had attempted to commit suicide several times in the past. The Alberta Medical Examiner’s report indicated that Cpl LANGRIDGE died as a result of asphyxiation caused by hanging.^{Footnote 1936}

623. MWO Watson testified he reviewed only the Initial Complaint, Case Summary, and Concluding Remarks.^{Footnote 1937} His covering letter omits some of the items found in WO Tourout’s revised Concluding Remarks. The covering letter mentions Cpl Langridge’s struggles with addiction and mental health issues, but does not include any inference that one followed the other.^{Footnote 1938} There is also no mention of an effort to provide structure and support. MWO Watson testified nothing should be read into these omissions as the cover letter was only a brief snapshot of the file, and his view was the relevant information could be obtained through the Case Summary or Concluding Remarks.^{Footnote 1939} Not surprisingly, there is no mention in the cover letter of anything connected with the investigation of the suicide watch issue.

624. It was the responsibility of the CFNIS supervisors to ensure the accuracy of the report and the investigation it represented.^{Footnote 1940} When the investigation records are in any way inaccurate, this should be raised with investigators. When the efforts of supervisors to edit investigation records themselves result in inaccurate or problematic statements, this can only compound the failure.

625. Overall, the changes made to the Case Summary or Concluding Remarks were of doubtful value. The edited version of the Concluding Remarks prepared by WO Tourout did add a specific reference to the ME’s finding that Cpl Langridge’s death was the result of a suicide by hanging, which was germane and important information. However, the edited version contained stronger conclusions about the efforts made by the Regiment to help Cpl Langridge before his death than the remarks made by MCpl Ritco, and, in this respect, neither version was well supported by the evidence gathered during the investigation itself.^{Footnote 1941}

Supervision for the 2008 investigation: overall conclusion

626. The overall supervision of this investigation was problematic. The investigative team was not equipped to conduct a sudden death investigation on its own and no steps were taken to compensate for its lack of experience. The interventions at the supervisory level with respect to witness interviews are open to question given the nature of the investigation that should have been conducted. The supervisory amendments to the SAMPIS entries are also open to question.

Recordkeeping

Recordkeeping policies, standards, and practices

627. It is essential for investigators to maintain complete and accurate records of the investigations they conduct. As Chapter 6 of the MPPTP states, the purpose and objectives of an MP investigation are “to reconstruct events, gather evidence, identify the elements of the alleged offence, and identify those responsible for it.”^{Footnote 1942} The MPPTP notes any investigation must be thorough, complete and accurate, and immediately recorded in a SAMPIS report.^{Footnote 1943} It also notes: “MP investigations are conducted as much as to exonerate individuals as to implicate them. All information gathered, whether inculpatory or exculpatory shall be reported, regardless of the initial, interim or final decisions with respect to culpability or the laying of charges.”^{Footnote 1944} It goes on to note all information obtained in background investigations is similarly to be included in the report.^{Footnote 1945} Thus, the MPPTP stresses the necessity of maintaining complete and accurate records that include all relevant information obtained, whether the information supports a conclusion that an offence was committed or not.

628. At the conclusion of an MP investigation, an MPIR is distributed to relevant authorities for review. The MPIR is meant to convey the facts uncovered and the findings made in the course of an investigation. Investigators are responsible for preparing all GO file entries, which includes MPIRs.^{Footnote 1946} Meanwhile, MP supervisors are responsible for verifying their accuracy and completeness.^{Footnote 1947}

629. The CFNIS investigators in this case employed three main recordkeeping systems: investigator notebooks, interview recordings, and SAMPIS.

630. Investigators’ notebooks are their primary recordkeeping tool. They permit investigators to take notes while conducting investigations. The notes form an important record of events for investigators as they conduct their investigations and potentially as they prepare for trials or later investigations. Notebooks are referred to when investigators type or dictate their investigative activity reports, and may be reviewed by case managers in the course of an investigation.^{Footnote 1948} Within the CFNIS, it is typical for investigators’ notebooks to be scanned into the investigation file, though it is unclear whether it is the responsibility of the notebook’s author or the lead investigator to scan the notebook into SAMPIS for the benefit of the GO file.^{Footnote 1949}

631. The MPPTP also outlines practices and procedures for conducting and recording witness interviews. In the normal course, interviews are conducted in teams of at least two investigators, with at least one taking notes.^{Footnote 1950} If no second investigator is available an interview may be conducted alone.^{Footnote 1951} Interviews are generally recorded in an audio or audio and video (‘video’) format,^{Footnote 1952} and recording capabilities may be determined by the location of the interview. If an interview is conducted at an MP detachment, it should be recorded,^{Footnote 1953} with the preferred format being video.^{Footnote 1954} Recordings of interviews are to be classified as official notes and handled with the same care and protection as written police notes.^{Footnote 1955}

632. Even though an interview may be audio or video recorded, investigators are still advised to take certain notes during an interview.^{Footnote 1956} This is because, in the event charges are laid and a case goes to trial, an investigator may have to explain the context and course of events of an interview. The MPPTP provides the examples of explaining any unusual incidents or prolonged periods of silence on an interview recording.^{Footnote 1957} MP members are advised to make substantive written notes from interview recordings as soon as possible, explaining in the notes how they were made (for example, from an audio or video recording).^{Footnote 1958}

633. The final, and most comprehensive, recordkeeping system employed by CFNIS is SAMPIS. It is a proprietary records management system that stores documents created or acquired in the course of MP investigations. It provides MP members with the ability to create electronic records of their investigative activities, which are stored under the General Occurrence (‘GO’) file opened after an initial complaint is received.^{Footnote 1959} It also allows investigators to scan in documents obtained in the course of an investigation (including, for example, investigators’ notebooks, personnel files, and medical records).^{Footnote 1960} SAMPIS is an online system,^{Footnote 1961} making it accessible to MP members wherever stationed. It is thus a very powerful tool for investigators and the MP as an organization. The final MPIR includes certain of the GO file records contained in SAMPIS.

634. All entries created within a GO file in SAMPIS have a date and document type associated with their creations. The date a document is created is automatically recorded and preserved within the system, even if the document type is subsequently changed. A secondary date, called the “Related date” in SAMPIS entries, is not automatically recorded, but is rather entered by the person creating or modifying an entry. ^{Footnote 1962} Based on the Commission’s review of the GO file in this instance, the “Related date” generally indicates the date on which the investigative activity occurred.

635. As with investigators’ notebooks, it is essential to an effective investigation that the SAMPIS entries created be complete and accurate.^{Footnote 1963} Ultimately, the contents of GO files should be capable of supporting any findings or conclusions made by investigators in the course of their investigations. Any factual inaccuracies or omissions may have the impact of undermining this purpose. It is therefore critical for investigators to be attentive to detail in creating their initial SAMPIS entries and in subsequently preparing any summaries of their investigative activities.

636. The hearing revealed that, once created, SAMPIS entries can be, and routinely are, reviewed and edited by investigators and their supervisors.^{Footnote 1964} This is of particular importance as SAMPIS does not retain a history of changes made to a document. It saves only the latest version.^{Footnote 1965}

Recordkeeping in this case

637. The recordkeeping practices employed by the investigators indicate they were aware of the importance of maintaining a complete record of the investigation. MCpl Ritco and Sgt Bigelow’s notebooks generally record the steps they took in the investigation, from the initial tasking on March 15, 2008^{Footnote 1966} to the file’s conclusion.^{Footnote 1967} Unfortunately, Sgt Bigelow’s notebook was not scanned into SAMPIS. While he accepted responsibility at the hearing for not doing so,^{Footnote 1968} this was a tremendous oversight on the part of the investigators and their supervisors.

638. The notebooks themselves appear to be well-maintained. The contents are chronologically ordered and late entries are noted as being so.^{Footnote 1969} At certain points MCpl Ritco has made corrections to his notes and has noted what was changed in the book.^{Footnote 1970} While it is ideal for investigators to take contemporaneous notes, it is not always possible. MCpl Ritco took the appropriate approach of recording the events and noting if the entry was not made contemporaneously. In this way, he ensured anyone reviewing the notebook would be aware of any changes and where late entries were made. As accuracy is integral to investigation reports, MCpl Ritco’s approach helped ensure the contents, as well as the conditions under which they were recorded, are accurately reflected in the report.

639. The entries within the notebooks are generally detailed and indicate what the investigators discovered through the investigative steps they took. Read together with the SAMPIS entries that followed them, they allow the reader to gain a fairly comprehensive understanding of the steps taken by the investigators. However, there is a lack of detail with respect to certain investigative steps the investigators elected not to take, mostly when decisions were made by supervisors.

640. The decisions not to contact Mrs. Fynes and Ms. A in particular are not recorded in any detail in MCpl Ritco’s notebook, and were never elaborated upon in SAMPIS entries. From MCpl Ritco’s notebook, it is only possible to conclude a decision was made by MCpl Ritco’s superiors that he did not need to contact Mrs. Fynes.^{Footnote 1971} It may well be MCpl Ritco was never given an explanation of the reasons for the decision. Similarly, the reasons behind the decision not to contact Ms. A are not recorded,^{Footnote 1972} and again it is possible MCpl Ritco was never told why it was deemed unnecessary. In any case, the result is that it is impossible to determine from the file the reasons for not interviewing these two potentially valuable witnesses. Nor did MCpl Ritco’s supervisors create any SAMPIS entries providing rationales for their decisions. These decisions proved to be controversial, and serve to highlight the great importance of maintaining complete records not only of investigative steps that are taken, but the reasons behind the decisions not to take others.

641. Variances in the nature of and venue for the witness interviews raise several issues. Four video-recorded interviews took place in the CFNIS WR Interview Room with two investigators present. Those interviews were with Sgt Hiscock,^{Footnote 1973} Cpl Hurlburt,^{Footnote 1974} MCpl Fitzpatrick,^{Footnote 1975} and MCpl Bowden.^{Footnote 1976} However, Capt Lubiniecki was interviewed in the LDSH Briefing Room,^{Footnote 1977} and interviews with CWO Ross^{Footnote 1978} and Capt Hannah^{Footnote 1979} were held in their respective offices. For these latter three interviews, which were held “off-site,” there was no video recording. The interview of CWO Ross took place with two investigators present,^{Footnote 1980} but MCpl Ritco conducted Capt Hannah’s interview alone and took no notes.^{Footnote 1981} To complicate matters more, although there was audio recording for the interviews with CWO Ross and Capt Hannah, there was no recording made of Capt Lubiniecki’s interview. The result was that only partial records of the interview exist and significant information may have been lost.

642. No clear explanation exists for these differences in approach. One explanation was offered by Sgt Bigelow regarding the decision to interview CWO Ross in his office: “[…] just to expedite the process, to get something from him,” possibly because of difficulty getting him to the interview room.^{Footnote 1982} Given that these interviews were voluntary, of course, it may be that this was the best option.

643. Comparing the interview transcripts against the written reports, there appear to be several discrepancies and omissions that call into question the investigators’ attention to detail in drafting them. The result is that the GO file may not always indicate fully what was learned during the interviews.

644. Sgt Hiscock’s interview summary appears to oversimplify some of his statements to the point it does not accurately reflect what he reported to investigators. He had reported he was told Cpl Langridge was under a suicide watch by either the off-going duty officer or MCpl Fitzpatrick, but that he felt it was odd Cpl Langridge would be allowed so much freedom if it was a suicide watch;^{Footnote 1983} “I guess it was a suicide watch, but it wasn’t really a suicide watch.”^{Footnote 1984} Sgt Hiscock added CWO Ross had pulled him into his office the day before his CFNIS interview and told him Cpl Langridge was not under suicide watch, but rather a set of conditions meant to provide more structure while still preserving his dignity.^{Footnote 1985} Despite this meeting, Sgt Hiscock explained to MCpl Ritco he still believed Cpl Langridge was under a suicide watch, “but put the little quotation marks around it,”^{Footnote 1986} as he believed a proper suicide watch would require more robust conditions.^{Footnote 1987} In his written summary, MCpl Ritco wrote simply: “Sgt HISCOCK was under the impression that Cpl LANGRIDGE was not […] on suicide watch”, noting the meeting with CWO Ross the day prior.^{Footnote 1988}

645. There were similar issues with Cpl Hurlburt’s interview report. He told the investigators that, approximately a week prior to Cpl Langridge’s death, he had been informed he was going to be a member of a suicide watch team for Cpl Langridge; although the watch was subsequently cancelled. He added he was not told following this cancellation that Cpl Langridge was under suicide watch. Reviewing Cpl Langridge’s conditions, though, Cpl Hurlburt stated he felt they constituted a suicide watch.^{Footnote 1989} MCpl Ritco’s report omits this final point.^{Footnote 1990} Thus, there is no indication in the report that Cpl Hurlburt felt the conditions amounted to a suicide watch. Additionally, the source of Cpl Hurlburt’s information that Cpl Langridge was going to be under suicide watch is not included in the summary. It states simply he had heard “rumours,”^{Footnote 1991} but given the circumstances in this case and the information from other witnesses, the Commission has difficulty in accepting that notion. To call the various statements and directions about a “suicide watch” or a “watch” going up and down the chain of command “rumour” would be to stretch the meaning of that word. In fact, in Cpl Hurlburt’s CFNIS interview, he stated MCpl Bowden told him directly there would be a suicide watch.^{Footnote 1992}

646. MCpl Bowden’s interview summary is a single page in length and is lacking in detail. It does not include her statement to investigators that, prior to the suicide watch being cancelled, there was already an individual keeping watch and attending to Cpl Langridge.^{Footnote 1993} Furthermore, the summary omits her statement about Cpl Langridge previously being the subject of “watches.”^{Footnote 1994} Given the centrality of the suicide watch issue, even on the narrow understanding of the negligence question adopted by MCpl Ritco,^{Footnote 1995} both of these statements were relevant and ought to have been reported in the summary.

647. Given the potential importance of the respective issues to the investigation, the interview summaries raise concerns. WO Tourout testified he reviewed the interview summaries, not the tapes,^{Footnote 1996} and it would not be reasonable to expect him to review the tapes. Incomplete or inaccurate summaries mean that supervisors may not stay apprised of important details. In the event a full negligence investigation was launched, it would have been important for investigators to determine whether the witness accounts matched the documentary record.

648. Capt Hannah’s interview report helps illustrate why investigators should strive to conduct interviews in teams and both take notes and record them. There was an apparent misunderstanding in the report and a subsequent document that may have been avoided with more attention to detail. The report noted Capt Hannah stated Cpl Langridge had medical records indicating suicide attempts as far back as 2003.^{Footnote 1997} In fact, Capt Hannah had stated “[Cpl Langridge’s] issues date back as far as 2003” in reference to his mental health diagnoses and drug dependencies.^{Footnote 1998} In specific reference to suicide attempts prior to June 2007, Capt Hannah had stated: “Are there others where he felt like doing something, or made gestures that aren't documented? That's possible, but I'd be speculating.”^{Footnote 1999} The mistaken reference to a 2003 suicide attempt then appears in MCpl Ritco’s summary of Cpl Langridge’s medical documents, erroneously creating the impression Cpl Langridge’s suicide attempts dated back far earlier than they did in reality.^{Footnote 2000}

649. Beyond the issues with the interview summaries are a number of incorrectly recorded dates throughout the investigation file. The Case Summary provides a good example, noting: Cpl Rohmer was interviewed April 8, 2008; Sgt Hiscock was interviewed April 18, 2008; MCpl Fitzpatrick was interviewed March 22, 2008; and MCpl Ritco’s requests for Cpl Langridge’s medical documents were granted March 23, 2008.^{Footnote 2001} In fact: Cpl Rohmer was interviewed March 18, 2008;^{Footnote 2002} Sgt Hiscock was interviewed March 18, 2008;^{Footnote 2003} MCpl Fitzpatrick was interviewed April 22, 2008;^{Footnote 2004} and MCpl Ritco’s requests for Cpl Langridge’s medical documents were granted April 23, 2008.^{Footnote 2005} These errors create an incorrect timeline of the conduct of the investigation. The erroneous chronology obscures the fact the investigation had lengthy gaps. In reality, no interviews were conducted between March 19 and April 22, 2008.^{Footnote 2006} Investigators should be cautious to ensure their file entries are factually accurate in case they are required to rely on those entries at a later date, such as in preparation for a trial.

650. Overall, the investigators maintained thorough notebooks and ensured they made SAMPIS entries with respect to their investigative activities. However, an apparent lack of attention to detail meant certain important pieces of evidence were not included in those entries. Going forward, investigators should ensure they pay close attention to both the content of their work as well as the technical aspects of it, including dates and times. If they need to rely on their records in the future, it is essential that the records be accurate. This is also essential for proper supervision and oversight of investigations.

File Status Reports

651. CFNIS supervisors were responsible for providing reports to CFNIS HQ under a new reporting system developed during the period Maj Frei served as DCO CFNIS. Maj Frei and LCol Garrick, then-CO CFNIS, introduced a new reporting system between the detachments and CFNIS HQ called File Status Reports. The reports were prepared every two weeks by the various detachments and then provided to HQ so “the leadership element of the [CFNIS] would have situational awareness on all of the investigations going on.”^{Footnote 2007} Case managers would go through their active files with MWO Watson and help prepare the documents. The reports employ a prioritization formula intended to “tell you where to devote your resources to, according to the priority assigned to each investigation.”^{Footnote 2008}

652. At the time of the 2008 Investigation, MWO Watson, as Senior MP Advisor, prepared the reports for CFNIS WR.^{Footnote 2009} The first Status Report mentioning Cpl Langridge’s death was sent some time before April 1, 2008.^{Footnote 2010} It states the investigation is “in the initial stages.”^{Footnote 2011} The second Report, dated April 1, 2008, adds to this, stating the investigation is “ongoing and all information acquired will be shared with the Morinville RCMP Department.”^{Footnote 2012} The third Report, dated April 8, 2008, simply indicates the investigation is continuing.^{Footnote 2013} A fourth Report, dated May 13, 2008, states: “File may be turning in a different direction due to information obtained indicating the deceased was on suicide watch when he committed suicide.”^{Footnote 2014} It also states investigators were waiting to obtain Cpl Langridge’s medical records.^{Footnote 2015} Reports dated June 3 and 10, 2008 note all documentation has been reviewed, the investigation has been completed and the final report is being written.^{Footnote 2016}

653. There are numerous issues with these File Status Reports.

654. The April 1, 2008 Report, indicating all information would be shared with the Morinville RCMP department, is apparently in error. MCpl Ritco was unaware of this issue. ^{Footnote 2017} WO Tourout suggested it could have been a “typo”, related to another investigation ongoing at the time.^{Footnote 2018} The statement continues to appear in all subsequent File Status Reports.^{Footnote 2019}

655. MWO Watson explained the CFNIS does not have the authority to compile a Report of Death, which is required for all fatalities in Alberta,^{Footnote 2020} implying RCMP assistance would be required in order to complete the Report of Death. According to MWO Watson, what presumably happened is that the ME accepted the CFNIS report as a Report of Death, making follow-up with the RCMP unnecessary.^{Footnote 2021} It may be that the Morinville RCMP detachment was never contacted about the matter – the investigation file notes a conversation on March 19, 2008 between MCpl Ritco and the RCMP, a member of which expressed they were “upset not [to] be called […] have MWO call.”^{Footnote 2022} It does not appear any information was shared with the RCMP with respect to the death before then, and it is not clear from the file when (or if) MWO Watson notified the RCMP of the investigation.^{Footnote 2023} It may be that the above reference was inserted based on an assumption that in light of the issue of authority to compile a Report of Death, there would be file sharing, but the report seems factually incorrect.

656. The May 13, 2008, File Status Report indicating the file may be turning in a “different direction”^{Footnote 2024} raises its own set of issues. It appears approximately two months after the investigation began. However, the investigators were initially made aware Cpl Langridge may have been under suicide watch at the time of his death when they first attended the scene^{Footnote 2025} or the next day.^{Footnote 2026}

657. MCpl Ritco did not know what this notation was intended to mean, as he had heard rumours of the suicide watch from the beginning of his investigation. He stated he was unsure as to what was meant by the statement the file may be turning in a different direction.^{Footnote 2027}

658. WO Tourout explained it was meant to indicate the investigators were querying whether Cpl Langridge was under a suicide watch in order to determine whether a second investigation into negligence needed to be opened. However, nothing was substantiated and so the file did not end up turning in another direction.^{Footnote 2028} MWO Watson, meanwhile, stated the change in direction would have been the investigators examining whether Cpl Langridge was under a suicide watch.^{Footnote 2029}

659. Maj Frei, then the DCO CFNIS, testified that this Report would suggest to him “an alert investigator had been twigged onto perhaps another avenue of the investigation that needed to be looked at.”^{Footnote 2030} The update certainly suggested something had changed between April 8 and May 13, 2008 that led investigators to believe Cpl Langridge may have been under suicide watch and the suicide watch was a key topic in most if not all the interviews conducted.^{Footnote 2031} The new development may have been the CFNIS interview with MCpl Fitzpatrick on April 22, 2008, during which he told the investigators about the abortive attempt to assemble a suicide watch for Cpl Langridge in March 2008.^{Footnote 2032}

660. Overall, the File Status Reports in this case do not serve their intended function. The entries are not always accurate and would not provide CFNIS HQ with meaningful situational awareness. It is difficult to see how these Status Reports could have been used to provide any meaningful oversight for the investigation. The one potentially important notation – indicating a possible new direction “due to information obtained indicating the deceased was on suicide watch when he committed suicide”^{Footnote 2033} – came too late in the process, on May 13, 2008, well after the investigation of the suicide watch was underway (and indeed was much closer to the conclusion of the investigation on June 2, 2008, than to the beginning). Moreover, there was no follow-up in the form of meaningful reporting to HQ of the conclusions drawn with respect to this aspect of the investigation.

4.1.6 Search Warrants

661. The investigators entered into, and seized items from, Cpl Langridge’s storage locker^{Footnote 2034} and Jeep^{Footnote 2035} without first obtaining search warrants.^{Footnote 2036} The decision to conduct these warrantless searches raises the issue of whether there was a proper basis to do so, as well as the prior and perhaps more troubling question of the investigators’ knowledge and understanding of their search and seizure powers.

The Searches Conducted

662. On March 15, 2008, after processing the barracks room where Cpl Langridge’s body was found, MCpl Ritco and Sgt Bigelow searched and seized items from Cpl Langridge’s locker in the defaulters’ room.^{Footnote 2037} They did not have a key, and so they “had to break into the locker [...] [W]e had to cut the lock off.”^{Footnote 2038} On March 16, 2008, they searched Cpl Langridge’s Jeep and seized certain items.^{Footnote 2039} They had found the keys to the Jeep while processing Cpl Langridge’s barracks room.^{Footnote 2040} In both cases, the searches and seizures were conducted without obtaining search warrants.^{Footnote 2041}

663. Nothing in the investigation file indicates either investigator or their case manager considered the possibility it might be necessary to obtain a search warrant prior to conducting either search. There is no evidence the issue was discussed within the investigative team at the time of the searches. There is also no evidence the issue was brought to members of the CFNIS chain of command or any legal advisor. Similarly, there is no evidence the ME Investigator was consulted on these matters.

Rationales Provided for the Searches

664. Both CFNIS investigators in this case testified they did not believe search warrants were required. MCpl Ritco, the lead investigator, stated he believed he was carrying out the investigation on Cpl Langridge’s behalf. As a result, he did not think he required any warrant to search the Jeep to acquire evidence related to the death.^{Footnote 2042} Sgt Bigelow (who assisted with the processing of the scene) also believed there was no requirement to obtain a search warrant, and testified “The Coroners Act [actually the Fatality Inquiries Act^{Footnote 2043} in Alberta] allows us to have access to the scene itself, as well as any other places that the person would have been privy to, be it his locker at the LdSH and/or his vehicle.”^{Footnote 2044}

665. WO Tourout (the case manager) offered a different explanation. When asked about the possible need for a warrant, he testified that because MCpl Ritco had obtained keys to Cpl Langridge’s Jeep, no warrant was required. He added, as the locker was “within a CF location,” and as the items were seized to “protect” them, no warrant was required.^{Footnote 2045} When asked if he wanted to reconsider his answers, he explained he believed the Regiment had provided the key to the vehicle and had thus authorized the access. In his testimony WO Tourout added, “as a policeman, if we have a key we don’t need a warrant.”^{Footnote 2046}

666. In their written Closing Submissions, the subjects of the complaint argue MCpl Ritco “had authority to search the barracks room, the defaulters room and the jeep” without a warrant pursuant to his powers of crime scene search as well as the powers granted to him by the Fatality Inquiries Act.^{Footnote 2047} During oral argument, counsel for the subjects clarified it was the subjects’ position those searches were conducted pursuant to the Fatality Inquiries Act.^{Footnote 2048} However, they stated it would not be appropriate for them to take a position as to whether the items were seized pursuant to the Alberta Medical Examiner’s direction, noting the Commission would have to refer back to the subjects’ testimony to determine this point.^{Footnote 2049}

Incompatibilities Between the Rationales and the Facts

667. The explanations provided by the investigative team are incompatible with one another and do not appear to be supported by the facts. MCpl Ritco’s stated belief he was conducting the investigation on Cpl Langridge’s behalf does not appear to have a basis. Criminal investigations are conducted by police officers in order to enforce the law, not on behalf of victims, decedents or the government.^{Footnote 2050}

668. WO Tourout’s explanation that the Regiment provided the investigators with access to the Jeep is not supported by the facts. In fact, the evidence discloses MCpl Ritco and Sgt Bigelow had simply found the key among Cpl Langridge’s personal effects, retained it and then used it to search the vehicle.^{Footnote 2051} Nothing in the investigation file demonstrates the Unit was involved in any way in the search of the vehicle. As for WO Tourout’s view a warrant was not required because the locker was within the CF location, the National Defence Act permits COs to issue warrants for the search of CF living quarters, lockers and storage spaces occupied by members subject to the Code of Service Discipline when they are satisfied there are reasonable grounds to believe property therein may provide evidence of an offence under the Act. In such circumstances, CO warrants may permit entry into, and the seizure of property from, these locations.^{Footnote 2052} No submissions were made by either the complainants or the subjects of this complaint with respect to CO warrants.

669. The testimony of MWO Watson (A/CO CFNIS WR) and Maj Frei (DCO CFNIS),^{Footnote 2053} is relevant to Sgt Bigelow’s stated belief the investigators were authorized under provincial ME legislation to search the locker and Jeep. Both testified the MP are not recognized under the Alberta Police Act. MWO Watson stated, as a result, the ME “does not have the authority to direct the military police.”^{Footnote 2054} Maj Frei added the MP are not recognized under the provincial Coroners Acts (in Alberta, the Fatality Inquiries Act^{Footnote 2055}). He stated, the fact the MP are not recognized under these Acts means their relationship with the ME is “less formalized” than it would ideally be.^{Footnote 2056}

670. There is, in any event, no indication in the investigation file the investigators searched these locations under such authority. There is no record of any discussion among the investigative team or between the investigators and the ME Investigator indicating this issue was considered. It does not appear Sgt Bigelow’s belief was shared by the other members of the investigative team or the ME Investigator at the time these searches were conducted.

The Law of Search Warrants

671. Sgt Bigelow’s contention about powers of the MP under the Fatalities Inquiries Act, as well as that argument’s variant in the subjects’ final submissions, are essentially legal arguments about the powers of police to search and seize.

672. When conducting searches and seizures, police officers are generally required to obtain a search warrant.^{Footnote 2057} Certain exceptions to this rule exist under common law and statute to allow police officers to search and seize property without a warrant. At common law, police maintain general powers to conduct warrantless searches and seizures on consent^{Footnote 2058} They also have a power of search without warrant incidental to an arrest^{Footnote 2059} or detention.^{Footnote 2060} Under the Criminal Code, meanwhile, there is an exception to the general warrant requirement where the preconditions to obtain a search warrant are present, but it is impracticable to obtain one due to exigent circumstances.^{Footnote 2061} Exigent circumstances include situations where there is an imminent threat of bodily harm to an individual or the loss or destruction of evidence.^{Footnote 2062}

673. The Supreme Court of Canada has recognized there is a reasonable expectation of privacy with respect to motor vehicles and warrantless searches of such vehicles may be conducted only where exigent circumstances require.^{Footnote 2063}

674. The Fatality Inquiries Act allows ME Investigators to conduct warrantless searches of, and make warrantless seizures from, any place a body, which is the subject of an investigation, is located, as long as the items seized “may be directly related to the death.”^{Footnote 2064} ME Investigators include (aside from those appointed to the position under the Act):^{Footnote 2065} “Every member of the Royal Canadian Mounted Police or a police service or peace officer responsible for the policing of any part of Alberta pursuant to an arrangement or agreement under section 5(1)(b) of the Police Act.”^{Footnote 2066} In order to conduct any such warrantless search or seizure, a ME Investigator must be acting under the ME’s authorization.^{Footnote 2067}

Application to the Facts

675. There may perhaps be arguments capable of justifying the searches performed in this case. However, none were presented in either the testimony of the subjects of the complaint or the submissions of their counsel. The ones that were advanced do not stand up to scrutiny.

676. The subjects’ submissions that the searches and seizures were conducted pursuant to the investigators’ powers under the Fatality Inquiries Act appear to stand in opposition to the position put forth by MWO Watson and Maj Frei’s testimony the MP are not recognized under the Alberta Police Act, which would appear to preclude them from being authorized as ME Investigators. Maj Frei’s evidence in particular confirms there are doubts even within the CFNIS about this being relied upon as an authorization for its members. Furthermore, the Commission could find no evidence of an arrangement or agreement between the Province of Alberta and the MP to suggest they are a recognized police force under the Police Act or otherwise capable of being authorized as ME Investigators.

677. There is no evidence to suggest the investigators were authorized by the ME to conduct warrantless searches or seizures. While MCpl Ritco testified he provided a list of Cpl Langridge’s medications to the ME Investigator at his request, and certain medications were recovered from the Jeep,^{Footnote 2068} there is no indication the investigators were authorized or directed to search the Jeep by the ME in the first place. There is no record in the investigation file and the Commission heard no evidence the ME or ME Investigator authorized the search of the locker. There is no indication the ME Investigator was even made aware of the searches prior to or following their execution.

678. The searches were not conducted on consent or as incident to an arrest or detention. There were no exigent circumstances requiring urgent action by MP members to respond to a potential threat or loss of evidence. The searches also do not appear to have been conducted in accordance with what the subjects’ counsel referred to as the “powers of crime scene search.”^{Footnote 2069} The locker was in a different building from the location where Cpl Langridge’s body was found and his Jeep was parked in a lot outdoors. There does not appear to have been any suspicion either of these two locations was related in any way to the death or was otherwise part of the “crime scene.” Even if the subjects were correct in alluding to a power of warrantless search of a “crime scene”, it is difficult to see how either of these locations could qualify.

Conclusion

679. Reviewing the available documents and testimony, it appears the searches of Cpl Langridge’s locker and Jeep were not conducted with proper legal authorization. They were not authorized by or conducted on behalf of the ME or under the Fatality Inquiries Act and were not otherwise justified by the common law or the Criminal Code. No tenable argument on the facts or the law was presented to justify the warrantless searches.

680. The differing explanations provided about the authority for the searches, along with the absence of any indication from the file or testimony that the issue was considered prior to conducting the searches, does not reflect well on the investigators’ knowledge about their legal authority in connection with searches and seizures. This may not be surprising in light of the broader failure to think through the reasons for conducting the searches in the first place, as noted elsewhere in this report.^{Footnote 2070} At the very least, the apparent gap in understanding the principles of when and why warrants are needed may reflect a deficit in understanding of basic police procedures.

681. Understanding the basic legal requirements to conduct searches and seizures is a critical aspect of CFNIS members’ role as investigators. The rules are integral to ensuring evidence is collected in a manner that will pass scrutiny and allow for admissibility in court proceedings when necessary. The investigators and their case managers should, at a minimum, have considered whether consultation with the CFNIS chain of command or a legal advisor was called for. The Commission is troubled by the fact these misunderstandings – including the alarming belief the mere possession of a key justifies using it to gain entry for purposes of a warrantless search – persisted up to the subjects’ testimony at the hearing.

4.1.7 Return of Exhibits^{Footnote 2071}

682. The complainants have alleged CFNIS members failed to dispose of Cpl Langridge’s property, seized as exhibits during the investigation of his death, when concluding the investigation. They further allege CFNIS members failed to have the property returned to the complainants in a timely manner.^{Footnote 2072}

683. The evidence discloses CFNIS members did fail to dispose of the property seized as exhibits at the conclusion of the investigation. Adequate processes were not put in place at the Detachment to ensure exhibits were returned in a timely manner. However, when they were notified of this failure, the CFNIS members took reasonable steps to have the property returned to the complainants. Subsequent delays appear to have occurred in returning the property from the Regiment to the complainants, but CFNIS members are not responsible for these delays.

The Property Seized

684. While processing the scene of Cpl Langridge’s death, CFNIS investigators seized 12 exhibits, which included between one and six items of property each. Among the seized items were the suicide note left by Cpl Langridge,^{Footnote 2073} his personal identification and cell phone, pamphlets and literature relating to drug and alcohol abuse, medical forms, an adult video, and personal correspondence, including get well cards.^{Footnote 2074} Further exhibits were seized while processing Cpl Langridge’s Jeep the next day, including prescription drug containers and medical documentation.^{Footnote 2075} Once the property was seized, it was temporarily stored in MCpl Ritco’s storage locker before being transferred to the CFNIS evidence room. It does not appear investigators examined the exhibits after seizing them.^{Footnote 2076} At the conclusion of the investigation all property seized – aside from the personal identification and adult video, which had been returned to the LDSH property custodian – remained in the CFNIS evidence room.^{Footnote 2077}

What Was the MP Policy for the Storage and Disposal of Exhibits?

685. The MPPTP includes an annex dealing with the collection, handling, disposal and return of evidence in MP investigations.^{Footnote 2078} The Senior MP Advisor is responsible for supervising the storage of seized evidence. He or she is directed to appoint primary and alternate evidence custodians and to ensure all evidence is inspected twice per year. An evidence inspector at the rank of a senior NCM or higher, and not the primary or alternate evidence custodian, must be appointed to conduct these inspections. The evidence inspector is required to complete full reviews of all evidence holdings and submit a report to the Senior MP Advisor for each of the reviews. These reviews include ensuring all current evidence is being handled in accordance with national MP policy and local forensic laboratory policy.^{Footnote 2079}

686. The Senior MP Advisor is also responsible for the disposal of exhibits. The MPPTP states generally all exhibits shall be disposed of following the expiration of the appeal period from any court case resulting from an investigation.^{Footnote 2080} An exception to this policy notes: “Physical evidence collected in the course of an investigation and not used as exhibits at a subsequent trial need not be retained with the status of evidence. Such items may be disposed of as appropriate under other regulations or returned to the rightful owner(s).”^{Footnote 2081} In the event there are no judicial proceedings resulting from an investigation and an owner cannot be identified, evidence shall be disposed of within one year of the conclusion of the investigation.^{Footnote 2082}

687. When the time comes to dispose of evidence, the Senior MP Advisor is responsible for requesting disposal instructions from the disposal authority. The disposal authority is the individual or body ultimately responsible for determining whether evidence will be returned to its owner after it is released by the MP.^{Footnote 2083} The disposal authority may be a local legal officer, Crown Attorney, DPM Police or CO of the Unit involved in an investigation, depending on whether charges were laid as a result of an investigation and the court that heard any resulting case.^{Footnote 2084} The Senior MP Advisor requests the disposal authority to direct the method of disposal and declare ownership of the property.^{Footnote 2085} Where the owner of property is known, the normal protocol is to return the property to that person.^{Footnote 2086} The MPPTP does not specify a method of delivery or whether the MP are to deliver the property directly to the rightful owners or by way of the disposal authority or by some other means.

688. The MPPTP, although it is not written as clearly as it could be on this point, appears to indicate it is necessary to seek disposal authority in all cases, even where items are no longer considered necessary for an investigation or will not be used in court proceedings.^{Footnote 2087} The reason for this requirement is not clear. The CFNIS witnesses who testified before this Commission have not provided consistent explanations about the applicable process or its rationale.^{Footnote 2088}

What Ought to Have Been Done in This Case?

689. Property was seized at the scene of Cpl Langridge’s death because investigators apparently believed it may have been relevant to their sudden death investigation.^{Footnote 2089} Holding the seized evidence while investigating the sudden death and the suicide watch issue was not unreasonable.^{Footnote 2090}

690. The lead investigator completed his Concluding Remarks on the investigation on June 2, 2008.^{Footnote 2091} His Case Manager completed the Supervisor Concluding Remarks on June 12, 2008, indicating he concurred with the investigative steps taken.^{Footnote 2092} MWO Watson, the Senior MP Advisor and Acting OC CFNIS WR, approved the investigation report on July 1, 2008.^{Footnote 2093} He distributed the report on the same day, with a cover letter detailing the conclusions of the investigation.^{Footnote 2094} The Deputy CO CFNIS reviewed the file on July 3, 2008, and concurred with the findings of the investigation.^{Footnote 2095} No charges were brought as a result of the investigation. It does not appear charges were ever contemplated regarding the sudden death^{Footnote 2096} or the suicide watch^{Footnote 2097} aspects of the investigation.

691. In accordance with MP policy, seized property can be disposed of when the investigative team determines it is no longer required for an investigation. It is possible a review of the evidence, while the investigation was ongoing, could have led CFNIS members to conclude certain items of evidence were not relevant to either aspect of the investigation they were conducting. However, investigators had not ruled out foul play, nor had they reached conclusions about the suicide watch issue, until the investigation was concluded.^{Footnote 2098} For this reason, at the latest, the investigative team ought to have determined the seized evidence could be disposed of at the conclusion of the investigation.

692. The MPPTP does not specify what event or document marks the conclusion of an investigation among the investigator’s Concluding Remarks, the Case Manager’s Supervisor Concluding Remarks, the OC’s approval of the report, the Deputy CO’s review or some other possible point. While it is possible the Deputy CO’s review could result in a file being referred back to a detachment, the Deputy CO did not sign off on this investigation.^{Footnote 2099} The final sign-off was done by the Acting OC for the Detachment.^{Footnote 2100} It occurred when the report was approved, and the investigation was officially marked as concluded, on July 1, 2008.^{Footnote 2101} The investigative team should have begun the process of cataloguing the seized evidence to prepare for its disposal on that date. Given the circumstances of this investigation – Cpl Langridge was a member of LDSH and no charges resulted from the investigation – the appropriate disposal authority under MP policy was the CO LDSH.

What Was Done in This Case?

693. At the conclusion of the investigation, no attempts were made by the investigative team to begin the process of disposing of Cpl Langridge’s property. No request was sent to the disposal authority, and there does not appear to have been any review of the property held.

694. On September 29, 2008, Mr. Fynes sent an email to the JAG Director of Estates office in Ottawa through his AO, Maj Stewart Parkinson. He identified himself as the executor of Cpl Langridge’s estate and requested a copy of the inventory of Cpl Langridge’s property being held at CFB Edmonton.^{Footnote 2102} Suzanne Touchette, who worked at the JAG Director of Estates office, sent a return email on October 23, 2008, copying MCpl Ritco and authorizing the release of Cpl Langridge’s property. The email noted MCpl Ritco had previously informed the Committee of Adjustments (COA) 13 items remained in CFNIS custody as part of its ongoing investigation. She asked MCpl Ritco to confirm the exhibits were no longer required and, if so, to release them.^{Footnote 2103}

695. MCpl Ritco responded the next day by seeking guidance from Sgt S.B. Miller of CFNIS WR.^{Footnote 2104} He testified he was told “senior staff” would handle the release of the items.^{Footnote 2105} A letter to the disposal authority, the CO LDSH, was drafted and signed by MWO Watson on October 31, 2008.^{Footnote 2106} It is not clear who drafted the letter. MWO Watson testified his normal practice was to draft such letters himself and have the lead investigator draft the list of evidence, though he did not have a specific recollection of drafting this letter.^{Footnote 2107} MCpl Ritco could not specifically recall his role in preparing the letter, but testified he may have compiled the list of items to be returned.^{Footnote 2108} He knew he had at least confirmed the items stored in evidence were no longer required.^{Footnote 2109}

696. MWO Watson’s letter noted the investigation into Cpl Langridge’s death was complete, and stated the Regiment CO’s authority was requested to dispose of the exhibits, in accordance with MP policies.^{Footnote 2110} It noted, once authority was received, the items listed would be returned to Cpl Langridge’s estate.^{Footnote 2111} The letter included a list of 13 items seized during the investigation,^{Footnote 2112} but did not list the suicide note, of which the Fynes, at that point, were unaware.^{Footnote 2113}

697. On November 17, 2008, Mr. Fynes requested all the items, including those seized by the CFNIS, be returned to the estate in one shipment. Capt Eric Angell, then the Adjt LDSH, agreed to this request and appears to have taken charge of returning Cpl Langridge’s property to his estate.^{Footnote 2114}

698. On January 21, 2009, the CO LDSH responded to the CFNIS’ request for authority to dispose of the exhibits.^{Footnote 2115} He granted authority, and indicated the items could be forwarded to the Regiment for inclusion with the remainder of Cpl Langridge’s effects.^{Footnote 2116} He noted the effects would be sent to the executor of the estate as soon as possible, and listed Capt Angell as the person to contact for additional inquiries.^{Footnote 2117}

699. The CFNIS released the seized items on January 26, 2009.^{Footnote 2118} The items were released to the LDSH Regiment, to be returned to the estate with the remainder of Cpl Langridge’s property. This was the end of the CFNIS’s involvement in returning Cpl Langridge’s property.

700. It is not clear whether Cpl Langridge’s property should have been sent by CFNIS WR directly to the executor of his estate or whether it should have been returned by way of the Regiment. The Regiment had, at the time of the conclusion of the investigation, been storing a number of Cpl Langridge’s items, including his Jeep. Given Mr. Fynes’ request, it appears returning the property to Cpl Langridge’s estate by way of the Regiment was not unreasonable. There is no evidence any delays in returning the property, once it was released to the Regiment, were the result of the CFNIS members’ actions.

701. The Commission heard little evidence with respect to evidence inspectors and whether CFNIS WR employed them to conduct the mandated biannual reviews of evidence held. However, CFNIS member testimony suggested returning seized property was not a high priority at the time. In discussing the return of the suicide note to the Fynes, Maj Dandurand testified the practice, at the time, was that items of evidence were held “until such time as they were disposed of.”^{Footnote 2119} He stated such items would come to CFNIS members’ attention as a part of regular evidence reviews, but they were not efficient in promptly returning property.^{Footnote 2120} He testified, “it was not uncommon for evidence to be held for several years.”^{Footnote 2121} MWO Watson, meanwhile, testified the inspection of the evidence room provided for in the policies would have been “a year-long project in itself,” and indicated he did not carry out any such inspection when he was the Acting OC for the Detachment.^{Footnote 2122} He also explained no one in the Detachment was specifically tasked with disposing of exhibits, and noted this task was “overlooked” in many investigations.^{Footnote 2123} He stated he did not routinely send requests for disposal authority.^{Footnote 2124} He testified, if it was not for Ms. Touchette’s letter, he would not have drafted his request to the disposal authority in this case.^{Footnote 2125}

Conclusion

702. The investigative team in this case did not promptly dispose of the exhibits upon the conclusion of the investigation. This failure appears to have been inadvertent. When MCpl Ritco received Ms. Touchette’s email, he acted quickly to begin the process of disposing of Cpl Langridge’s property. MWO Watson’s letter requesting disposal authority was sent shortly after, and the remaining delay occurred while the CFNIS was waiting for the Regiment’s response. However, had Ms. Touchette not sent her email, there is no indication the CFNIS would have taken any steps to return the exhibits. The evidence in this hearing has revealed there were no adequate processes in place at the Detachment to dispose of evidence.^{Footnote 2126} The CFNIS members in charge of the Detachment were responsible for this broader failure.

703. While they did not dispose of the exhibits as soon as they should have, the CFNIS members involved in the investigation responded promptly once they were notified of the oversight. Though they are responsible for not disposing of the property immediately at the conclusion of the investigation, any delays encountered once the property was released to the Regiment were not attributable to CFNIS members.

4.1.8 The Quality Assurance Review

704. In early June 2009, following the discovery of the failure to disclose Cpl Langridge’s suicide note to the Fynes, the CFNIS initiated a Quality Assurance (QA) review of the investigative file respecting the 2008 investigation.^{Footnote 2127} The review was conducted by WO Ken Ross,^{Footnote 2128} then the Acting Detachment MWO for CFNIS WR.^{Footnote 2129}

The QA Review Policy

705. A QA review provides an additional potential layer of supervision with respect to an investigation. The relevant CFNIS SOP states the process is intended “to ensure a consistent and high level of investigative service [and] ensure all investigations carried out by [CFNIS] are conducted to a high level of professionalism and in accordance with the law, standard police practices, regulations and SOPs.”^{Footnote 2130}

706. The Detachment MWO or WO is responsible for maintaining quality control and conducting QA reviews at the detachment level. The QA review process may be triggered when a complaint is filed, where a file is complex and merits review, or at random.^{Footnote 2131} The review process consists of three phases: a physical review of the file, recommendations for corrective action, and follow-up.^{Footnote 2132} It is the responsibility of the Detachment MWO or WO to conduct training sessions to address issues identified during the QA review process. An “after action review” is then to be forwarded to the CFNIS HQ CWO on the training and results.^{Footnote 2133}

707. Following a QA review, the Case Manager is to review the QA report with the applicable investigator(s) and counsel them on any deficiencies, reporting any action taken to the Detachment MWO. The Case Manager is also to ensure all subordinates either attend or review any training sessions resulting from the QA review and is to attend or review the training sessions him or herself as well.^{Footnote 2134} Investigators are instructed to review the QA report with their supervisor and provide feedback or explanations where appropriate. In addition to attending or reviewing the training sessions, investigators are to action any lessons learned and report on this to the Detachment MWO or WO on an ongoing basis.^{Footnote 2135}

The QA Review Findings

708. The QA review conducted by WO Ross is dated June 19, 2009.^{Footnote 2136} The initiating event for the review is stated to be “a complaint brought forward by Cpl LANGRIDGE’s family who were concerned with the lack of optics of the suicide note and the delay in the delivery of the [subject] suicide note.”^{Footnote 2137}

709. The report is divided into four sections entitled respectively: Comments on Investigative Procedures, Comments on Administrative Procedures, Action Taken to Rectify Procedural Problems Discovered, and Recommendations.^{Footnote 2138}

Investigative procedures

710. The opening sentence of the first paragraph of the report informs the reader, “the totality of investigation conducted was found to be technically sound.”^{Footnote 2139} It also informs the reader, “the observations brought forward were found not to have a direct impact on the investigative integrity of this file.”^{Footnote 2140} Presumably these findings were meant to apply specifically to the four observations cited in the section on investigative procedures.

711. This Commission has found numerous deficiencies in the investigative steps taken in connection with processing the death scene and carrying out the investigation in general.^{Footnote 2141} By contrast, the QA only lists two investigative procedures for apparent critical comment. It notes investigators failed to examine and take photographs and videos of the exterior of the building as a follow-up to the discovery that the window to Cpl Langridge’s third floor room was open.^{Footnote 2142} It also notes a failure to authenticate the suicide note or to obtain any handwriting samples for comparison purposes, but then seems to indicate this may not have been necessary due to the scene indicators and the ME Investigator’s initial opinion.^{Footnote 2143} Another observation in this section notes the investigators did not follow up on a mention by the family of a person they believed responsible for introducing Cpl Langridge to drugs, whom they did not want at the funeral, and indicates this information had now been forwarded to intelligence for follow-up.^{Footnote 2144} The final observation consists of a commendation for appropriate use of resources in conducting background checks.^{Footnote 2145}

712. Fixing on the issues of failure to examine the area outside of Cpl Langridge’s third storey window and the failure to authenticate the suicide note is particularly striking in light of the fact the investigators also did not employ any forensic measures in examination of the doors, windows, ligatures or hanging apparatus and took inadequate measures to safeguard the scene against contamination.^{Footnote 2146} There is no consideration at all of the investigative procedures taken over the rest of the three month span of the investigation, with the possible exception of the comments in the “Administrative Procedures” section critical of the attempt to investigate negligence. The other two observations seem tangentially related, at best, to investigative procedures for processing the scene or investigating the suicide.

713. Given the limited findings in connection with investigative procedures, it is not surprising the report finds no direct impact on investigative integrity. If what is meant is the validity of the conclusion of suicide by hanging is not brought into question by the deficiencies cited, the observation is correct. However, beyond that, neither limiting the deficiencies to those listed in the report nor the consequent conclusions of investigative integrity or technical soundness seem justifiable.

Administrative procedures and recommendations

714. As might be said about the report as a whole, the section dealing with Administrative Procedures^{Footnote 2147} seems somewhat hastily drafted and is not easy to navigate. It is not always clear whether observations are simply factual notes or whether they are critical comments. Nor is it clear what importance is being attached to any individual observation. Observations of minor deviations from record keeping protocol are interspersed with identification of matters that constitute major deficiencies in the investigative file. Comments about the suicide note are followed by discussions of the disposal of evidence.

715. Some assistance in navigating this section and understanding the intended meaning of its observations may be found in the Recommendations section.^{Footnote 2148} That section seems, as much as anything, to constitute a series of conclusions (followed by a single recommendation) with respect to some of the observations made in the Administrative Procedures section.

716. In the Recommendations section, the problematic issues with the steps taken in reaching the finding of suicide by hanging are listed as:

clear articulation of the measures which were taken to come to those findings and what they were;
maintenance of a deliberate focus of the investigation in order that only the criminality or lack thereof remains the focus and to ensure that the mandate of the BOI is not assumed by the CFNIS; and
that a cognizant and informed decision is made when to effectively engage the family to advise them of the status of the investigation and to divulge to them, as was in this instance, that a suicide letter existed, when to allow them to view that note and when it is appropriate to release the original note to the family.^{Footnote 2149}

No clear articulation of measures taken to come to findings

717. This conclusion seems linked to the critical comments set out in the Administrative Procedures section about the Case Summary and Concluding Remarks in the investigation file. The list cited regarding evidentiary findings omitted from these sections is lengthy and largely accurate.^{Footnote 2150} The evidence before this Commission suggests the omissions may be the result of the investigators themselves never putting together the evidentiary findings in any analytic manner to indicate suicide or to rule out foul play.^{Footnote 2151} In any case, this conclusion in the Recommendation section seems justified.

Maintaining a focus only on criminality

718. This conclusion is linked both to a number of the matters discussed in the Administrative Procedures section as well as to the single explicit recommendation in the Recommendations section, namely:

It is recommended that the Case Manager of a suicide file remain focused on the "what" of the investigation and at the very most touch on the "why". Additionally, it is incumbent upon the Case Manager to ensure that the focus remain within the CFNIS mandate rather than assuming, in some instances that of the BOI mandate.^{Footnote 2152}

719. Insofar as they direct investigators to focus on the “what” rather than the “why” in a suicide investigation, both the observation and the recommendation reflect the existing MPPTP at the time of the investigation.^{Footnote 2153} As such, it was appropriate and defensible to cite this approach in the QA report as the correct investigative framework. However, as set out elsewhere in this report, the evidence before this Commission establishes that framework does not reflect best practices.^{Footnote 2154} Issues related to the “why” are relevant and ought to be pursued in a sudden death investigation in addition to issues related to the “what.”

720. Less defensible in these comments, and in similar comments in the Administrative Procedures section, is the specific suggestion the investigation should deal only with issues of criminality and not with negligence. In its observations about the Investigation Plan in the Administrative Procedures section, the QA report suggests step #13 of the IP dealing with “‘possible negligent actions … resulting in possible involvement in death’” is not a CFNIS mandate but rather falls within the purview of a Board of Inquiry.^{Footnote 2155} This observation comes after a rather opaque critique of the Investigation Plan for not setting out “the elements of the offence,” which notes this did not impact on the integrity of the investigation because the investigators demonstrated they “approached the sudden death with open minds, not focused solely on suicide as a manner of death.”^{Footnote 2156}

721. As discussed at length in this report, negligence is clearly within the mandate of the CFNIS both in terms of the Criminal Code offences related to Criminal Negligence and in terms of the service offences of Negligent Performance of a Military Duty and Conduct to the Prejudice of Good Order and Discipline.^{Footnote 2157} The 2008 investigation is deficient in a number of ways relating to how negligence was investigated, but the identification of negligence as being potentially relevant to an investigation of the death of Cpl Langridge is not one of them.^{Footnote 2158}

Engaging the family and releasing the suicide note

722. The QA review, in this case, was the result of complaints by the Fynes about how the suicide note was handled. The QA describes this complaint somewhat inelegantly as dealing with “the lack of optics of the suicide note” as well as with the delay in its delivery to the family.^{Footnote 2159}

723. Somewhat buried as point 2(f) of the Administrative Procedures section is the following observation:

detailed in MCp1 Ritco's OF2 text box, at para 61, he articulates that at “1700 hrs, 9 Apr 08, Mr. CAUFIELD (ME) returned call, no need to bring items in, as 10 of the 11 tests have been conducted. There appears to be no evidence to support foul play, therefore at this time it will be classified as suicide.” It is at this point consideration by the investigators in consult with the Case Manager, be given to the fact of meeting with the family and providing them with the salient points of the investigation to date and would have presented an opportune time to have the family members review the suicide note to verify the authenticity of the handwriting and possibly give them a copy at that time. If the decision was made not to move forward with any briefings to the family until such time as they received the official report from the ME, the Certificate of Medical Examiner was received 15 May 08, which provided definitive conclusion concerning the manner of death – suicide;^{Footnote 2160}

724. The timing issues regarding disclosure of the suicide note are discussed elsewhere in the Commission’s report.^{Footnote 2161} While the suggestion the note should have been disclosed to the Fynes at a much earlier time is clearly appropriate, the suggested timing would not have responded to their major complaint of not having had Cpl Langridge’s wishes about his funeral disclosed to them in time for them to comply with them.^{Footnote 2162} The practicalities of the timing being suggested also lead to questions about the utility of the suggestions, namely, the Fynes could have been consulted either at the point the ME provisionally confirmed the death as suicide or at the point of the ME’s final determination. Consulting the Fynes about the authenticity of the suicide note would have made sense in combination with disclosure of the note had it been undertaken before the funeral. By the time the ME Investigator had tentatively or conclusively confirmed Cpl Langridge’s death was suicide, measures to authenticate the note would have had little practical or investigative significance.

725. Section 2 of the Administrative Procedures section continues with two observations in connection with CFNIS dealings with the Fynes, without comment or criticism. It states MCpl Ritco was informed there was no need to contact Mrs. Fynes, and it indicates when he did speak with the Fynes, they did not raise the existence of the suicide note.^{Footnote 2163} Insofar as this may be read as justifying the failure to disclose the suicide note or to take steps to contact the Fynes before they contacted the CFNIS, it is not appropriate.^{Footnote 2164}

Actions to rectify

726. The section entitled Actions Taken to Rectify Procedural Problems Discovered precedes the Recommendations section, but, practically speaking, it can be seen as a logical extension of the conclusion about the suicide note in the Recommendations.^{Footnote 2165} The remediation measures discussed in the Actions Taken section are entirely confined to the issue of the suicide note. As such, they don’t deal with investigative problems discovered by the QA, but rather with the Fynes’ substantive complaint.

727. The first of the two paragraphs in this brief section reads:

Resultant of the complaint brought forward by the family of Cpl LANGRIDGE [with respect to] the delay in disclosure of the suicide note; the CFNIS WR Chain of Command has become extremely cognizant of the issue of disclosure of any suicide notes left by the deceased at the scene. Additionally, in depth analysis/discussions have occurred regarding best practices concerning the requirement to engage the families of the deceased members in concert with the respective AOs and have in fact ensured that a more proactive approach is being taken [with respect] to ongoing files being investigated by CFNIS WR.^{Footnote 2166}

728. The second paragraph, which can be read either as a Recommendation resulting from the QA review or as a statement about actions the CFNIS has mandated for the future, reads:

In addition to the foregoing, a full debrief of the subj QA shall be incorporated in a Professional Development day for all investigators and Case Manager (TTBD). In the interim more stringent monitoring/case managing concerning these types of issues have/will be implemented. Finally, CFNIS WR is anxiously awaiting the proposed new Victim Services Annex, currently being drafted, which upon receipt will be disseminated by means of a PD session.^{Footnote 2167}

729. The evidence before this Commission appears to cast some doubt on these paragraphs either as a description of measures already taken or as a prediction/recommendation of measures yet to take place.

730. It does not appear the report was shared with the investigators or that any professional development day was held as a result of this QA review.^{Footnote 2168} MCpl Ritco testified he had spoken to WO Ross once, when the report was being finalized.^{Footnote 2169} He testified he had seen the report itself at some point,^{Footnote 2170} but it is not clear when he was provided a copy. Sgt Bigelow, meanwhile, testified he was not provided a copy of the report; and no member of the CFNIS chain of command reviewed the report with him.^{Footnote 2171} MWO Watson had also never seen the report prior to these proceedings and was not aware of the recommendations it contained.^{Footnote 2172} Maj Dandurand testified there were no PD days devoted to the report in the Detachment.^{Footnote 2173}

731. As a further exercise of supervision with respect to the 2008 Investigation, the QA report falls short of the mark.

4.1.9 The Consequences of Inexperience

732. The evidence reveals many of the CFNIS members involved in the three investigations conducted in this case had only limited field experience related to the investigation of sudden deaths in a domestic context.^{Footnote 2174} The Commission recognizes some of the members had significant experience in conducting death investigations during deployed operations, particularly with respect to battlefield deaths.^{Footnote 2175} However, the Commission finds there is a significant difference between the conduct of such investigations and the conduct of death investigations in a domestic context. As such, CFNIS members’ experience with conducting investigations into battlefield deaths did not constitute adequate preparation for the conduct of sudden death investigations in Canada.

733. The evidence confirms the CFNIS members received appropriate formal training to conduct criminal investigations, including training relevant to the processing of death scenes.^{Footnote 2176} There is no indication the formal training was lacking or inadequate in any way.^{Footnote 2177} However, the Commission finds formal training alone cannot be a substitute for “hands on” field experience. This is why the services of seasoned investigators with significant experience are normally required to provide field assistance and training for other investigators.

734. The lack of experience of members involved in the 2008 Sudden Death investigation was particularly striking. The lead investigator, MCpl Ritco, had never previously conducted a death investigation or attended at a death scene.^{Footnote 2178} His immediate supervisor, WO Tourout, had also never been involved in conducting or supervising a death investigation.^{Footnote 2179} Sgt Bigelow, who attended at the scene with MCpl Ritco, had been involved in four to six death investigations during a secondment with the RCMP, as well as one CFNIS suicide investigation.^{Footnote 2180} He played only a limited role in the 2008 investigation.^{Footnote 2181} MWO Watson, the Detachment MWO and Acting OC, who had overall responsibility for overseeing the investigation, had significant experience conducting death investigations in the theatre, but he had limited experience in conducting or supervising death investigations domestically.^{Footnote 2182}

735. Many of the deficiencies observed in the 2008 investigation were a direct result of the lack of experience of the members involved. From the outset, the investigation lacked focus, clear objectives, or a meaningful plan. In the name of keeping an open mind, the members did not form or test hypotheses, and they lacked the flexibility and judgment to respond appropriately to new information or critically assess ambiguity and contradictions in the evidence.^{Footnote 2183} The apparent overriding concern to avoid arriving at any conclusion until the ME had ruled conclusively, and perhaps not even then,^{Footnote 2184} was largely the result of inexperience. The members also had difficulty adjusting their investigative methods to the evidence uncovered and did not appear to understand how to handle seized items properly, including the suicide note.^{Footnote 2185} The supervisors lacked the necessary experience to provide appropriate guidance and assistance to the investigators and failed to provide this assistance and guidance.

736. While the CFNIS members did have some access to assistance and advice from other police forces, including an RCMP member seconded to the CFNIS,^{Footnote 2186} they did not request assistance.^{Footnote 2187} It is not reasonable to expect inexperienced members to be able to recognize their own shortcomings or needs. Measures must be taken to ensure investigators with significant field experience are involved in leading and supervising investigations.

737. Of particular concern to the Commission, the lack of experience of the members directly involved in the 2008 investigation cannot be treated as an isolated event or circumstance.^{Footnote 2188} The significant lack of experience by those involved in the 2008 investigation may be a reflection of the fact the CFNIS has only been conducting domestic sudden death investigations since 2005,^{Footnote 2189} and in the normal course, incidents of sudden death on Defence Establishment property will not be as frequent as in large urban centers^{Footnote 2190} and will be spread over the entire geography of Canada. It is not surprising the members involved in the 2008 investigation did not have the opportunity to acquire extensive experience.

738. The glaring deficiencies in the conduct of the sudden death investigation identified by this Commission were not recognized at all by the CFNIS or its members. Instead, in the Quality Assurance review subsequently conducted by the CFNIS Detachment, the investigation was found to have been “technically sound.”^{Footnote 2191} The CFNIS witnesses, including those in leadership positions, agreed with this conclusion.^{Footnote 2192} They further testified they fully supported the qualifications of the lead investigator to conduct the investigation and stood by the investigation conducted in this case.^{Footnote 2193}

739. The subjects argued in their final submissions that the investigation conducted in this case was thorough and professional.^{Footnote 2194} They submitted all applicable policies and procedures were followed.^{Footnote 2195} They further argued the lead investigator possessed the requisite qualifications to conduct the investigation, as he had prior experience as an MP and CFNIS investigator, and he sought appropriate guidance and assistance from other members where necessary.^{Footnote 2196} The views expressed were consistent with the testimony of the members of the CFNIS and of its chain of command.^{Footnote 2197}

740. Based on the testimony of senior leadership, it appears the investigation conducted in this case was not viewed as having fallen below the standards expected for sudden death investigations conducted by the CFNIS. Nor was the lack of experience of the members involved viewed as concerning or exceptional. Neither the very serious deficiencies in the sudden death investigation identified by the Commission nor the lack of experience that led to these deficiencies was recognized as problematic by the CFNIS witnesses who testified before the Commission, and there is no evidence they have been addressed by the CFNIS. This leads to a possible inference that this investigation may conform to the standards currently expected by the CFNIS for the conduct of sudden death investigations. If this is the case, it is of great concern and highlights the need for the CFNIS to take immediate measures to ensure its members acquire sufficient experience to conduct sudden death investigations.

4.2 The Suicide Note Left by Cpl Langridge

1. Cpl Stuart Langridge left a suicide note in the room where his body was found. It read:

Sorry but I can’t take it anymore. I love you mom, Shaun, James, Mike, Grandma, Aunti, Tom. Please know that I needed to stop the pain. xoxo Stu

PS I don’t deserve any kinda fancy funeral just family. Ty.^{Footnote 2198}

2. The note was seized by CFNIS investigators on March 15, 2008.^{Footnote 2199} No one at the time told Cpl Langridge’s parents – nor anyone else in his family – about the contents or even the existence of this note. The Fynes learned about it over 14 months after Cpl Langridge died. They did not learn about it from the CFNIS.

Disclosure of the Suicide Note to the Fynes

3. On May 22, 2009, 14 months after Cpl Langridge had died, Mr. Fynes received a phone call from Maj Bret Parlee, President of the BOI convened by the CF to inquire into Cpl Langridge’s death.^{Footnote 2200} The BOI was unrelated to the CFNIS investigation into the death, which had been concluded much earlier. In May 2009, Maj Parlee’s work on the BOI was near completion.^{Footnote 2201} The witness testimony had already been heard, and the preparation of the report was in its final stages.^{Footnote 2202}

4. During the telephone conversation, Maj Parlee advised Mr. Fynes “he’d received special permission to provide information to [Mr. Fynes] in regards to a further exhibit.”^{Footnote 2203} He then told Mr. Fynes that Cpl Langridge had left a suicide note when he died.^{Footnote 2204} He read the note to Mr. Fynes over the phone.^{Footnote 2205} This was the first time the Fynes learned about Cpl Langridge’s suicide note. At the time, no explanation was provided to them as to why the note had not been disclosed previously.

5. The same day, Mr. Fynes wrote to Maj Stewart Parkinson, the Fynes’ AO, to tell him about his conversation with Maj Parlee and the information he had revealed. Mr. Fynes commented: “unbelievable that it took over fourteen months to learn of this.”^{Footnote 2206} This was also the first time Maj Parkinson learned of the existence of the suicide note.^{Footnote 2207}

6. After his conversation with Mr. Fynes, Maj Parlee reported: “the news was well received on the phone, however, there may be a backlash due to the fact it was not provided to them shortly after the death.”^{Footnote 2208} In testimony, he explained the conversation was pleasant, as Mr. Fynes always conducted himself in a professional manner.^{Footnote 2209} He added he “fully expected him and Mrs. Fynes to be upset, as anyone would be.”^{Footnote 2210} On the whole, he agreed the Fynes’ reaction was very tempered, considering the situation.^{Footnote 2211}

7. Mrs. Fynes testified about the impact the news had on her:

I was devastated, to be honest. I just had this image of my son sitting there and going through a shopping list of the people who he thought was important, the people who were important in his life who actually would still care about it. Sorry.

And I just thought what a horribly lonely place he was in when he wrote that note, and then nobody even cared enough to think that we might want to see it.^{Footnote 2212}

8. In addition to the obvious pain and suffering they endured when they discovered their son’s last words had not been communicated to them, the Fynes were also significantly distressed to learn they had been unable to attempt to honour the wishes he had expressed about his funeral.^{Footnote 2213} On March 26, 2008, long before anyone was informed about the suicide note, a full military funeral was held for Cpl Langridge. Mr. Fynes testified:

[...] our son’s last request, the last thing he said to us was he wanted to have a small family funeral. His wishes, his last wishes were not honoured because we did not know that...^{Footnote 2214}

How Did the Suicide Note Come To Be Disclosed?

9. As Mr. Fynes testified, “had it not been for the Board of Inquiry we would never have known our son had left a suicide note.”^{Footnote 2215} Indeed, the CFNIS did not come forward of its own accord to reveal the existence of the note.

10. The note had been seized by the CFNIS on the night Cpl Langridge died.^{Footnote 2216} The CFNIS investigation was concluded in June 2008.^{Footnote 2217} No steps were taken to advise the Fynes about the note. Approximately six months later, the CF convened the BOI to inquire into Cpl Langridge’s death. On January 26, 2009, Maj Parlee wrote to the OC of the CFNIS WR Detachment, Maj Daniel Dandurand, to request a copy of the CFNIS investigation report for the BOI.^{Footnote 2218} A redacted copy of the report was provided on February 3, 2009.^{Footnote 2219}

11. According to Maj Parlee, the copy of the CFNIS report contained no reference to the suicide note.^{Footnote 2220} He testified he learned about the existence of the note subsequently, from a footnote in the Certificate of Death from the province of Alberta.^{Footnote 2221} He explained he received the Certificate later in the BOI’s investigation.^{Footnote 2222}

12. The copy of the CFNIS report received by this Commission did contain references to the suicide note.^{Footnote 2223} However, as submitted by counsel for the subjects of the complaint, there is no evidence the CFNIS disclosed the entire investigation file to the BOI.^{Footnote 2224} In fact, Maj Parlee’s testimony and the contemporaneous correspondence indicate they did not. The Commission has reviewed the Certificate of the Alberta Chief Medical Examiner and found it was accompanied by an External Examination Form, which contained a reference to the suicide note.^{Footnote 2225} Maj Parlee appended a copy of this form when he wrote to the CFNIS to request the note.^{Footnote 2226}

13. On March 11, 2009, Maj Parlee wrote to Maj Dandurand:

In the course of conducting the Langridge BOI, I have come across evidence that indicated that there was a suicide note left in Cpl Langridge’s room. The NIS report does not have any record of a suicide note. Can you confirm that there was or was not a suicide note found in Cpl Langridge’s room during the NIS or MP investigation?^{Footnote 2227}
[Emphasis added]

14. Two days later, Maj Dandurand replied: “you’re best to call me on this one.”^{Footnote 2228} Maj Parlee wrote again, indicating he expected Maj Dandurand would require a formal request and asking to whom it should be addressed.^{Footnote 2229}

15. Maj Parlee testified his first reaction upon learning the note existed was to request it, as the note was a piece of evidence he believed was relevant to the BOI.^{Footnote 2230} He also indicated he felt compassion for the family and hence attempted to provide the note to them.^{Footnote 2231}

16. Maj Parlee recalled having a meeting with Maj Dandurand to discuss the suicide note after their initial exchange of correspondence.^{Footnote 2232} He stated Maj Dandurand then expressed the view that this particular piece of evidence was not to be released based on CFNIS regulations.^{Footnote 2233} Maj Dandurand did not mention any ongoing investigation and did not explain why he referred to the suicide note as “evidence.”^{Footnote 2234}

17. On Friday, March 13, 2009, Maj Dandurand wrote to Maj Parlee. He advised him to forward the official request for the suicide note to him and indicated he would need to seek approval from Ottawa.^{Footnote 2235} He then forwarded Maj Parlee’s initial email to the DPM Police and the CFNIS DCO, indicating: “the subject BOI is looking for additional information above and beyond what we have already provided. Do we have authority to disclose the suicide note?”^{Footnote 2236} Maj Francis Bolduc, the DCO, asked if this matter could wait until the following week. Maj Dandurand replied it could and commented: “they’re just looking for evidence above and beyond what we normally give to BOIs.”^{Footnote 2237} He added he was seeking approval from the DPM Police for the disclosure and wanted to inform the DCO.^{Footnote 2238}

18. The following Monday, March 16, 2009, Maj Parlee sent a formal letter addressed to the CFNIS CO, requesting a certified true copy of the suicide note found in Cpl Langridge’s room.^{Footnote 2239} He attached a copy of the External Examination Form from the Alberta ME’s Office and noted the suicide note was referred to in the form.^{Footnote 2240} In testimony, Maj Parlee explained he understood there was a necessity for Maj Dandurand to determine, through his chain of command, whether they could release the suicide note.^{Footnote 2241} He stated this “took a considerable amount of time.”^{Footnote 2242}

19. On April 7, 2009, Maj Parlee sent a follow up email asking whether Maj Dandurand could provide a timeline as to when the copy of the note would be received.^{Footnote 2243} On April 16, Maj Parlee wrote again, asking Maj Dandurand whether there was any word on when he would receive the note.^{Footnote 2244} The same day, Maj Dandurand wrote to the DPM Police in Ottawa, copying Maj Bolduc. He indicated there was a request from the BOI “for a copy of the suicide letter seized” and asked whether the Detachment had the concurrence of the DPM Police to provide it.^{Footnote 2245} A few minutes later, the DPM Police responded in the affirmative and advised Maj Dandurand to provide the copy to the BOI.^{Footnote 2246}

20. In testimony, Maj Dandurand explained he viewed the BOI’s request as unusual.^{Footnote 2247} As there had been several requests from BOIs in the Region for actual evidence in the CFNIS holdings, Maj Dandurand was careful in approaching this request.^{Footnote 2248} He believed BOIs were entitled to receive the entire investigative file, but thought handing over seized items would be an issue because of the need to maintain continuity.^{Footnote 2249} He assumed a copy of the suicide note would have been scanned into the file and provided to the BOI along with the report.^{Footnote 2250} He thought this would have been sufficient for the BOI.^{Footnote 2251} He could not explain why Maj Parlee did not have a copy of the note.^{Footnote 2252} He could not explain why sending another copy to the BOI would be an issue, or why authorization was required.^{Footnote 2253}

21. Maj Bolduc explained his understanding was Maj Dandurand was requesting authorization to disclose the suicide note to the BOI, in accordance with applicable policies.^{Footnote 2254} The DPM Police was responsible for determining what information could be provided to BOIs.^{Footnote 2255} Maj Bolduc indicated the amount of information provided would depend on what was requested. There was no standard policy about disclosing or not disclosing suicide notes to BOIs.^{Footnote 2256} The general rule was BOIs were entitled to receive all of the information they requested, unless it could prejudice an ongoing police investigation.^{Footnote 2257}

22. The BOI received the copy of Cpl Langridge’s suicide note on April 17, 2009, just under six weeks after discovering its existence.^{Footnote 2258} Maj Dandurand could not recall why it took this long for the copy to be provided.^{Footnote 2259} Another five weeks then passed before the Fynes were advised about the existence of the note. At the time, the CFNIS took no steps to advise them.

23. In testimony, Maj Dandurand indicated he believed the initial communication from Maj Parlee was the first time he became aware of the existence of a suicide note in this file.^{Footnote 2260} He had assumed command of the Detachment in July 2008, shortly after the investigation into Cpl Langridge’s death was concluded.^{Footnote 2261} He testified Maj Parlee’s communication did not cause him to review the file.^{Footnote 2262} Instead, he focused on addressing the BOI’s request.^{Footnote 2263} It is not clear whether, at the time, Maj Dandurand was aware the suicide note had not been disclosed to the family.^{Footnote 2264} It does not appear he took any steps to verify whether it had been. He testified Maj Parlee’s request did not cause him to question the members involved in the investigation.^{Footnote 2265} He stated the request “did strike me as a little bit odd and I did look into it I believe, but I don’t -- I can’t recall to what depth I looked into it.”^{Footnote 2266}

24. Maj Bolduc testified he had not been told by Maj Dandurand or anyone else the suicide note had not been disclosed to the family when he received information about the BOI’s request.^{Footnote 2267} Similarly, LCol Gilles Sansterre, the CFNIS CO, noted Maj Dandurand’s correspondence with DPM Police and CFNIS HQ about this matter provided no indication the suicide note had never been disclosed to the family.^{Footnote 2268} He testified the BOI’s request for the suicide note was not brought to his attention at the time, as disclosures to BOIs were routine matters generally looked after by the DCO and not requiring his involvement.^{Footnote 2269}

25. Meanwhile, Maj Parlee, who had had direct discussions with Maj Dandurand about the suicide note, was well aware the family did not know about it. Ten days after receiving the copy of the note, he began to inquire about the process for disclosing the note to the Fynes. On April 27, 2009, he wrote to Maj Serge Côté, an advisor from the DND Administrative Investigation Support Centre (AISC), indicating:

I have obtained a suicide note from the NIS (it was not mentioned in the report that we got from them, although the report may have been severed). The family has no idea that there was a suicide note... am I obligated in any way to inform them at this point? If not now, when (and who should be informing them)? It will most certainly be used as evidence in the report.^{Footnote 2270} [Emphasis added]

26. The next day, Maj Parlee followed up with another e-mail asking Maj Côté whether he had an answer about the suicide note.^{Footnote 2271} In testimony, Maj Parlee explained he was seeking Maj Côté’s advice on whether to disclose the suicide note to the family because “it was quite an unusual circumstance.”^{Footnote 2272} The following week, Maj Côté wrote back with his advice. He suggested “given the present interaction with the family,” Maj Parlee should speak with the BOI’s legal advisor, with public affairs, and with the BOI Convening Authority to determine whether to tell the family about the suicide note “as it may not appease them.”^{Footnote 2273} Since the suicide note was part of the BOI evidence, Maj Côté noted it would be revealed “in due course” when the report was completed.^{Footnote 2274} He added, the family could then be briefed about it after the report had been reviewed by the Convening Authority.^{Footnote 2275} It should be noted that, as of the close of this hearing, the Fynes had still not been briefed officially about the BOI report or provided with a final copy.^{Footnote 2276} Had this advice been followed, they may have remained unaware of their son’s suicide note to this day. However, a different decision prevailed.

27. On May 22, 2009, Maj Parlee called Mr. Fynes and told him about the note. On the same day, he advised Maj Côté that the BOI Convening Authority had authorized him to inform the Fynes about Cpl Langridge’s suicide note.^{Footnote 2277} He reported he had advised the family by telephone, and would be providing them with a copy of the note.^{Footnote 2278} In response, Maj Côté expressed concern about giving a copy of the note to the family, since it was part of the evidence before the BOI.^{Footnote 2279} He noted the family was only to get a verbal briefing about the findings in the report, and would be provided a severed copy of the report only after approval by the CDS and with the concurrence of the Convening Authority.^{Footnote 2280} He added Maj Parlee should consult with his legal advisor first if he still wanted to provide a copy of the note to the family.^{Footnote 2281} Maj Parlee’s response was redacted in the documents produced before this Commission. Following the response, Maj Côté indicated Maj Parlee was “good to go.”^{Footnote 2282}

28. In testimony, Maj Parlee could not recall the specifics of his discussions with the Convening Authority about this issue, but was “quite certain” the question of whether to give a copy of the note to the family was discussed.^{Footnote 2283} In a message he wrote during the days that followed the disclosure of the note to the Fynes, he had explained:

[...] Once I actually received the note I informed the Convening Authority who sought advice from the LEGAD before releasing it to [the Fynes].

Technically, we are not obligated to provide the family with any evidence uncovered during the course of the BOI, however, due to the obvious importance to them in this case, the Comd authorized the release of this piece of evidence.^{Footnote 2284}

Obtaining the Original Suicide Note

29. On May 27, 2009, the copy of Cpl Langridge’s suicide note arrived at the Fynes’ residence.^{Footnote 2285} Mr. Fynes recalled:

[…] in the first instance when we were apprised of the suicide note they forwarded the – they Purolated the note out to the NIS in Esquimalt. A Captain hand-delivered it to my wife.

I came home from work that night and the Purolator envelope was sitting on our table unopened. My wife couldn’t bring herself to open it.

And I have to tell you when we opened that envelope together and I saw that it was a photocopy with an exhibit stamp on it, I was just through the roof.^{Footnote 2286}

30. That evening, Mr. Fynes wrote to his AO, Maj Parkinson, to request the original note:

Attached is a copy [of a photocopy] of Stuart’s farewell to his family.
That his note was concealed and withheld from us for over fourteen months was cruel, callous and disrespectful.

I expect the “original” to be provided to us immediately. Would you please arrange?^{Footnote 2287} [Emphasis added]

31. Maj Parkinson forwarded the message to Capt Eric Angell, the Adjutant for Cpl Langridge’s Regiment, asking him to action Mr. Fynes’ request.^{Footnote 2288} Capt Angell contacted the CFNIS Detachment to find out how to obtain the original suicide note. On May 28, 2009, WO Ken Ross, the Acting Detachment MWO (chief investigator),^{Footnote 2289} wrote to Capt Angell, copying Maj Dandurand, with what the complainants described as a “shocking statement.”^{Footnote 2290} He advised:

Concerning the family’s desire to have the suicide note: The best course of action would be to have the AO to the family, make an ATI request on their behalf.

Should you have any further questions, please feel free to contact me.^{Footnote 2291}

32. In response, Capt Angell indicated he was sure WO Ross could “appreciate the sensitive nature of this request.”^{Footnote 2292} Capt Angell advised that the family already had a copy of the note and wanted to obtain the original.^{Footnote 2293} As an ATI request would only produce a copy, he noted this was not a viable option and asked WO Ross whether other avenues could be explored.^{Footnote 2294} In a message, also copied to Maj Dandurand, WO Ross responded:

We appreciate the sensitivity of this matter, however, the original note is still retained as evidence. I do not foresee the original note being turned over. That being said, I will make some further inquiries once I am back in the office tomorrow.^{Footnote 2295} [Emphasis added]

33. The next day, Maj Dandurand received authority from the DPM Police in Ottawa to release the original suicide note.^{Footnote 2296} At the time, there were communications about this matter involving the CF Regiment, the Brigade in charge of the Regiment (1 CMBG) and the Area in charge of the Brigade (LFWA). Maj Dandurand advised LFWA the Detachment would be providing the note on the following Monday.^{Footnote 2297} LFWA asked him to have WO Ross provide the note as soon as possible to Brigade staff, who would find an appropriate way of delivering it to the family.^{Footnote 2298} In testimony, the LFWA Chief of Staff, Col Jamie Hammond, commented Maj Dandurand’s reaction upon learning about the failure to disclose the suicide note was professional.^{Footnote 2299} He noted Maj Dandurand “may have hesitated a little bit because he was worried about evidence and all that sort of stuff,” but believed he ultimately came to the right conclusion quickly and obtained authorization to release the original note to the family.^{Footnote 2300}

34. WO Ross, for his part, indicated he would coordinate with the evidence custodian the following Monday to release the original note.^{Footnote 2301} However, he appeared less than pleased about this development. He wrote to Maj Dandurand:

I was under the impression that the family had made ATI application and subsequently received the note. However, it was Maj Hamilton-Brown [the Brigade G1] who took it upon himself to provide a copy to the family, which obviously wasn’t a very good copy at that and I assume was the copy which we provided him? It would appear that those wishing to do the “right thing” have caused more angst for the family than they have good.^{Footnote 2302} [Emphasis added]

35. The following day, the G1 for the Brigade, Maj Glen Hamilton-Brown, wrote to the LSDH Regiment Adjutant, Capt Angell, indicating he believed the delivery of the original note should be done through the Regiment as the Fynes had requested.^{Footnote 2303} On Monday, June 1, 2009, he advised Capt Angell the CFNIS Detachment would be providing him with the original note to deliver to the Fynes.^{Footnote 2304} The note was provided to Capt Angell by WO Ross on the same day.^{Footnote 2305} The CFNIS file noted the disposal of the note was authorized by Maj Dandurand, under the authority of the CO for the Regiment, and the note was “returned to Unit Adj at the request of the family.”^{Footnote 2306}

36. On June 3, 2009, Maj Parkinson delivered the original suicide note to the Fynes.^{Footnote 2307} Mr. Fynes testified:

And we went back and demanded that we get our son’s suicide note, his last communication to us, and that was delivered shortly thereafter in person by our Assisting Officer who stood in our room and reached it to us and said – I believe his exact words were: “I have no words.”^{Footnote 2308} [Emphasis added]

Immediate Reactions

37. After the Fynes received the copy of the note and wrote to their AO to request the original, news of the issue circulated quickly within the CF leadership at the Regiment, Brigade and Area, even reaching the Chief of the Land Staff. Mr. Fynes’ comment indicating withholding the note had been “cruel, callous and disrespectful” was forwarded again and again throughout the CF, giving rise to numerous email discussions about the issue.^{Footnote 2309} Many expressed shock and disbelief, while others appeared to be scrambling to obtain or provide explanations, and still others were immediately concerned about the public relations impact.

38. Upon learning of the issue, Maj Hamilton-Brown asked the Regiment Adjutant to speak with Maj Parlee and draft a response to the Fynes’ message.^{Footnote 2310} Maj Parlee provided his account of the situation, insisting the CFNIS had not informed the BOI about the suicide note nor included it in the redacted investigation report they provided.^{Footnote 2311} He suggested Public Affairs be “brought back into the loop” to prepare Media Response Lines (MRLs).^{Footnote 2312} The Chief of Staff to the Brigade Commander, LCol Thomas Bradley, commented about the points to be covered in the response:

Let’s ensure that the legalities of release are also highlighted in the response.
For example, if a person gives a suicide note to a doctor the family never sees it. Important also is that once we got the item, despite having no obligation to do so, the document was
released to them.^{Footnote 2313}

39. Capt Angell then provided the following explanation to Maj Parkinson:

The NIS kept the suicide note as evidence during their investigation, LdSH(RC) [the Regiment] did not know it existed. Maj Parlee found out about the note through the course of the BOI investigation, and obtained a copy of the document from the NIS...^{Footnote 2314} [Emphasis added]

40. When she learned about the issue, Ms. Norma McLeod from Casualty Support in Esquimalt commented:

The first attachment is the suicide letter from the member to his family in which he left specific funeral instructions. Edmonton released this to the family over 14 months later. I will withhold my comments on the matter.

[...] I don’t know if you have been following what happened after Cpl Langridge’s suicide in Edmonton, but it has been quite horrendous for the family in Victoria. This is going to explode in the media. [...] I have attached salient info that I have received to date so that you have some background information. I would like to discuss with you ASAP as urgent intervention is required by you in Edmonton. The family is still asking for things such as medals and a copy of the pers file, etc. We really need to sort this out right now.^{Footnote 2315} [Emphasis added]

41. In the lengthy message he wrote to respond to some of the issues Ms. McLeod had raised, Maj Hamilton-Brown commented: “The note is a very hot topic for us as we are just as surprised as the Fynes are about some aspects.”^{Footnote 2316}

42. Ms. McLeod’s message was forwarded throughout the CF.^{Footnote 2317} Ottawa and LFWA staff were advised of the potential for media attention she identified.^{Footnote 2318} It was recommended the LFWA Public Affairs Officers’ branch be made aware of the situation.^{Footnote 2319} Subsequently, once the news had travelled to even higher levels, the Director of Army Public Affairs (DAPA) was instructed to liaise with LFWA Public Affairs to prepare MRLs “for when this breaks.”^{Footnote 2320}

43. When he was advised of the issue, the LFWA Public Affairs Officer (PAO), Maj David Muralt, commented:

This was Cpl Langridge’s letter saying goodbye to his family and giving specific instructions for his funeral. A copy of the note was eventually provided by someone here in Edmonton to the family 14 months after his death.^{Footnote 2321}

44. Upon receiving the news, the Area Chief of Staff, Col Hammond, immediately enquired:

Are we sure that no-one gave a copy to a member of the family earlier (it is a bit shocking if we did not)?^{Footnote 2322}

45. Before this Commission, Col Hammond testified about his reaction when he learned the suicide note had not been disclosed:

I thought it was a bit shocking. Personally I was flabbergasted that the suicide note was not passed to the family within days of knowing we had a suicide note. I think that speaks for itself. To me, it's unforgivable, and the family said it was callous and disrespectful. And I think -- I don't know if everybody in the Canadian Forces, but I think most people in the Canadian Forces would agree with that.^{Footnote 2323}

46. In his response to Col Hammond’s question, LCol Bradley explained the CFNIS were the only ones with a copy of the suicide note and had not revealed it to the BOI.^{Footnote 2324} He went on:

When we found out we quickly figured that although not mandated to do so, it would clearly be in the families’ interest to have this and also so that they wouldn’t find out when the BOI documentation was released at the end and really be unhappy.^{Footnote 2325}

47. Col Hammond advised the LFWA Commander, BGen Michael Jorgensen, of the situation and noted the Public Affairs Officer (PAO) was preparing “renewed MRLs” to address the issue.^{Footnote 2326} He also brought Maj Dandurand into the conversation, asking him whether the original note could be released “ASAP at this point” and telling him they needed “to find a way to ensure this doesn’t happen again (family not aware of its existence for 14 months in case like this).”^{Footnote 2327} He recalled discussing the issue with Maj Dandurand at the time:

[...] I can't remember exactly when, but I remember having a phone conversation with [Maj] Dandurand and saying come on, this is Keystone Cops. This should not happen. And that's what I said in the e-mail back to him, that we need to find a way to ensure this doesn't happen again.^{Footnote 2328} [Emphasis added]

48. In testimony, Maj Dandurand stated:

I don't recall reading anywhere in an email the reference to Keystone Kops. And the reason why I bring that up is, if I had, that would have definitely soured that relationship.

There was no doubt in my mind that he was very concerned with this and very quickly many opinions on the issue began flying around Western Region, and what I had engaged in a conversation with Colonel Hammond about is, let's not be so quick to be critical and let's see what's going on here. I wanted people to calm down. And had he made a reference to Keystone Kops at the time -- I remember exactly where I was when I was discussing this with him, I was on my front porch and I was on Blackberry, and had he done that, the neighbours would have heard about it.

So, there's no doubt he was upset. [...] And there's no doubt that we were coming at this from two different angles, but we were in agreement that this was not acceptable and we needed to rectify this.^{Footnote 2329}

49. In the response he wrote to Col Hammond at the time, Maj Dandurand agreed the family “should have at least been told” but cautioned he would look into the case to find out what happened as he noted it was his experience “everything in these circumstances are not always 100 per cent accurate when first reported.”^{Footnote 2330}

50. There was much confusion within the CF and the CFNIS about who Cpl Langridge’s NOK was, and about whether anyone at all had been told about the suicide note.^{Footnote 2331} Col Dominic McAlea, a JAG Officer in Ottawa who was also advised about the issue, commented to the CLS Chief of Staff: “this may be as much about NIS culture as it is about CF administrative stovepipes.”^{Footnote 2332}

51. The confusion and the concern about public relations were not limited to the CF leadership. The CFNIS leadership had similar reactions. On May 30, 2009, Maj Dandurand briefed the CFNIS CO about the issue. He copied the CFNIS PAO, Maj Paule Poulin, on this message and wrote:

We have a situation arising that may draw media attention. It is as a result of a BOI into the suicide of one of our soldiers and the parents alledging [sic] they were never told about a note. The LFWA staff were up in arms until I told them that perhaps the true unfolding of events were not as initially reported. I will be looking at the report Monday in SAMPIS to determine if anyone, NOK, were told of the letter and also whether the parents were told. They have a copy of the letter; however, they want the original. We will be giving NOK/estate holder and executor the original so long as they want it. This may turn out to be that the parents are not NOK which may be where the messiness of the situation arose.

I wanted to give you a heads up in case anything came up over the weekend. Unfortunately, West coast PAOs with 39 CBG are claiming this is going to “blow up” and have not demonstrated calm in my reading of their initial reports.^{Footnote 2333} [Emphasis added]

52. Maj Poulin, who had learned about the issue from the LFWA PAO,^{Footnote 2334} reported the information she had obtained, further illustrating the ongoing confusion about what had happened:

Apparently, the soldier still had his ex-common law wife as primary NOK on PEN form at the time. The family apparently was told to go through ATI to obtain the note by an investigator.^{Footnote 2335}

53. The preparation of Media Response Lines (MRLs) about the issue soon became an important focus both for the CFNIS and the CF Area and Brigade. MRLs are draft questions and answers, key messages and talking points used by spokespersons to prepare for discussions with the media and to determine what information can be released publicly.^{Footnote 2336} From the moment the Fynes’ message about the failure to disclose their son’s suicide note began to be circulated, the CFNIS and Area PAOs were in contact to discuss the preparation of the Lines.^{Footnote 2337}

54. During the following days and weeks, the documentary record revealed there was extensive activity and discussions about coordinating the response to the media and determining the content of the Lines. There were literally hundreds of pages of correspondence and draft MRLs with numerous revisions produced before this Commission for just this short period of time.^{Footnote 2338} There were also numerous additional discussions and meetings about the matter.^{Footnote 2339} It is clear the issue received considerable attention from many different organizations within the CF, including at the highest levels of the CDS and VCDS offices.^{Footnote 2340}

55. In addition to the communications between the PAOs for different units and the comments made by the different chains of command on the draft MRLs, there were also many inquiries from the PAOs in their attempt to understand and explain what happened. The CFNIS leadership was involved. The DCO, Maj Bolduc, noted there was much discussion and activity at CFNIS HQ in the immediate aftermath of discovering the failure to disclose the note about “the whole media aspect that was about providing answers, preparing our media lines, replying to journalists.”^{Footnote 2341} Information was also compiled in preparation for anticipated queries from Parliamentary Affairs and the VCDS office.^{Footnote 2342} Maj Poulin made early contact with Maj Dandurand, asking for clarification and a review of the file in order to be able to provide responses.^{Footnote 2343} She also sought information from Maj Bolduc and, subsequently, from LCol Sansterre.^{Footnote 2344} The CFNIS participated in the creation of the LFWA MRLs, but also eventually created its own separate MRLs.^{Footnote 2345}

56. The overall CFNIS approach in its media response was to admit the wrong and focus on positive aspects related to measures taken for the future. Messages from the CFNIS included expressions of regret, statements about procedures having been revised, and statements about the importance to the CFNIS of providing assistance to victims and their families.^{Footnote 2346} Limited information was provided about what went wrong. The CFNIS PAO would subsequently use the suicide note incident “as a good teaching example” when briefing a more junior PAO who began working in the office the following year, indicating: “this is how you admit that you are wrong, and it is good to do so.”^{Footnote 2347}

57. There was strong concern throughout this period, both at the CFNIS and within the CF more generally, about the negative public perception that could result from the failure to disclose the note. When the Brigade Commander, Col K.A. Corbould, initially reviewed the draft LFWA MRLs, he took issue with wording indicating the CFNIS had initially “refused” to release the note.^{Footnote 2348} He noted this sounded “too much like us and them” and suggested the MRLs be revised to state the CFNIS “could not” release the note.^{Footnote 2349} His Chief of Staff, LCol Bradley, suggested:

Let’s look at wording that says something to the effect that [in accordance with] policies in effect the existence of this note and its release were governed under Evidence rules and would not have been released to either the BOI or the family. Recently, in part due to queries from this BOI, this rule has been changed to enable this release of info.

If everyone concurs, this wording highlights the positive changes that the system has made.^{Footnote 2350} [Emphasis added]

58. During the following weeks, there was further back and forth between Area and the CFNIS when Area “added their two cents” to the CFNIS messages by highlighting the CFNIS’ failure to advise the Regiment or the BOI about the note.^{Footnote 2351} In the end, the CFNIS did not take steps to have the messages modified, since they were thought to relate to the BOI and were not inaccurate.^{Footnote 2352}

59. When the Brigade received a call from reporter David Pugliese on June 12, 2009, and set up an interview, Maj Dandurand expressed concern Mr. Pugliese might be trying to “back door” the CFNIS by interviewing a CF Commander.^{Footnote 2353} He wanted to have the questions about CFNIS issues directed to the CFNIS CO instead.^{Footnote 2354} In the end, LCol Sansterre did not participate in the interview, but he did have changes made to the MRLs before it proceeded.^{Footnote 2355}

60. The interview took place on June 16, 2009, with the LFWA PAO.^{Footnote 2356} On June 18, 2009, Mr. Pugliese contacted the CFNIS PAO with follow up questions.^{Footnote 2357} In particular, he asked whether “any discipline measures were taken against the investigators” in connection with the failure to disclose the note.^{Footnote 2358} In response, Maj Poulin “just repeated the line about procedures being amended.”^{Footnote 2359} When Mr. Pugliese called a second time to ask again about disciplinary measures, Maj Poulin “spoke about process again.”^{Footnote 2360} When he was advised about this, Maj Dandurand was concerned. He wrote:

Mr. Pugliese’s persistence in asking about disciplinary measures needs to be curbed because it would be completely inappropriate for any actions to be taken against anyone in this case. Believe me, if there was an appropriate disciplinary action […] to be recommended and taken, I would be the first to say so. I suspect this will be the last of his questions; however, if it is not what are we prepared to say on the matter?^{Footnote 2361} [Emphasis added]

61. Following this, media coverage was monitored closely.^{Footnote 2362} Maj Poulin noted the CFNIS’ messages about regret, revising procedures and the importance of victim assistance were published.^{Footnote 2363}

62. When LCol Sansterre contacted Mrs. Fynes shortly after,^{Footnote 2364} Maj Poulin was concerned Mrs. Fynes might contact the media again, and immediately prepared an additional line for the MRLs.^{Footnote 2365} When the Fynes then requested a copy of the investigation report, Maj Poulin commented it would be “key” to provide the report as soon as possible and added she hoped the report did not end up going to the media.^{Footnote 2366} During his subsequent interactions with the Fynes, LCol Sansterre asked Maj Poulin to “screen” one of his responses before he sent it.^{Footnote 2367} In testimony, Maj Poulin explained it was not usual for her to be asked for advice about communications with families.^{Footnote 2368} She believed her input was sought about wording or “the way that things are said” because of the previous media interest about the issue.^{Footnote 2369}

63. The next two years saw continued significant activity to coordinate responses to the media every time the issue came in the public spotlight again. Hundreds of additional pages of correspondence and documents were created.^{Footnote 2370} The CFNIS messages about the suicide note were incorporated into CF-wide MRLs created to address all of the issues related to Cpl Langridge’s file.^{Footnote 2371} They were also repeated in a statement issued by the CDS himself, after Mrs. Fynes held a press conference in October 2010.^{Footnote 2372} Throughout this period, the concern about the CF’s and the CFNIS’ public image continued, and significant time, energy and resources were expended to prepare official responses. By comparison, less energy and fewer resources went into investigating what led to the failure to disclose Cpl Langridge’s suicide note.

The Facts: How Did the Failure to Disclose the Suicide Note Occur?

64. Once it was discovered Cpl Langridge’s suicide note had not been disclosed to his family for over 14 months, the obvious next step was to find out how this could have happened. During the days, weeks and months that followed the discovery of the failure to disclose the note, the CFNIS and its members provided many different explanations to the public, to other CF members and to the Fynes. Unfortunately, these explanations were not always compatible with each other, or even related to the facts of this case. The source or basis for some of them remains a mystery to this day. In many cases, the explanations were provided before steps were taken to find out what actually occurred.

65. Before this Commission, the Fynes have complained not only about the failure to disclose the suicide note, which they described as “inexcusable,”^{Footnote 2373} but also about the CFNIS members having provided inaccurate rationales to explain and justify their actions.^{Footnote 2374} The evidence reveals the efforts made by the CFNIS to obtain and provide accurate information about the facts fell far short of what should have been expected under the circumstances. The CFNIS created no record indicating it found out the exact reasons for not disclosing Cpl Langridge’s suicide note to the Fynes. No clear explanation was ever provided to the family. What the Commission has learned about what happened through the witness testimony in this hearing was not compatible with many of the explanations provided previously.

Explaining What Happened

66. Very soon after the failure to disclose the suicide note was discovered, various explanations began to be advanced by CFNIS members.

67. On May 29, 2009, two days after the Fynes’ initial message complaining about the failure to disclose the note, Maj Dandurand was in communication with Col Hammond about the issue. In these exchanges, he wrote:

It is worthwhile to note this letter is held as evidence and it is not routine for us to divulge or release evidence in a case and evidence is held for [several] years.^{Footnote 2375} [Emphasis added]

68. On May 30, 2009, the Chief of the Land Staff (CLS) requested an explanation from the Land Force Provost Marshal (LFPM) about “why the NIS withheld the note from the BOI and the family for some 14 months.”^{Footnote 2376} LCol Rod Lander was the LFPM at the time. He testified his role in this case was to gather information from the CFNIS and provide it to the Army Commander, who needed to know what the issues were in order to address any future complaints about how the CF handled the case.^{Footnote 2377} When he received the request for an explanation, LCol Lander forwarded it to LCol Sansterre and to the CFPM.^{Footnote 2378} He asked LCol Sansterre if they could discuss the matter on the following Monday “as the CLS will want an answer, and I want to make sure I have it right.”^{Footnote 2379}

69. The following Monday, June 1, 2009, LCol Lander provided the following explanation:

This is the information I have to this point:

The incident occurred 15 Mar 08. The MP Investigation was concluded in July 08. It appears that the MP investigative team did not reveal the existence of the note to the family as it, in their opinion, would not have added anything to the information already passed during the normal victim services provided, and they felt it may have even had a negative effect. The fact that the note existed was passed to the BOI with the original documentation provided by the CFNIS. The BOI asked for a copy and were provided one 3 Feb 09 once permission from DPM Police was granted. The OC of CFNIS Western Region is conducting a detailed Quality Assurance (QA) review of the file and the investigation it represents, which should be concluded by 5 Jun 09. This will include the decision to not reveal the existence of the note to the family by the investigative team. The original note is no longer deemed evidence and is in the process of being passed to the family [in accordance with] their request.

This is another incident which indicates to me that the role of MP Victim Services and its interaction with other agencies involved with Casualty Care/Administration is still not well understood by all involved parties, nor is it working particularly well all the time. This will form part of the QA review mentioned above and I will discuss this issue again with the CO CFNIS when he lands in Ottawa.^{Footnote 2380} [Emphasis added]

70. In mid-June 2009, an additional explanation was provided in a revised version of the CFNIS MRLs:

If pressed on whether the suicide note was mentioned during the interview of the mother and stepfather of Cpl Langridge

The mother and stepfather did not ask about a note, and were aware of the coroner’s findings into the cause of death. They did not ask about a note and the investigators did not mention it as the investigation was still ongoing…^{Footnote 2381} [Emphasis added]

71. On June 18, 2009, Maj Dandurand provided yet another explanation. In his message to Maj Poulin about Mr. Pugliese’s questions on disciplinary measures, he wrote:

In a nutshell, the investigator and the case management team did everything in good faith and at no point was the family’s well being pushed aside. As you can appreciate, unless a person goes through an identical situation, a series of assumptions are made regarding what is in the best interest of the family. Those assumptions are based on personal experiences in dealing with such matters in the past and those involved in this particular case, they had many previous investigations of suicide in their repertoire. We do this constantly when dealing with estates and returning of personal belongings. There are personal belongings that families of deceased have no reason to be given and we make those careful decisions as and when required. By returning those items, they only serve to tarnish the remaining image a mother, spouse, loved one has of their deceased family member. […]

As always, I submit my “two cents” worth for your consideration in dealing with these issues.^{Footnote 2382} [Emphasis added]

72. During his first meeting with the Fynes in November 2009, Maj Dandurand provided a different explanation:

First off, we, at the time, had a policy where we just -- we don't divulge all of these notes, and you have to appreciate that, at the time, when you're dealing with a death, it's viewed as suspicious.

Now, until such time as we determine that, in fact, we're dealing with suicide as opposed to a suspicious death, we're not going to communicate on that note.^{Footnote 2383} [Emphasis added]

73. Another explanation was provided in January 2011. The Fynes had transmitted a series of questions to the CF, including a specific question about the failure to disclose the suicide note. The following statement was included in the answer they received:

The suicide note found with Corporal Langridge was seized as part of the criminal investigation into the sudden death. Upon conclusion of the investigation, the suicide note was intended to be released to the decedent’s parents. However, this was not conducted as expediently as it could have been.^{Footnote 2384} [Emphasis added]

74. Individually, these explanations provided little clarity. Taken together, they made it difficult if not impossible to understand exactly what happened with Cpl Langridge’s suicide note and what the reasons were for not disclosing it.

Finding Out What Happened

75. LCol Sansterre was advised about the failure to disclose Cpl Langridge’s suicide note on May 30, 2009.^{Footnote 2385} He testified the first step he took as soon as he learned about it was to “gather the facts” to find out what happened.^{Footnote 2386} For this purpose, he ordered a Quality Assurance review of the entire 2008 investigation.^{Footnote 2387} He explained:

[...] I asked that a quality assurance review be done on that entire investigation to determine what happened and what could have been done differently and to make sure that if something went wrong, we didn't do that again.^{Footnote 2388}

76. Maj Bolduc was notified of the issue at the same time.^{Footnote 2389} He indicated his first reaction was to wait until the facts were verified, to find out “whether it was true that the letter was not given and what the circumstances surrounding it all were.”^{Footnote 2390} He explained it was not common or habitual for the CO to order a QA review on a specific file.^{Footnote 2391} In this case, the QA analysis was requested as a direct result of the events surrounding the failure to disclose the suicide note.^{Footnote 2392} Maj Bolduc also explained the CO asked for the complete file to be reviewed “to see [...] whether there were other things we had not done properly, whether there were other problems besides the suicide note that had not been given to the family.”^{Footnote 2393} Maj Dandurand, for his part, explained the QA review was designed “to highlight our lessons that we have to learn.”^{Footnote 2394} He noted it was understood the investigation “was now going to be called into question” as a result of the surfacing of the suicide note, and he explained the CFNIS leadership wanted to ensure they had access to in-depth knowledge about the case, since this knowledge “was not as fresh in everybody’s mind as what a quality assurance would afford us.”^{Footnote 2395}

77. In addition to ordering the QA review, LCol Sansterre also testified he had immediate discussions with Maj Dandurand to try to determine why the suicide note had been withheld.^{Footnote 2396} In testimony, Maj Bolduc indicated there were numerous discussions about the suicide note at CFNIS HQ at the time “to try to determine, to understand the reasons why it had not been given to [the family].”^{Footnote 2397} The questions being discussed included: “what happened in that case; why were the parents not informed that a note existed? Why was it not given to them?”^{Footnote 2398} The CFNIS CO was involved in these discussions and also had separate discussions with Maj Dandurand about the issue.^{Footnote 2399}

78. On June 18, 2009, a little over two weeks after he found out about the note, LCol Sansterre had a telephone conversation with Mrs. Fynes.^{Footnote 2400} He had still not received the report for the QA review at the time.^{Footnote 2401} He told Mrs. Fynes he did not know “how this could have happened” and stated the CFNIS were “going to get to the bottom of it and we’ll figure out what happened.”^{Footnote 2402}

79. During the exchanges immediately following the discovery of the failure to disclose the note, Maj Dandurand had also separately told the LFWA Chief of Staff, Col Hammond, he would look into the matter to find out what happened. On May 29, 2009, he indicated he would “speak with investigators and review the file” and get back to Col Hammond the following week.^{Footnote 2403} In testimony, Maj Dandurand could not recall what steps were taken in the following days to provide answers to Col Hammond, and could not recall getting back to him “on that specific issue.”^{Footnote 2404} Col Hammond testified he never received a satisfactory explanation about why the note was not disclosed for 14 months.^{Footnote 2405} At the time, Maj Dandurand did not speak with the investigators or review the file.^{Footnote 2406} He explained he relied on WO Ross to gather information and convey it to him.^{Footnote 2407} He expected WO Ross to be “intimately aware of the file” and relied on his input.^{Footnote 2408}

80. WO Ross had been involved in the early discussions about the Fynes’ request for the original suicide note. At the time, he had suggested they make an ATI request to obtain it. He was then tasked with conducting the QA review requested by LCol Sansterre.^{Footnote 2409} Maj Dandurand explained QA reviews were generally conducted by the Detachment MWO “due to their years of experience and [...] their ability to be critical” but also because it required taking the person out of the normal activity of the Detachment for a period of five to ten days devoted solely to the review.^{Footnote 2410} The QA review in this case was ordered shortly after May 30, 2009 and was completed on June 19, 2009.^{Footnote 2411}

81. WO Ross was well aware the QA review had been initiated as a result of the failure to disclose the suicide note. When questions were received from the media about the issue during the review, WO Ross was asked for an update and was advised there would be a “media issue” about this.^{Footnote 2412} The report itself specified the QA review was initiated “resultant of a complaint brought forward by Cpl LANGRIDGE’s family who were concerned with the lack of optics of the suicide note and the delay in the delivery of the [subject] suicide note.”^{Footnote 2413} Yet, the QA report provided no information about what actually happened with the suicide note in this case and why it was not disclosed to the Fynes.

82. The report opened with a statement indicating “the totality of the investigation was found to be technically sound” and provided a series of comments about “investigative procedures” and “administrative procedures.”^{Footnote 2414} In total, a little over one page of the seven-page report was devoted to the suicide note. In the comments on investigative procedures, the report noted no steps were taken to compare the handwriting from the note to a known sample of Cpl Langridge’s handwriting or otherwise confirm the authenticity of the note.^{Footnote 2415} However, the report concluded the “scene indicators” and the comments made by the ME at the scene “led the investigators to make the assumption [the note] was drafted by the deceased.”^{Footnote 2416} In one of the comments about administrative procedures, the report also noted there was no mention of the suicide note in the Case Summary for the investigation, indicating reference to this “key element” would have “further supported the manner of death.”^{Footnote 2417}

83. A separate comment, still in the section devoted to administrative procedures, related directly to the disclosure of the suicide note. It stated:

f. detailed in MCpl Ritco’s OF2 text box, at para 61, he articulates that at “1700 hrs, 9 Apr 08, Mr. CAUFIELD (ME) returned call, no need to bring items in, as 10 of the 11 tests have been conducted. There appears to be no evidence to support foul play, therefore at this time it will be classified as suicide.” It is at this point consideration by the investigators in consult with the Case Manager, be given to the fact of meeting with the family and providing them with the salient points of the investigation to date and would have presented an opportune time to have the family members review the suicide note to verify the authenticity of the handwriting and possibly give them a copy at that time. If the decision was made not to move forward with any briefings to the family until such time as they received the official report from the ME, the Certificate of Medical Examiner was received 15 May 08, which provided definitive conclusion concerning the manner of death – suicide;^{Footnote 2418}

84. Another comment related to telephone conversations the lead investigator, MCpl Matthew Ritco, had with the Fynes in May 2008, before the investigation was concluded. The report noted, “at no time through the course of either of these conversations was the existence of a suicide note discussed.”^{Footnote 2419} The following explanation was provided:

In speaking with MCpl Ritco, it was not something that was in the forefront of topic of discussion and that neither Mrs nor Mr FYNES broached the subject or made inquiries of this nature...^{Footnote 2420}

85. The concluding section of the report contained three recommendations. One related to the suicide note and simply suggested “a cognizant and informed decision” be made about when to advise the family of the existence of a suicide note, when to allow the family to view the note and when to release the original note to the family.^{Footnote 2421}

86. The report provided no information about the actual reasons why Cpl Langridge’s suicide note was not disclosed in this case. It did not indicate whether this was the result of an oversight or a conscious decision. It did not provide any insight about who was responsible for making decisions about disclosing the note, whether such decisions were made, and if so by whom, when or why. Having received this report, the CFNIS chain of command would have had no further information about what happened with Cpl Langridge’s suicide note. In testimony, LCol Sansterre recognized nothing in the QA report explained why the suicide note was not disclosed in this case.^{Footnote 2422} He recalled discussing the report with members of the HQ staff, but did not recall any concerns arising out of the report.^{Footnote 2423}

87. Maj Bolduc testified he was not involved in any attempt to find out why the suicide note was not disclosed and believed the CFNIS CO and the Detachment OC were looking after this aspect. He explained:

À ce moment-là, je me concentrais plutôt à essayer de trouver une façon pour pas que ça se reproduise. Alors, l'explication de pourquoi que c'est arrivé, je laissais ça entre le commandant du détachement et puis le colonel Sansterre à gérer. J'essaie plus de développer le SOP, m'assurer qu'on ne refasse plus ce genre d'erreur-là.

Alors, la discussion du pourquoi, comment c'est arrivé, tout ça, ce n'était pas nécessairement ce qui m'avait été donné comme tâche, mais plutôt pour éviter que ça se reproduise.^{Footnote 2424}

[TRANSLATION]

At that point, I was more focused on trying to find a way to make sure it didn’t happen again. So the explanation of why it happened, I left that for the detachment commander and Colonel Sansterre to handle between them. I tried more to develop the SOP, to make sure we didn’t make that kind of mistake again.

So the discussion of why and how it happened, all that, it was not necessarily the task I was given[,] that was to avoid it happening again.^{Footnote 2425} [Emphasis added]

88. LCol Sansterre testified he did not personally interview the investigators to find out what happened, nor task anyone else to do so.^{Footnote 2426} He thought this would have been done during the QA review.^{Footnote 2427} However, only one of the members involved in the investigation was contacted during the review.^{Footnote 2428}

89. In testimony, MCpl Ritco recalled being contacted by WO Ross, who was “drafting up his report” at the time and wanted to get clarification before submitting it.^{Footnote 2429} The report only mentioned information obtained from MCpl Ritco when discussing the reasons for not mentioning the note during the conversations with the Fynes.^{Footnote 2430} It contained no indication MCpl Ritco (or anyone else) was asked about the reasons for not disclosing the suicide note at any other time during or after the investigation.

90. The case manager, WO Ross Tourout, and the other investigator involved in the seizure of the suicide note, Sgt Jon Bigelow, were not interviewed by WO Ross during the review.^{Footnote 2431} The Detachment MWO and Acting OC who had overall responsibility for the supervision of the investigation, MWO Barry Watson, was also not contacted.^{Footnote 2432} MWO Watson testified:

[...] I was never consulted when this quality assurance was being conducted. Whether or not I was a member of the unit or a member of a different unit, I was the senior person in place at the time, if they're going to do a quality assurance, then I should have been con -- not consulted, and be spoken to about the conduct of the investigation.^{Footnote 2433}

91. Maj Dandurand, the Detachment OC, also did not have any discussions with Sgt Bigelow, WO Tourout or MWO Watson about what happened with the suicide note.^{Footnote 2434} In fact, these members all testified they were never asked for an explanation by anyone prior to this hearing.^{Footnote 2435}

92. Maj Dandurand testified he did have a discussion with MCpl Ritco about the suicide note.^{Footnote 2436} However, he could not recall when the discussion took place or what its content was.^{Footnote 2437} No record could be located indicating what explanations he received from MCpl Ritco, if any, about what happened.

93. During the months following the discovery of the failure to disclose the note, Maj Dandurand also did not review the file to find out what happened.^{Footnote 2438} When he did review it months later in preparation for a meeting with the Fynes, his focus was on the redactions done to the file, and he did not do an “intricate delving” into the file or inquire about what the exact process was which led to the suicide note still being held in the evidence room so long after the fact.^{Footnote 2439}

What Happened?

94. The suicide note was first located by the CFNIS investigators, MCpl Ritco and Sgt Bigelow, on March 15, 2008, the day Cpl Langridge died. They found the note on the desk shortly after they entered the room where Cpl Langridge’s body was found.^{Footnote 2440} Sgt Bigelow first transcribed its contents in his notebook.^{Footnote 2441} The note was then seized and placed in an evidence bag.^{Footnote 2442} It was treated the same as other exhibits. The investigators wore gloves while handling it.^{Footnote 2443}

95. A copy of the note was made for the Alberta Medical Examiner while the note remained in the evidence bag.^{Footnote 2444} The ME’s office was satisfied to take only a photocopy of the note and did not require the original.^{Footnote 2445} At the time, there were no discussions about whether and when to release the note to the family.^{Footnote 2446} According to the testimony of the ME investigator present at the scene, the ME’s office would have had no objection to a copy of the note being provided to the family at any time, and did not need the CFNIS to retain the original for any period of time.^{Footnote 2447}

96. After the copy was provided to the ME investigator, MCpl Ritco kept the original note.^{Footnote 2448} When he returned to the Detachment that night after processing the scene, he put it in his temporary evidence locker.^{Footnote 2449} An Evidence Collection log was prepared, and the suicide note was listed as Exhibit number 2.^{Footnote 2450}

97. MWO Watson, the Detachment MWO and Acting OC for the Detachment, was briefed about the suicide note on the day it was seized.^{Footnote 2451} WO Tourout, the Case Manager for the investigation, was advised about the note in the following days.^{Footnote 2452}

98. MCpl Ritco testified that in the early days of the investigation, he and WO Tourout discussed whether the suicide note could be released.^{Footnote 2453} They talked about whether the note had evidentiary value, who was the next-of-kin and to whom the note should go.^{Footnote 2454} They specifically asked themselves whether the note could be released or if it had to be kept.^{Footnote 2455} A decision was made not to release the note.^{Footnote 2456} The factors considered in making the decision included the fact the investigation was in the early stages, the possibility of foul play and the uncertainty surrounding Cpl Langridge’s common-law status.^{Footnote 2457} In testimony, MCpl Ritco explained:

As the lead investigator my stance was this is early on in the investigation, that this potentially could be evidence. Now, if we were to turn over the suicide note, the original copy to the family, we could be giving away potential evidence.^{Footnote 2458}

99. At the time, the only options considered were to release the original note to the family or not release it.^{Footnote 2459} There was no discussion about advising the family of the existence of the note or providing a copy.^{Footnote 2460}

100. There was no record of this discussion in the investigative file or in MCpl Ritco’s notebook.^{Footnote 2461} Several entries in the notebook documented briefings to WO Tourout or discussions with him. Most included a general mention of the purpose of the discussions but no detail about their contents.^{Footnote 2462} None referred directly to a discussion about the suicide note, but MCpl Ritco testified he had a clear recollection about it.^{Footnote 2463} In his testimony, WO Tourout did not specifically refer to a discussion with MCpl Ritco but confirmed a decision was made not to release the note in the early stages of the investigation. When asked whether the investigative team considered telling the family about the funeral wishes contained in the note, he testified:

It certainly crossed our mind and it's very unfortunate at that point in time that we couldn't release it and we feel, obviously we feel bad about that, but as at that time it was just too soon, in our mind, in our mind in our investigation, in Sergeant Ritco's investigation.^{Footnote 2464} [Emphasis added]

101. MWO Watson did not recall being involved in discussions about releasing the suicide note to the family.^{Footnote 2465} He believed he would have been consulted about this issue.^{Footnote 2466} He did not recall any issue being brought to his attention during the investigation that raised flags for him.^{Footnote 2467} He testified he did not have any specific expectation about the disclosure of the note and did not recall those issues coming into his mind at all at the time.^{Footnote 2468} Sgt Bigelow was also not aware of a decision not to disclose the suicide note to the family.^{Footnote 2469} He explained, because his role in the investigation was circumscribed, he would not necessarily have expected to be advised.^{Footnote 2470}

102. MS Eric McLaughlin, who was briefly involved in the investigation as a note-taker during a witness interview, testified he was aware of the existence of the suicide note while the investigation was ongoing.^{Footnote 2471} He did not recall how he learned of it or when.^{Footnote 2472} He was not involved in any discussions about the note, and was not aware of any steps being taken or decisions being made with respect to disclosing the note to the family.^{Footnote 2473}

103. On March 20, 2008, five days after Cpl Langridge died, MCpl Ritco met with Maj Earl Jared from the Regiment.^{Footnote 2474} As he was leaving Maj Jared’s office, an individual, who identified himself as 2Lt Adam Brown, approached him and indicated he was the AO for Cpl Langridge’s common-law spouse.^{Footnote 2475} He then told MCpl Ritco he “heard that there is a note” and asked if he could tell him about it.^{Footnote 2476} MCpl Ritco answered he could not say anything as the investigation was ongoing.^{Footnote 2477} In testimony, MCpl Ritco explained he provided this answer because he did not know who 2Lt Brown was when he approached him.^{Footnote 2478} Even once his identity was confirmed, MCpl Ritco did not think he should be providing him more information.^{Footnote 2479} He explained:

[…] until the completion of my investigation, it wasn’t -- nothing was revealed. I wasn’t going to tell Lieutenant Brown that there was a note even though he was the AO. The same thing [if] Mr. and Mrs. Fynes had an assisting person. I wouldn’t tell him, either. If I was going to brief anybody, it would be directly to the family or the next of kin.^{Footnote 2480}

104. MWO Watson believed MCpl Ritco would have sought guidance about whether to reveal the existence of the suicide note to 2Lt Brown.^{Footnote 2481} He did not recall being consulted on this point.^{Footnote 2482} WO Tourout, for his part, testified he was not aware 2Lt Brown had asked about the note.^{Footnote 2483}

105. On April 2, 2008, approximately two weeks after Cpl Langridge’s death, MCpl Ritco was contacted by MWO Remi Mainville from the Regiment.^{Footnote 2484} MWO Mainville was in charge of inventorying and handling Cpl Langridge’s personal effects.^{Footnote 2485} He asked MCpl Ritco to provide him with a list of the items the CFNIS had kept so he could include it in his inventory.^{Footnote 2486} The next day, MCpl Ritco provided a list of some of the items he retained.^{Footnote 2487} The list included Cpl Langridge’s Blackberry, an AA book, a Bible and family get well cards.^{Footnote 2488} The suicide note was not listed or mentioned. In his message to MWO Mainville, MCpl Ritco advised: “after going [through] my evidence here [are] the only things that I feel that are of a personal effect would be as follows: [...]. Other items do not personal[ly] belong to Cpl LANGRIDGE. Should you require any more information please let me know.”^{Footnote 2489} In testimony, MCpl Ritco explained his reasons for not including the suicide note in the list provided to MWO Mainville:

[A]t the time I felt that it was an ongoing investigation. I was still dealing with a sudden death. I didn't know which way it was going. I didn't think that --although MWO Mainville was looking after his personal effects, I didn't feel that he needed to know that there was a suicide note.^{Footnote 2490}

106. MWO Watson did not recall being consulted about the decision not to include the note in the list provided to the Regiment.^{Footnote 2491}

107. Shortly before sending the list to MWO Mainville, MCpl Ritco had scanned a copy of the suicide note into the electronic investigation file.^{Footnote 2492}

108. On April 9, 2008, MCpl Ritco took the original suicide note from his evidence locker and placed it in the Evidence Room for the Detachment.^{Footnote 2493} Prior to this date, he had not taken the note out of his locker at any time.^{Footnote 2494}

109. Nothing more was done with the suicide note until the BOI discovered its existence in March 2009.^{Footnote 2495} The note was not mentioned again anywhere in the investigative file or in the two investigators’ notebooks.^{Footnote 2496} There was no reference to it in the Investigation Plan, the Case Summary or the Concluding Remarks for the investigation.^{Footnote 2497} No sample of Cpl Langridge’s handwriting was obtained to compare it to the handwriting on the note.^{Footnote 2498} The note was never fingerprinted.^{Footnote 2499} No other tests were performed to confirm its authenticity.

110. There is no indication the CFNIS members involved intended to contact Cpl Langridge’s family at any time to advise them about the note. On April 15, 2008, WO Tourout told MCpl Ritco there was no need to contact Cpl Langridge’s mother for the investigation.^{Footnote 2500} On May 27, 2008, MCpl Ritco was advised WO Tourout and MWO Watson had determined there was also no need to contact Cpl Langridge’s common-law spouse.^{Footnote 2501} When the Fynes initiated contact, MCpl Ritco had separate telephone conversations with Mrs. and Mr. Fynes on May 5 and May 9, 2008.^{Footnote 2502} He did not mention the suicide note.

111. MCpl Ritco concluded his investigation on June 2, 2008.^{Footnote 2503} WO Tourout reviewed the file on June 12, 2008.^{Footnote 2504} On July 1, 2008, MWO Watson approved the report and officially marked the file as concluded.^{Footnote 2505} On July 3, 2008, the Acting CO for the CFNIS, LCol Brian Frei, reviewed the investigative file.^{Footnote 2506} LCol Frei was the DCO for the CFNIS throughout the investigation.^{Footnote 2507} He did not recall being specifically advised about the suicide note during the investigation.^{Footnote 2508} When he reviewed the file, he testified he would have seen references to the note being seized and a copy being provided to the ME, and he “wouldn’t have thought anything [...] further about the note.”^{Footnote 2509} The references to the suicide note found in the file did not raise any flags for him.^{Footnote 2510} He made no mention of the note in the entry he added to the file after his review.^{Footnote 2511}

112. LCol Bud Garrick, the CFNIS CO until June 2008, did not recall whether he was advised about the suicide note in this case.^{Footnote 2512} He also did not recall whether he asked about a note being found at the time.^{Footnote 2513}

113. After the investigation was concluded, no immediate steps were taken to dispose of the exhibits seized.

114. On October 23, 2008, MCpl Ritco was contacted about the release of Cpl Langridge’s personal effects. Ms. Suzanne Touchette, who worked at the JAG Director of Estates office in Ottawa, sent a message to the Fynes’ AO and the President of the Committee of Adjustments (COA), providing authorization to the Regiment to release Cpl Langridge’s effects to his executor, Mr. Fynes.^{Footnote 2514} She stated MCpl Ritco, who was also copied on the message, “had informed the COA that approximately 13 items were being held in support of their ongoing investigation.”^{Footnote 2515} She asked the recipients to ensure the items were no longer required by the CFNIS and had been returned.^{Footnote 2516} She added it was important to make sure any items still required by the CFNIS for any reason were eventually returned to the executor.^{Footnote 2517}

115. When he received this message, MCpl Ritco forwarded it to Sgt S.B. Miller at the CFNIS WR Detachment, asking him to provide “guidance regarding the release of Cpl LANGRIDGE’s personal effects from our evidence room that we no longer require.”^{Footnote 2518} In response, MCpl Ritco testified he was told the process for the release of the exhibits would be handled “by the senior staff.”^{Footnote 2519} Prior to this exchange, MCpl Ritco had not been involved in any discussions about holding or releasing the exhibits since the conclusion of the investigation.^{Footnote 2520}

116. As a result of MCpl Ritco’s inquiries, a letter requesting authority to dispose of the CFNIS evidence was prepared.^{Footnote 2521} The letter was dated October 31, 2008, and was addressed to the CO for Cpl Langridge’s Regiment.^{Footnote 2522} It was signed by MWO Watson.^{Footnote 2523} In testimony, MWO Watson explained the request for disposal authority was prepared because the Detachment had received a request for the return of Cpl Langridge’s property.^{Footnote 2524} He testified that, had this request not been received from the Regiment, the letter seeking authority to dispose of the exhibits would likely never have been prepared by the Detachment.^{Footnote 2525}

117. MWO Watson’s letter advised the investigation into Cpl Langridge’s death was complete, and stated the Regiment CO’s authority was requested “to dispose of evidence that was seized during the course of this investigation,” in accordance with applicable MP policies.^{Footnote 2526} It noted the items listed would be returned to Cpl Langridge’s estate once authority was received.^{Footnote 2527} Included in the letter was a list of 13 items seized during the investigation.^{Footnote 2528} The suicide note did not appear in the list.

118. MWO Watson testified he did not send requests for disposal authority routinely.^{Footnote 2529} He did not recall who prepared the request in this case.^{Footnote 2530} His normal practice would have been to draft the letter himself and ask the lead investigator or another investigator to draft the list of evidence.^{Footnote 2531} MCpl Ritco did not have a clear recollection, but testified he may have compiled the list of items to return.^{Footnote 2532} At a minimum, he knew he had input in the preparation of the request and was certain he at least confirmed he “no longer required anything that was in our evidence room in regards to personal effects or seized items.”^{Footnote 2533}

119. On the day the letter was sent, MCpl Ritco added an entry to the file and contacted MWO Mainville at the Regiment to notify him.^{Footnote 2534} He advised once approval was granted, the evidence custodian for the Detachment would contact him to make arrangements for him to take possession of Cpl Langridge’s effects.^{Footnote 2535}

120. On January 21, 2009, the Regiment CO, LCol Derek Macaulay, granted authority for the disposal of Cpl Langridge’s effects listed in MWO Watson’s letter.^{Footnote 2536} On January 26, 2009, the items were turned over to MWO Mainville by the Evidence Custodian.^{Footnote 2537} As it was not listed in the request, the suicide note was not turned over to MWO Mainville.^{Footnote 2538} Nothing further was done with the suicide note until the BOI requested a copy.

Taking Stock

121. On the basis of the testimony heard, it is clear the suicide note was initially seized because it was viewed as evidence relevant to the determination of the cause of Cpl Langridge’s death.^{Footnote 2539} While there was no actual plan or intent to test the note when it was seized, or at any other time during the investigation,^{Footnote 2540} the CFNIS members involved believed the note had to be seized, handled and retained as an exhibit during the investigation to ensure it would be available for testing if foul play was suspected or if there was question about the cause of death.^{Footnote 2541} No testing was done because there were no serious concerns about foul play or about the authenticity of the note.^{Footnote 2542}

122. After the seizure of the note and the early determination by MCpl Ritco and WO Tourout that the original could not be released to the family at this stage, nothing further was done with the note.^{Footnote 2543} As it quickly became increasingly clear Cpl Langridge had indeed committed suicide, the note lost prominence and was eventually forgotten. WO Tourout testified:

Unfortunately, as I testified earlier and, I think, Sergeant Ritco and others before me, the suicide note was forgotten. It's regrettable. I know action has been taken within the CFNIS to correct that issue.

I'm sorry. I'm sorry, myself as well as everybody else who has testified. It's unfortunate but it happened.^{Footnote 2544} [Emphasis added]

123. He explained both he and MCpl Ritco forgot about the note.^{Footnote 2545} His testimony was not entirely clear as to the precise time when this happened. At times, he appeared to indicate it was at the end of the investigation.^{Footnote 2546} At other times, he indicated it was earlier. In particular, he explained the investigation’s focus moved away from foul play in the very early days and indicated the suicide note was not relevant to the other aspects investigated and was forgotten.^{Footnote 2547} He also stated it was because the note had been forgotten that there were no discussions about the possibility of concluding the investigation sooner to ensure the family could be advised earlier.^{Footnote 2548}

124. From the Commission’s review of the file, there is no evidence any of the investigators remembered the note at any time after MCpl Ritco put it in the Evidence Room on April 9, 2008.^{Footnote 2549} Aside from the entries related to its seizure, not a single entry in the 714-page investigation file refers to the suicide note. Even the Investigation Plan and the Case Summary (where both LCol Garrick and LCol Frei expected to see a reference to it) did not mention the note. ^{Footnote 2550} It was not discussed during the interviews, not tested, not referred to and its existence was not disclosed to anyone. MCpl Ritco did not mention the note when he spoke to the Fynes in early May, although during his testimony at the hearing, he indicated he believed he should have done so.^{Footnote 2551} He provided no explanation for not discussing the note at this time. From the totality of the evidence, it is clear he had forgotten about it by then.

125. During their testimony before this Commission, the members involved in the investigation all appeared to agree the original suicide note had to be retained until the end of the investigation to ensure it was available if testing became necessary.^{Footnote 2552} However, they expressed different views about whether the existence of the note could have been revealed and a copy provided to the family before the end of the investigation. Some thought the family could and should have been advised about the note right away or very early on, and did not think there was any reason for not telling others, like Ms. A’s AO or the Regiment, about the note.^{Footnote 2553} Others thought the family could only have been notified once foul play was ruled out or the note was no longer required for evidentiary purposes, and did not think the Regiment or anyone else should have been advised.^{Footnote 2554}

126. On several occasions during his testimony, MCpl Ritco referred to the absence of a specific policy about the handling of suicide notes as a reason why he did not think the family could or should have been advised about the note or provided a copy before the end of the investigation.^{Footnote 2555} His testimony was not entirely clear on this point. On the one hand, he emphasized no policy provided for the specific option of advising the family about the contents of the note without providing the original.^{Footnote 2556} On the other hand, he stated in the absence of a specific policy, he could make his own determination about disclosing the note in consultation with his chain of command.^{Footnote 2557} He also stated he thought the note was to be treated like any other piece of evidence because there was no policy.^{Footnote 2558} He could not provide any evidentiary reason for not disclosing the existence of the note to the family.^{Footnote 2559}

127. Regardless of the views expressed at the time of their testimony about what could or should have been done to advise the family about the note, what is clear from the evidence is none of those factors were actually considered by the members involved in the investigation at the time of the events. The only question considered by MCpl Ritco and WO Tourout was whether the original note could be released. The possibility of advising the family of the contents of the note without releasing the original was not discussed or considered.^{Footnote 2560} Sgt Bigelow and MWO Watson were not involved in the discussions, and both testified they did not turn their mind to the issue at all at the time.^{Footnote 2561} In fact, MWO Watson testified the only reason Cpl Langridge’s family was not advised about the note early on was because “it didn’t come into my mind to release it to the family like it should have.”^{Footnote 2562}

128. The Commission finds the reason the Fynes were not told about Cpl Langridge’s suicide note during the investigation is that no one at the CFNIS thought about whether they should be told. It cannot be known what the result would have been if the CFNIS members had considered the issue.

129. As for the original suicide note, it was not provided to the family when the investigation was concluded because, as MCpl Ritco put it, “it fell through the cracks.”^{Footnote 2563}

130. MCpl Ritco had assumed the note would be released at the end of the investigation in the normal course.^{Footnote 2564} He believed there was a process in place for disposing of the exhibits once an investigation was concluded.^{Footnote 2565} In reality, MWO Watson explained there was no such process, and no one in the Detachment was tasked with ensuring evidence was disposed of when investigations were concluded.^{Footnote 2566} He noted this was a task “that was overlooked in a lot of investigations” and “should have been delved into more on a regular basis.”^{Footnote 2567} As a result, exhibits seized during the Detachment’s investigations often would “just remain in our evidence room.”^{Footnote 2568} He testified:

If I can compare it to a smaller detachment [...], their evidence load is pretty low, so they have the ability to go in there and review their evidence and dispose of it, and ask for disposal authority, on a regular basis.

NIS [Western Region] holds an incredibly large amount of evidence. So did we go in there as much as we should have to request disposal on any investigation? No.

There is evidence held on investigations that are years old at CFNIS Western Region.^{Footnote 2569}

131. In his testimony, Maj Dandurand confirmed the Detachment was “not very efficient at disposing of our evidence in a swift manner” and also testified as a result “it was not uncommon for evidence to be held for several years.”^{Footnote 2570} There was a policy requiring the Detachment OC to conduct an annual inspection of the evidence room, which technically would have required going through each piece of evidence to determine if it was still required.^{Footnote 2571} However, MWO Watson testified this would have been “a year-long project in itself” and indicated he did not carry out any such inspection when he was the Acting OC for the Detachment.^{Footnote 2572}

132. Maj Bolduc also testified about the CFNIS’ practices for disposing of evidence seized. In principle, he explained the evidence custodian should have been put in charge of making determinations about the return of evidence and the Detachment OC should have been responsible to verify files periodically.^{Footnote 2573} In practice, he indicated some Detachments proceeded more quickly than others with the disposal, and some actually waited in case new information came to light, even where charges were not brought.^{Footnote 2574} LCol Robert Delaney, who was the CFNIS CO in 2011-2012, testified the time required to dispose of evidence depended on “the operational workload of the detachment.”^{Footnote 2575}

133. When the investigation into Cpl Langridge’s death was concluded in June 2008, the exhibits seized simply remained in the evidence room and nothing was done to return them to anyone. Because no one remembered the suicide note by then, none of the members involved in the investigation followed up to ensure it was provided to the family at the end of the investigation.

134. When steps were taken three months later to return the exhibits because MCpl Ritco happened to be contacted by the Director of Estates, there was an oversight on the part of the investigator who prepared the list of items to be returned – most likely MCpl Ritco – and the note was not included.^{Footnote 2576} Because it had long been forgotten by then, no one noticed its absence.^{Footnote 2577}

135. On the basis of the evidence heard about the Detachment’s evidence-handling practices, there is every reason to believe, had it not been for the BOI’s intervention, Cpl Langridge’s suicide note would have simply remained in the CFNIS WR evidence room for years, with no one ever being advised about it.

Making Sense of the Explanations

136. Having ascertained the reasons why Cpl Langridge’s suicide note was not disclosed to his family, it is readily apparent the facts are difficult to reconcile with many of the explanations provided about them.

137. First, in the days following the discovery of the failure to disclose the note, Maj Dandurand had written the note was “held as evidence” and explained it was “not routine” for the CFNIS to release evidence as it was generally “held for [several] years.”^{Footnote 2578} We know the members involved in the investigation expected the original note would be released immediately at the end of the investigation.^{Footnote 2579} No one thought it needed to be held for any period of time, much less for several years. MWO Watson did state that in practice, evidence often ended up remaining in the evidence room for years after cases were concluded, but this was the result of lax practices for returning exhibits and not of any policy requirement.^{Footnote 2580}

138. Maj Dandurand testified he believed the note was still “classified as evidence” at the time he provided his explanation.^{Footnote 2581} When asked what it was evidence of, he explained:

Simply as a classification not necessarily of anything because thought had been given to whether we should be disposing of it or not at that time.^{Footnote 2582}

139. He indicated his understanding was, if the CFNIS was still holding the suicide note so long after the investigation when all other personal belongings had already been returned, they would have been holding it “only because it was evidence.”^{Footnote 2583} This understanding, as well as his belief evidence was usually held for several years, came from a conversation he had with members of his Detachment who were “experienced in this domain.”^{Footnote 2584} Maj Dandurand had never personally encountered this issue previously.^{Footnote 2585} He had not had the opportunity to speak with those involved in the investigation before he provided his explanation, but he had discussed the matter with the then Detachment MWO, WO Ross, and they were both of the view the suicide note was still classified as evidence pursuant to the procedures for evidentiary holdings applicable at the time.^{Footnote 2586} In testimony, Maj Dandurand recognized that what he then viewed as the “policy” was, in fact, a practice to hold suicide notes as evidence “until such time as they were disposed of,” which would happen “as part of a regular review” of the evidence holdings when the notes would “come to the surface.”^{Footnote 2587} He also admitted the evidence often ended up being “held for several years” due to the lack of efficient processes for disposing of evidence.^{Footnote 2588} Based on these explanations and on what Maj Dandurand wrote when he was first advised about the failure to disclose the note, it appears the lack of adequate processes for the return of exhibits had become viewed by the Detachment chain of command as a policy requirement or best practice. Regrettably, because it was the way things were done, the members and even the chain of command came to believe it was the way things were supposed to be done.

140. The explanation provided by LCol Lander a few days later focused on the reasons why the existence of the note was not revealed to the Fynes and indicated the investigative team decided not to disclose it because “in their opinion, [it] would not have added anything to the information already passed during the normal victim services provided, and they felt it may have even had a negative effect.”^{Footnote 2589} This bears no relation whatsoever to the events that occurred. The Fynes received no information – through victim services or otherwise – about the investigation.^{Footnote 2590} The only decision made during the investigation was not to release the original note. The members involved never even turned their minds to the possibility of advising the Fynes about the note, let alone did they decide not to do it for the reasons listed.

141. In testimony, MCpl Ritco indicated he had “nothing to do” with the statements made in LCol Lander’s explanation.^{Footnote 2591} He noted the information available through victim services was never a factor he considered, and indicated he never believed revealing the note could have had a negative effect on the family.^{Footnote 2592} Sgt Bigelow was also not aware of any determination or consideration of whether revealing the existence of the note would have had a negative effect on the family.^{Footnote 2593} MWO Watson, who was also unaware of any such determination, wondered where LCol Lander obtained this information.^{Footnote 2594}

142. LCol Lander himself had difficulty making sense of the explanation he provided. He testified:

[...] in my opinion, from what I knew about the case, I don't see why -- especially if the suicide note, as I understand it, was addressed to the family, why they wouldn't have divulged that right away. I didn't get that.

But, again, it was the NIS chain of command to sort out, not mine. My responsibility was to make sure the army commander knew what the issue was.^{Footnote 2595}

143. Since LCol Lander did not have any information about the matter, he had to have obtained the information included in his explanation from the CFNIS. In testimony, he could not recall whom it was he spoke with, but thought it would have been the CFNIS CO or the Operations Officer.^{Footnote 2596} LCol Sansterre and Maj Dandurand both believed they spoke to LCol Lander at the time, but denied providing the information included in his explanation.^{Footnote 2597} LCol Sansterre testified he had “absolutely no idea where [LCol Lander] would have come up with that information.”^{Footnote 2598} The source of LCol Lander’s explanation remains a mystery. It is clear the information he received from the CFNIS was inaccurate or seriously misunderstood, but it cannot be known who provided it. The explanation also included another inaccurate statement indicating information about the existence of the note had been passed to the BOI with the original documentation provided by the CFNIS, which was not in fact the case.

144. The subsequent MRL explanation about the reasons why the note was not mentioned during an interview with the Fynes is also problematic. First, there was no “interview” with the Fynes, only brief telephone conversations with MCpl Ritco when they contacted him. Second, the MRL stated the parents were aware of the coroner’s findings into the cause of death,^{Footnote 2599} which would not have been possible at the time since the ME’s report had not yet been received when MCpl Ritco spoke to them. More importantly, the rest of the explanation, indicating the Fynes did not ask about a note and the investigator did not mention it “as the investigation was still ongoing”^{Footnote 2600} was not consistent with the explanations provided by MCpl Ritco during the QA review or before this Commission. While, according to WO Ross’ report, MCpl Ritco did mention the Fynes had not asked about the note, he never stated he did not reveal its existence then because the investigation was still ongoing.^{Footnote 2601} On the contrary, his view as conveyed in his testimony was he should have revealed it.^{Footnote 2602} The reason he did not had nothing to do with the status of the investigation. It was because the note had been forgotten. The CFNIS witnesses could not confirm the source of the information included in this MRL, but agreed it would have been obtained by the PAO from someone at the CFNIS who had knowledge of the file, likely LCol Sansterre, Maj Bolduc or Maj Dandurand.^{Footnote 2603} As to the content of the information, Maj Dandurand did not think it was correct, while LCol Sansterre saw no inaccuracies.^{Footnote 2604}

145. The explanation provided by Maj Dandurand two weeks later, when he learned about the questions on disciplinary measures, was surprising. He was adamant the “investigator and the case management team did everything in good faith and at no point was the family’s well being pushed aside.”^{Footnote 2605} He went on to discuss the need to make assumptions in the best interest of the family based on previous experience, noting the members involved in this investigation “had many previous investigations of suicide in their repertoire.”^{Footnote 2606} He discussed decisions about the return of sensitive personal belongings that could cause embarrassment and concluded no disciplinary measures were warranted.^{Footnote 2607}

146. This explanation did not reflect the facts of the case. The members involved in this investigation did not have extensive experience in conducting suicide or sudden death investigations. In fact, for both the lead investigator and the case manager, this was their first sudden death investigation.^{Footnote 2608} In testimony, Maj Dandurand acknowledged his statements were based on his own assumptions at the time, as he was unaware of the experience of the members involved.^{Footnote 2609} As for the explanation about making assumptions in the best interest of the family, there is no evidence the CFNIS members involved ever considered the possibility of advising the family about the note before providing the original, and their decision not to release the original during the investigation was based on what was viewed as the requirements of the investigation, not the interests of the family. In testimony, Maj Dandurand could not confirm whether he had spoken to MCpl Ritco or anyone involved in the investigation before providing this explanation.^{Footnote 2610} He believed the decisions made about the release of the note were based on what the investigators thought was in the best interest of the family, but he did not recall how he came to this understanding.^{Footnote 2611} He acknowledged the other statements in his message about the return of sensitive or embarrassing items were unrelated to the suicide note or to this specific investigation.^{Footnote 2612}

147. The explanations provided by Maj Dandurand during his November 2009 meeting with the Fynes, which focused on the existence of a “policy” not to divulge suicide notes, also do not reflect the facts of this case.^{Footnote 2613} Whatever the policy may have been,^{Footnote 2614} it is clear it had nothing to do with the investigators’ “decision” not to advise the family about the note’s existence and contents. While their views on policies, evidence and the requirements of the investigation may have influenced MCpl Ritco and WO Tourout’s early decision not to release the original note, they never considered the possibility of divulging the note’s existence without releasing the original. As a result, any views they may have held about the policies applicable in this respect could have played no part in what they did. As for MWO Watson, had he turned his mind to the issue, it was his view there was nothing preventing the disclosure of the note and he would have advised the family at an early point in the investigation.^{Footnote 2615}

148. As for the explanation provided in January 2011, stating the note was intended to be released to the Fynes at the end of the investigation but “this was not conducted as expediently as it could have been,”^{Footnote 2616} this is also not an entirely accurate description of what happened. While at least some of the members involved believed the note would be returned at the end of the investigation, by the time the investigation was concluded, it was more than a mere lack of expediency which caused the note not to be returned. The note was omitted when steps were taken to return Cpl Langridge’s personal belongings because it had been forgotten by then, and there is no indication it would ever have been returned if the BOI had not requested a copy and provided it to the Fynes. The source of the information provided in this explanation is unknown. Maj Dandurand, whose Detachment was in charge of passing on the information for inclusion in these responses, testified he was not personally aware of anyone having the intention to release the suicide note at the conclusion of the investigation.^{Footnote 2617}

Learning From Past Mistakes

149. Of all the explanations provided by CFNIS members to the Fynes, the public or other CF members, not a single one contained a complete and accurate reflection of what happened in this case. On the basis of the evidence heard before this Commission, there is no indication this was the result of any intent to misrepresent the facts or mislead. However, there are indications the CFNIS chain of command never did discover why Cpl Langridge’s suicide note had not been disclosed. This is the reason why they could not provide consistent explanations.

150. Aside from the explanations examined here, no record was produced before this Commission of any explanations received by the CFNIS chain of command about what happened in this case, much less of any accurate explanation. Most of the CFNIS witnesses who testified before this Commission could not provide an answer.^{Footnote 2618} One witness thought there was probably a “legitimate reason” why the note was not returned right away, but did not know what it was, while others thought it was a mistake.^{Footnote 2619} But no one knew exactly what happened.

151. Only two members of the chain of command, LCol Sansterre and Maj Dandurand, testified they knew why Cpl Langridge’s suicide note had not been disclosed. The explanations they provided were not consistent with each other.

152. Maj Dandurand testified:

I believe -- and this is very hard for me to do, to differentiate between what I know now and what I knew then with respect to this [...]

So, it would have been -- it would have been in around the summer time when I found out -- or when I assessed that the note hadn't been provided and when I asked the investigators -- when I asked people and started searching around, it was under the explanation of, this was evidence, everything else was returned with the exception of a few articles, but it was the opinion of people that this was still evidence.^{Footnote 2620} [Emphasis added]

153. LCol Sansterre stated:

MR. FREIMAN: […] Sitting here today, do you know why the suicide note was not turned over?

LCOL SANSTERRE: Yeah, they collected it as evidence and they forgot to give it.

MR. FREIMAN: When did you first hear that it had been collected as evidence and forgotten?

LCOL SANSTERRE: I don't -- I don't know.

MR. FREIMAN: Was it during the course of these proceedings as a result of evidence that we've heard?

LCOL SANSTERRE: I would – I would have thought it was before that, but I can't be sure.^{Footnote 2621}

154. On the basis of the evidence, it does not appear LCol Sansterre was informed of what happened before this hearing was held. Had he been, the CFNIS and its members would not have continued to provide the inconsistent official explanations seen by the Commission. To the extent that senior leadership of the CFNIS did, in fact, know what happened, it is clear they did not make it known to the members of the organization or of the chain of command. Maj Dandurand, the OC for the Detachment involved, continued to believe the reason for not releasing the note was because it was seen as evidence that needed to be retained. This did not reflect the actual belief of the members involved in the investigation, who all thought the note did not need to be retained after the investigation ended. Instead, it appears to have reflected WO Ross’s and Maj Dandurand’s own beliefs about applicable evidence policies or procedures.

155. Not having found out what happened in this case, it is difficult to understand how the CFNIS chain of command could take measures to address the issue. Both in the immediate aftermath of the discovery of the failure to disclose Cpl Langridge’s suicide note and throughout the ensuing period, up to and including during their testimony before this Commission, members of the CFNIS chain of command insisted their priority was to ensure this did not happen again.^{Footnote 2622} However, the question arises: how could they fix the problem if they did not know what was broken? Considering the answers they obtained and provided, it is difficult for this Commission to see how they could have been in a position to be truly certain any measures they put in place would address what went wrong in this case.

156. Further, having endured the pain of learning about their son’s suicide note fourteen months after his death and of knowing they had been unable to honour his funeral wishes, the Fynes were entitled to an explanation about how this could have happened. Despite having asked the question many, many times, by the time they testified before this Commission, they still did not know the reasons why their son’s suicide note was not disclosed to them.^{Footnote 2623} Because the CFNIS did not take sufficient steps to find out what happened, the Fynes were not provided the answers they were entitled to receive.

157. Worse, the failure to provide a factual account of what happened, the inconsistent explanations provided and the attempts at justifying what occurred contributed to creating an impression there was an attempt to minimize the seriousness of the problem or even to cover up the issue. This may have contributed to the Fynes’ belief that withholding the note was intentional in the first place. In testimony, Mr. Fynes indicated he believed the failure to disclose the suicide note “was a very calculated deception designed to protect the uniform from embarrassment.”^{Footnote 2624} He explained:

The fact that it wasn’t even disclosed to the Regiment when they asked why NIS exhibits were being held tells me they were hiding it because it supported that my son had PTSD, he was in pain and he couldn’t take the pain anymore. That was the truth of that note and that was part of the cover-up.^{Footnote 2625}

158. The members involved in the investigation denied there was any intent to hide the note and provided numerous, and undoubtedly sincere, apologies for the situation during their testimony.^{Footnote 2626} MCpl Ritco testified:

[…] So at the end of my investigation, in the end of May, [...] the items should have been returned to the rightful owners.

Obviously, it didn't happen, and, as the lead investigator -- I believe it was 14 months or 15 months before it was returned to the rightful owner, and, as the lead investigator, I have to bear part of the responsibility on that, is that [sic] it should have been returned, but it wasn't.

It wasn't that we intentionally tried not to return it. It fell through the cracks. And for that I'm sorry. There's no family that should have to grieve the death of their son, along with not knowing or not having to know that there -- there was a suicide note written by their son.

We didn't mean to do it. But, at the end of the day, it happened.^{Footnote 2627}

159. The evidence heard before this Commission provides no support for the notion there was any intentional attempt by the CFNIS members to hide the suicide note. The Commission finds the failure to disclose the note was not part of an intentional cover-up. However, the Commission also finds the failure to provide a timely and straightforward explanation to the Fynes about what happened contributed to arousing suspicions and breeding mistrust.

Apologizing

160. The lack of answers and the inconsistent explanations provided to the Fynes also likely contributed to fostering the dispute between the Fynes and the CFNIS about whether there was or was not an apology provided to the Fynes. The Fynes were obviously left with the strong impression there was no apology, or at a minimum that whatever apologies were made were not adequate. The debate continued when this hearing was held.

161. Mrs. Fynes testified:

Q. We understand that at some point you were offered an apology about the suicide note. Can you tell us about that?

A. No, I can’t.

Q. To your mind there was no apology?

A. No.^{Footnote 2628}

162. Mr. Fynes testified there was a “token apology” made by Maj Dandurand, but added he “then immediately went on to justify their actions, which completely deflated and defeated the purpose of any acknowledgement that they had messed up.”^{Footnote 2629} He maintained Maj Dandurand “admitted this should not have happened” and even provided “an expression of empathy,” but did not provide an actual apology.^{Footnote 2630} Mr. Fynes insisted no formal apology was presented.^{Footnote 2631} He testified:

[T]here has never been a formal apology for this from the Chief of Defence or from the chain of command or directly from the NIS. There may have been references in casual conversation.

We have never been given a proper apology for not having received our son’s suicide note, for having been deprived of that and why our son’s personal property didn’t even appear on the Exhibit Lists. It was suppressed. We only learned of it because of the Board of Inquiry.^{Footnote 2632}

163. Mr. Fynes believed CF members were actually prevented from presenting an apology because of applicable regulations.^{Footnote 2633} About the public statement issued by the CDS in this case, which included a mention indicating the CFPM “deeply regretted the delay in releasing Cpl Langridge’s suicide note,”^{Footnote 2634} Mr. Fynes said:

If this was an apology, it was made to the media, it was not made to us. It was never communicated directly with us.^{Footnote 2635}

164. In contrast, the CFNIS and its members all maintained there had been numerous apologies presented to the Fynes. In early 2011, responses provided to the Fynes by the CF stated the CFNIS had “formally apologized to the family” for the late disclosure of the note.^{Footnote 2636} In their closing submissions, counsel for the subjects argue the CFNIS “has repeatedly recognized that failing to provide the suicide note to the family until 14 months after the death in the 2008 investigation was unacceptable.”^{Footnote 2637} They submit both LCol Sansterre and Maj Dandurand apologized to the Fynes, recognized “it was wrong for them to have delayed the handing over of the suicide note” and expressed their regret.^{Footnote 2638} They add the CDS also issued a statement apologizing to the Fynes publicly.^{Footnote 2639}

165. On the basis of the evidence heard, the Commission finds there were apologies provided to the Fynes by the CFNIS. When he spoke to Mrs. Fynes on June 18, 2009, LCol Sansterre apologized.^{Footnote 2640} He testified:

I said, I’m terribly sorry for what happened, I don’t know how it happened.

[...] I certainly felt -- I felt terrible about what had happened, and to this day I still feel terrible about what happened. I mean, if we could turn back time, this wouldn't happen. And I know when I spoke to her I said, I'm very sorry, I don’t know how this could have happened [...]^{Footnote 2641}

166. During his meetings with the Fynes, Maj Dandurand also made statements which were clearly meant to convey expressions of regret and apology. He agreed with Mrs. Fynes there was no excuse for this and stated he was “not disputing [the Fynes’] anger one bit.”^{Footnote 2642} He also indicated not disclosing the note for over a year after the investigation was concluded was “completely inappropriate.”^{Footnote 2643} He said he would “never stop feeling horrible” about the late disclosure.^{Footnote 2644} He stated the CFNIS could not “make right the wrong” but could only tell the Fynes “it will never happen again,” indicating this was a view he shared with the CFNIS CO, LCol Sansterre.^{Footnote 2645} He told the Fynes:

[…] the fact that the letter took so long, Shaun, Sheila; wrong. Wrong. Okay? It shouldn’t have happened.^{Footnote 2646}

167. In addition to these direct apologies, there were also public apologies. One occurred in June 2009, when the CFNIS PAO’s message during a media interview indicating the CFNIS “regrets the situation” was published,^{Footnote 2647} and there was another in October 2010, when the CDS’ public statement indicating the CFPM “deeply regretted” the delay in disclosing the note was released.^{Footnote 2648}

168. Nevertheless, there are two reasons why it is not surprising the Fynes were not satisfied with these apologies. First, they were not provided at the right time and in the right manner. Second, some of the apologies were not unqualified, but were rather accompanied or followed by statements attempting to justify some of what had occurred.

169. When Cpl Langridge’s case began to attract significant media attention in the fall of 2010, questions were asked by the CF chain of command about whether (and when) an apology had been provided to the Fynes for the failure to disclose the suicide note.^{Footnote 2649} The CFPM was provided the following information, which he passed on to his contacts at JAG and VCDS:

Mrs. Fynes received a face to face personal apology from the [Detachment] Commander (Major) for NIS Western Region. This apology and explanation of why the delay happened and how the CFNIS would stop recurrence was given at the time that the original note from Stuart Langridge was provided to her.^{Footnote 2650} [Emphasis added]

170. Regrettably, this information was not accurate.^{Footnote 2651} It was provided as a result of confusion and misunderstandings on the part of the CFNIS members tasked with gathering information for the CFPM.^{Footnote 2652} In actual fact, when the Fynes were told by Maj Parlee about the existence of their son’s note, no one from the CFNIS contacted them. It was the BOI President, not the CFNIS, who made arrangements to provide them with a copy of the note. When they requested the original and the issue was brought to the attention of the CFNIS chain of command, the CFNIS took no steps to deliver the note personally or provide a formal apology.^{Footnote 2653} The first contact with the CFNIS occurred three weeks later and was not in person but over the phone, when LCol Sansterre spoke to Mrs. Fynes. Face-to-face contact did not occur until many months later.^{Footnote 2654}

171. Even LCol Sansterre’s call was not part of any plan to provide a formal apology and would likely not have been perceived as such by the Fynes.^{Footnote 2655} LCol Sansterre did not intend to call the Fynes directly. He was trying to reach their AO to set up a briefing, but ended up speaking with Mrs. Fynes because of a mistake in the contact information provided to him.^{Footnote 2656} At the time, Mrs. Fynes told LCol Sansterre she felt strongly the measures taken by the CFNIS to contact the Fynes were “as a result of the media.”^{Footnote 2657} While LCol Sansterre did the right thing in providing an unqualified apology once he was on the phone with Mrs. Fynes, it appears no one at the CFNIS had thought about providing an apology to the family prior to this accidental contact. When the CFNIS PAO was asked during a media interview shortly before LCol Sansterre’s call to the Fynes “why the CFNIS never called the family to apologize about not giving them the suicide note,” she had no lines about the issue and could not provide an answer.^{Footnote 2658} Based on the MRLs she had, she only stated she was aware “the family was interviewed as per the normal process at the beginning of the investigation,” which in itself was not even accurate.^{Footnote 2659} Her reports to the chain of command about the questions she was asked, and the ultimate publication in the media article of a statement indicating the CFNIS had “never contacted the family to explain, or apologize,” did not lead to further discussions within the chain of command about the need to provide a formal apology to the Fynes.^{Footnote 2660}

172. When face-to-face contact between the Fynes and the CFNIS finally occurred in November 2009, it was in the context of a meeting with Maj Dandurand to discuss the CFNIS investigation into Cpl Langridge’s death. The expressions of regret Maj Dandurand provided about the failure to disclose the suicide note during this and subsequent meetings were qualified by other statements which appeared to indicate at least some of the actions taken in handling the note were justified. In particular, Maj Dandurand indicated a suicide note would never be taken “straight to the parents” but would always need to be kept for a certain period of time after the death.^{Footnote 2661} The views he expressed indicated he believed it was wrong to keep the note for 14 months, but did not believe it had been wrong to keep it initially, even if it meant the Fynes would not have been advised about their son’s funeral wishes.^{Footnote 2662} He specifically stated relying on the wishes expressed in the suicide note before foul play was ruled out would have been dangerous.^{Footnote 2663}

173. During a subsequent interview with Maj Parkinson, Maj Dandurand also made the following comments:

MAJ DANDURAND: [...] The issue is there's very much a recognition by the NIS that, you know what, there should have been a review of evidentiary holdings at least at the end of the file, and we would have been able to give it to them at that point. I believe the file was concluded within three months.

At the point where it's determined that foul play is ruled out – [...] we accept and we've changed our practices that, yes, actually, it's at that point.

The part where I think it would have had no bearing on the funeral dealings is that the determination of no foul play had not yet been made at the point of the funeral.

[…]

And we've explained at this [sic] at length, and I'm explaining this now because you do still have contact with Shaun and Sheila Fynes, and, funny enough -- not funny, but oddly enough this still does come up, even though they've had it explained twice to them. [...]

The issue is that, until that determination's made, that's considered non-disclosable evidence, from a police investigation point of view. It's frustrating for the family perhaps, but had it been foul play, had it been foul play and the note had been falsified – [...] and then they had acted on that for the funeral – [...] that could have been equally traumatic. Yeah.

[...] But it's kind of...as long as we accept that the circumstances, and I described them. What happened, unacceptable – [...] and we've changed that. That will not happen again.

What they're insinuating, that they should have been told right away --

MAJ PARKINSON: Would never happen.

MAJ DANDURAND: -- I'm not --

MAJ PARKINSON: Highly unlikely.

MAJ DANDURAND: -- entirely sure. It's not something that we can get pigeonholed into, that we can get backed into, because it's not healthy for the interest of the investigation.^{Footnote 2664} [Emphasis added]

174. In their testimony, the Fynes made it clear they did not accept the explanations provided by Maj Dandurand.^{Footnote 2665} They largely viewed them as after-the-fact justifications for the failure to disclose the note.^{Footnote 2666} Mr. Fynes stated from his own review of CFNIS records, he did not believe “there was any legitimate examination of that note beyond finding it and hiding it.”^{Footnote 2667} Mrs. Fynes stated the CFNIS members “were trying to excuse” their failure to disclose the note and commented: “it was a lot of waffling and a lot of excuses.”^{Footnote 2668} When they became aware of the comments made to Maj Parkinson from the interview recording, the Fynes took strong offence and viewed the comments as “very disparaging,” which, in turn, caused them to question the sincerity of the expressions of regret and empathy Maj Dandurand had provided when he met with them.^{Footnote 2669} Mrs. Fynes testified:

As he says there, their justification for withholding the note was that they had to investigate foul play. It was deemed a suicide within the first two and a half minutes, I think, after having found Stuart. They were waiting for toxicology which I believe came in around May. Their file was closed in June.

I have read a lot of material about the investigation into Stuart’s death and I have yet to see anything that constitutes even the beginning of an inquiry into could he have been murdered. It just isn’t there. Everyone knew it was a suicide, so I just don’t see anywhere ever there is any justification for that note being withheld for one minute.^{Footnote 2670}

175. In 2011, when the Fynes asked, “Why is it still not understood by the NIS that there was no legitimate justification for suppression and improper retention of a suicide note written by Stuart?”, the following response was initially prepared by the WR Detachment:

This question was posed, answered, and the situation apologized for on two separate occasions with the family. While the letter should have been provided to the family (ie: executor of the estate) at the conclusion of the investigation, following a review of evidence held, it would have only been provided at the time when it was deemed to have no bearing on the investigation (ie: ruling out of foul play or relevance of the note in this regard). During the interview of the parents, it was clear they had the belief this note should have immediately been provided to them and they did not agree with the explanation provided.^{Footnote 2671} [Emphasis added]

176. While this response was ultimately not transmitted to the Fynes in this form,^{Footnote 2672} it does provide an indication of the continued disagreement between the CFNIS and the Fynes about exactly what was done wrong and where an apology was needed.

177. Both in their testimony and in the allegations they made before this Commission, the Fynes also maintained one of the “inaccurate rationales” provided to explain or justify CFNIS actions was that the suicide note needed to be kept after the investigation because “there might be an appeal.”^{Footnote 2673} The allegations stated this statement was made during a meeting with CFNIS members.^{Footnote 2674} The transcripts for the three meetings between the Fynes and the CFNIS contain no mention of the possibility of appeals.^{Footnote 2675} The first meeting was not recorded in its entirety.^{Footnote 2676} However, MS McLaughlin, who was present at the meeting, did not believe there was any discussion about a need to keep the suicide note in case of appeals, as this would not apply in this case because no charges were laid.^{Footnote 2677} MCpl David Mitchell, who was present at the subsequent meetings, also did not recall any discussion about this topic during the meetings or during his other interactions with the Fynes.^{Footnote 2678} As noted by Mr. Fynes during his testimony, there was a mention of a policy requiring the retention of evidence in the event of an appeal in one of the written responses provided to the Fynes by the CF in 2011.^{Footnote 2679} The reference was included in the response about the reasons for not returning the exhibits seized at the end of the investigation – which technically would include the suicide note – but not in the response specifically related to the failure to disclose the suicide note.^{Footnote 2680}

178. While it does not appear there was any direct reference to the possibility of appeals to justify the failure to disclose Cpl Langridge’s suicide note, it is clear many of the explanations that were provided to the Fynes were not entirely accurate, and some of them did appear focused on justifying at least some of the actions taken by the CFNIS members with respect to the suicide note. As a result, it is not surprising the Fynes were left with the general impression there was more justification than regret being expressed by the CFNIS. The CFNIS’ failure to provide a formal apology to the Fynes immediately upon discovering the issue also did not help.

179. In light of what had happened, the Fynes should have received a more formal and timely apology. First, the CFNIS should have made inquiries to verify whether the note had been provided to the family as soon as they were contacted by the BOI in early 2009. Immediately upon learning the note had not been disclosed, an official apology should have been provided to the Fynes by the CFPM or his delegate or by the CO for the CFNIS. The CFNIS should have also offered immediately to deliver the original suicide note to the Fynes personally. Finally, immediate measures should have been taken to find out exactly what happened and to provide the necessary explanations to the Fynes. This should have received at least as much attention as was given to the public relations aspect of the matter.

Revising Policies and Procedures

180. In all of the statements prepared for the public, and most of its communications with the Fynes, the CFNIS has consistently maintained that policies and procedures were revised to ensure the failure to disclose the suicide note never happens again. Yet, the evidence heard before this Commission reveals there was no clear and consistent understanding within the CFNIS about what the policies and procedures applicable at the time were, and whether they would have precluded (or required) the disclosure of Cpl Langridge’s suicide note. Nor could clear and consistent answers be obtained about exactly what were the revised procedures.

Media Response Lines and Statements

181. All of the MRLs prepared by the CFNIS and other organizations within the CF about the suicide note contained a statement indicating policies or procedures had been changed as a result of the failure to disclose Cpl Langridge’s suicide note.

182. In the first MRLs prepared by LFWA after the issue came to light, the following statement was included:

A prior policy dictated that all evidence in an investigation could only be released to the family of the deceased after severance under the Access to Information Act. This policy has been changed and a copy of the suicide note was provided to the family.^{Footnote 2681} [Emphasis added]

183. The corrected version of the MRL prepared by the CFNIS PAO contained similar statements, with more detail.^{Footnote 2682} The Background section indicated:

The CFNIS had gathered the note as evidence and initially could not release it, in accordance with the policies in effect, which prohibited the informal release of such information to family members without going through Access to Information. Recently, in consultation with Director of Information and Privacy, the family including secondary next-of-kin may request content of CFNIS investigations through their Assisting Officer. Although the documents still have to be severed under Access to Information and Privacy Acts, there is no longer a requirement for the family to staff official request under Access to Information/Privacy Act.^{Footnote 2683} [Emphasis added]

184. In the Questions and Answers section, the following statement was included:

At the time of the investigation, policy dictated that all evidence in an investigation could only be released to the family of the deceased through the Access to Information Act.^{Footnote 2684} [Emphasis added]

185. Approximately two weeks later, the MRLs were modified at LCol Sansterre’s request.^{Footnote 2685} The explanation about the policies applicable was different, but the statement indicating the policies had been changed remained. The relevant portions of the Background section of the LFWA MRLs now read:

The CFNIS had gathered the note as evidence and unfortunately initially did not release a copy of it to the family. The CFNIS has revised its procedures to ensure such a situation does not happen again.^{Footnote 2686} [Emphasis added]

186. Access to information policies were discussed separately, in connection with statements about the procedures for access to CFNIS investigation reports, but not in connection with the disclosure of the suicide note.^{Footnote 2687} In the Questions and Answers section, the following information was added:

Q1. Why did it take 14 months for Cpl Langridge’s family to receive a copy of his suicide note?

A1. The CFNIS had gathered the note as evidence and unfortunately initially did not release a copy of it to the family. The CFNIS has since revised its procedures to ensure such a situation does not happen again. A copy of the note should have been provided to the family right away, with the original released to them after the completion of the investigation. The CFNIS regrets the situation and has revised its procedures to ensure that it does not happen again.

The primary concern of the CFNIS investigators is to assist the victims (in the case of a CF member’s death, the family) while preserving the integrity of the investigation.^{Footnote 2688} [Emphasis added]

187. In the CFNIS-specific MRLs updated at the same time,^{Footnote 2689} the same lines were included, and one of the “Key Messages” was:

The CFNIS has revised their procedures with respect to the release of such documents as suicide notes to ensure this type of situation does not happen again.^{Footnote 2690} [Emphasis added]

188. The CFNIS MRLs also provided additional content:

If pressed on usual procedure with regards to suicide notes

A copy of the suicide note should be provided to the family [at] the earliest opportunity, unless this could compromise the integrity of the investigation. The primary concern of the CFNIS investigators is to assist the victims (in the case of CF member’s death, the family) while preserving the integrity of the investigation.^{Footnote 2691}

189. The message about the CFNIS having revised its procedures to ensure this situation did not happen again was included in all subsequent CFNIS and CF MRLs.^{Footnote 2692} It was repeated every time the CFNIS spoke to the media and was quoted in the articles published about the issue.^{Footnote 2693} In October 2010, it formed part of the public statement issued by the CDS about the case.^{Footnote 2694} The relevant portion, which had been previously approved by the CFPM, read:

Furthermore, the Canadian Forces Provost Marshal deeply regrets the delay in releasing Cpl Langridge’s suicide note, and the Canadian Forces National Investigation Service has since revised its procedures to ensure a situation such as this does not happen again.^{Footnote 2695} [Emphasis added]

190. When this Commission launched its public interest investigation into this matter in May 2011, the message was again included in the updated MRLs created at the time.^{Footnote 2696}

191. The CFNIS and its members also made statements about the revision of policies or procedures in other contexts. When Maj Dandurand met with the Fynes in November 2009, he indicated processes, policies and procedures had been changed:

MAJ DANDURAND: [...] There's one area that you mentioned, right off the bat, and we haven't addressed it yet; the suicide note. Okay?

Suicide note -- Sheila, you said in your interview with Matt, Matt Ritgo [sic] that if anything, what you would hope for, is that --

MRS. FYNES: Some change.

MAJ DANDURAND: Some change.

MR. FYNES: Something good to come from this.

MRS. FYNES: Yes.

MAJ DANDURAND: I hope -- I really do hope that you are able to draw some satisfaction from this, that there has been change as a result of this. And I'll describe these changes to you. First off, we, at the time, had a policy where we just -- we don't divulge all of these notes...^{Footnote 2697} [Emphasis added]

192. During a subsequent meeting held in March 2010, Maj Dandurand told the Fynes all the CFNIS could do about the failure to disclose their son’s suicide note was to “make it right for the future, and we have.”^{Footnote 2698} He stated:

I cannot even come to describe the amount of discussion that occurred surrounding this with respect to right.
What is the next policy move on this? And now we have it.^{Footnote 2699} [Emphasis added]

193. In January 2011, the following information was provided to the Fynes by the CFNIS (through Col Gerard Blais) in response to their question about the failure to disclose their son’s suicide note:

While the letter should have been provided to the family (ie: executor of the estate) at the conclusion of the investigation, following a review of the evidence held, it would have only been released when it was deemed to have no bearing on the investigation (ie: ruling out of foul play or relevance of the note in this regard). [...]

Clearly, the release of such a note 14 months following the death is not normal practice and the CFNIS has formally apologized to the family for this omission. They have also explained that this occurrence has led to the revision and “tightening” of the Standing Operating Procedure associated with this topic. The likelihood of this recurring is even more remote.^{Footnote 2700} [Emphasis added]

How and When Were the Procedures Revised?

194. LCol Sansterre testified one of the first steps he took upon learning of the failure to disclose Cpl Langridge’s suicide note was to direct a CFNIS Standard Operation Procedure (SOP) on sudden death investigations and interactions with family be drafted.^{Footnote 2701} Previously, the CFNIS had no SOP on these topics.^{Footnote 2702} According to LCol Sansterre, the drafting of the SOP would assist in determining the appropriate time for advising families about the existence of suicide notes. He testified:

That's why the SOP was being drafted. When is the best time, and initially, when you initially have a meeting with the family, what type of information do you provide? That goal was get the best practices and detail this SOP.^{Footnote 2703} [Emphasis added]

195. LCol Sansterre tasked the OC for Atlantic Region (OC AR) with the drafting of the SOP in early June 2009.^{Footnote 2704} He was to begin work immediately on gathering information about best practices in other police forces and CFNIS Detachments and preparing the SOP.^{Footnote 2705} On June 22, 2009, he requested input from his colleagues in other Detachments about past experiences and best practices for the conduct of family briefings.^{Footnote 2706} On August 4, 2009, he provided an update and advised a draft would be ready within two weeks.^{Footnote 2707} In November 2009, he made a presentation about the issues involved to members of the HQ and Detachments chain of command, but was still working on a draft of the SOP to be sent to CFNIS HQ.^{Footnote 2708} In early 2010, the draft SOP was still not completed. Sgt Scott Shannon, who worked in the AR at the time, was asked to provide comments and assist with the drafting of an Annex specifically related to family briefings.^{Footnote 2709} In April 2010, a revised draft of the SOP was provided to the CFNIS DCO.^{Footnote 2710} The SOP was only finalized in October 2010.^{Footnote 2711} By then, more than a year had passed since the discovery of the failure to disclose Cpl Langridge’s suicide note.

196. LCol Sansterre testified he was not concerned about the delay in finalizing the SOP, considering the other matters the OC AR had to attend to and the amount of work required to prepare this SOP.^{Footnote 2712} The evidence before this Commission indicates the process for drafting an SOP can be lengthy and complex, generally involving research about best practices, legal review and translation.^{Footnote 2713} According to LCol Delaney, who replaced LCol Sansterre as the CFNIS CO in April 2011,^{Footnote 2714} the time it takes will depend on a number of factors, including the workload of the members involved and the level of priority for the issue.^{Footnote 2715} In this case, several drafts were prepared, discussed and circulated.^{Footnote 2716}

197. The final SOP promulgated in October 2010 was a comprehensive 55-page document which provided guidance about the conduct of sudden death investigations, the processing of death scenes, the collection of evidence, the conduct of neighbourhood canvass and witness interviews, the review of autopsy reports and the conduct of family briefings.^{Footnote 2717} A seven-page Annex specifically devoted to these briefings contained detailed lists of points to research, verify, prepare and discuss in meetings with families.^{Footnote 2718} However, there was no reference at all to the disclosure of suicide notes in the SOP or the Annex on family briefings.

198. Some of the points included in the SOP could have been viewed as having an impact on the disclosure of suicide notes. The list of points to be considered in preparing initial family briefings included “return of personal items at the conclusion of the investigation-if possible,” and the items to be covered in the final briefing included scene examination and evidence collected.^{Footnote 2719} There was also a general direction to ensure information released during the briefings was limited to “investigative processes and not investigative activity especially during ongoing investigations,” which meant the specifics of the investigation were not to be discussed.^{Footnote 2720} However, the witnesses who testified before this Commission were unanimous none of these points were meant to address the disclosure of suicide notes, as this topic was simply not covered in the SOP.^{Footnote 2721}

199. It was not until July 2011, over two years after the failure to disclose Cpl Langridge’s suicide note was discovered, that a specific reference to the disclosure of suicide notes was added to the SOP.^{Footnote 2722} At the time, Maj Bolduc explained an annual review of the SOPs was being conducted when the administrative officer, Capt David Dey, suggested it would be a good idea “to include the passage of a copy of notes from the deceased to the family (in cases determined to be suicide) in SOP 237.”^{Footnote 2723} Maj Bolduc agreed, particularly since he realized many of the members of the chain of command who had been aware of the issue with the suicide note in this case had moved on or were about to move to different positions.^{Footnote 2724} Maj Bolduc then immediately proceeded to draft a short paragraph, which was incorporated in the SOP before the end of the month.^{Footnote 2725} It read:

Any suicide notes found with a deceased person are seized as part of the criminal investigation into the sudden death. Upon conclusion of the investigation, the suicide note needs to be released to the next of kin (NOK). Furthermore, the NOK should be advised of the existence of any notes as soon as it is practicable to do so, and released to them or to whom it is addressed as soon as it is no longer required for the investigation.^{Footnote 2726} [Emphasis added]

200. Since the CFNIS had begun making public statements in June 2009 indicating it had already revised its procedures to ensure the failure to disclose the note did not happen again – and Maj Dandurand made similar statements to the Fynes beginning in November 2009 – the question arises: what revisions to CFNIS procedures were put in place between June 2009 and July 2011?

201. Both LCol Sansterre and LCol Delaney testified verbal directives by the CFNIS CO could be used to advise members of the procedures to follow or to cover any intervening period during the drafting or revising of SOPs.^{Footnote 2727} LCol Sansterre explained police procedures did not need to be written in order to be communicated to members and enforced.^{Footnote 2728}

202. LCol Delaney indicated, as a practical matter, verbal directives would generally be followed up or transmitted by an email “to ensure that the information gets out there in a timely manner,” particularly since the members are often on the road.^{Footnote 2729} He also testified he would want to capture the contents of any “explicit direction” he gave in a written message, particularly where the direction was “a deviation from what we’re doing currently,” was technical in nature, or was related to a particularly important issue.^{Footnote 2730} LCol Sansterre, for his part, testified many procedures were only communicated verbally to the investigators, in particular during training or case management discussions.^{Footnote 2731}

203. The CFNIS records contain no trace of any correspondence, instructions, directive, educational or training materials about the procedure to be followed for the disclosure of suicide notes between June 2009 and July 2011.^{Footnote 2732} However, LCol Sansterre, Maj Bolduc and Maj Dandurand all testified the issue was discussed extensively, and assured this Commission the members of the Detachments were advised about the problems having occurred in this case and the need to ensure this did not happen again, and were provided instructions about the procedure to follow in future cases.^{Footnote 2733} In particular, LCol Sansterre testified he addressed the issue in early June 2009 during an OC Conference involving senior personnel and Officers Commanding from CFNIS HQ and all the Detachments.^{Footnote 2734} He noted this was “very high on the agenda,” as he took the matter very seriously.^{Footnote 2735} He provided a directive, “effective immediately,” about the handling of suicide notes in future cases:

I directed that as soon as it was possible, that the family members at least know that it exists, and that they be given either a copy or the actual original as soon as it's possible to do that.^{Footnote 2736} [Emphasis added]

204. At the time, LCol Sansterre also told the members suicide notes needed to be released, and families advised, as soon as the notes were “no longer evidence.”^{Footnote 2737} He explained discussions then followed about the appropriate time for advising the family.^{Footnote 2738} LCol Sansterre’s own direction was to provide a copy of the note to the family “as soon as it was possible without jeopardizing the investigation.”^{Footnote 2739} However, he did not provide a specific direction about when to release the original or about when to advise the family about the existence of the note, because “every case is completely different.”^{Footnote 2740}

205. Maj Bolduc, for his part, while he recalled many discussions of the issue at HQ and during conference calls and conferences with the OCs, could not specifically recall whether the suicide note was discussed at the June 2009 Conference, nor whether there was a discussion at the Conference of the procedure to follow while awaiting the written SOP.^{Footnote 2741} He also had no specific recollection of the exact directive provided by LCol Sansterre about the handling of suicide notes.^{Footnote 2742} Maj Bolduc did recall discussions about assessing when to turn the note over, or how soon should “as soon as possible” be, once it was determined the note was no longer required for the investigation.^{Footnote 2743} He also recalled numerous discussions where the CO made it clear to all he did not want the failure to disclose the suicide note to happen again.^{Footnote 2744}

206. In testimony, LCol Sansterre explained, although he did not put it in writing, the directive he gave about disclosing suicide notes as soon as possible “would have become a procedure” from the moment the issue was discussed at the June 2009 OC Conference.^{Footnote 2745} He added the issue of the disclosure of suicide notes and the directive he gave continued to be discussed in most of the OC conference calls and other OC conferences during the following year.^{Footnote 2746}

207. LCol Sansterre explained he relied on the Detachment OCs to understand his instructions and pass them on to their subordinates in the Detachments.^{Footnote 2747} He did not have an expectation those who received his direction would commit it to writing, but thought records would be created in the minutes for the OC Conferences and conference calls, and added once the SOP was drafted, “it would be clear in the SOP.”^{Footnote 2748} As it turns out, the Minutes for the OC Conferences and conference calls contained general references to the drafting of the SOP on family briefings, but no references to the disclosure of suicide notes.^{Footnote 2749} And the SOP itself at first also did not mention the disclosure of suicide notes.

208. In testimony, Maj Bolduc explained he did not think it was necessary to have the procedures to be followed for the disclosure of suicide notes put in writing while the SOP was being revised, or even to include them in the SOP, because the issue had been discussed “inside and out,” the chain of command had “answered the question,” the issue was fresh in everybody’s mind, the “lesson had already been stamped” and everyone “understood the message.”^{Footnote 2750} He indicated the paragraph he did add to the SOP in July 2011 was generally consistent with the direction already provided and understood by all.^{Footnote 2751} LCol Sansterre was also confident the message had been well understood, and had no concern about the lack of references to the disclosure of suicide notes in the 2010 SOP.^{Footnote 2752} He testified the new SOP was meant to address all aspects of “dealing with families” and was not “an SOP that was specific to suicide notes.”^{Footnote 2753} He explained:

Well, I mean, the SOP itself was not focused on suicide notes. The SOP was focused on sudden death and dealing with families or victims of sudden death. The fact that it wasn't mentioned in here doesn't mean that we didn't pay particular attention to whether there was suicide notes or not.

I see "Return of personal items at the conclusion of investigation." We could have listed it there. Personal items included the individual's watches, maybe, and other items. We could have listed a whole lot of items there, but that would become cumbersome. I know without a doubt that the OCs knew that personal items, personal property, would include any notes left by anybody.^{Footnote 2754}

209. At first glance, this is difficult to understand. It was as a direct result of the failure to disclose Cpl Langridge’s suicide note that the CFNIS CO and senior leadership ordered the drafting of an SOP to address the issue of family briefings.^{Footnote 2755} The drafting of this SOP was viewed as one of the measures taken to ensure the failure to disclose the note did not happen again.^{Footnote 2756} Yet, when the SOP adopted over a year later entirely failed to address the issue of the disclosure of suicide notes, the same members of the CFNIS senior leadership testified it was not necessary to address it in any event. To make sense of this, two points must be understood. First, previous policies or procedures were not viewed by the CFNIS chain of command as having caused the failure to disclose Cpl Langridge’s suicide note. Second, the case-by-case monitoring practised by the chain of command in the aftermath of the incident was viewed as the most important and effective measure taken to address the situation, making broad revisions of policy or procedures less pressing or necessary.

210. Despite the discussions about revising procedures, it is clear no one thought Cpl Langridge’s suicide note was withheld in this case because of the policies or procedures applicable at the time. While the CFNIS chain of command never did find out exactly what happened, no one believed there was any previous policy or procedure preventing the disclosure of the note for 14 months. LCol Sansterre and Maj Bolduc’s testimony was clear on this point. They both indicated the failure to disclose Cpl Langridge’s suicide note was a “mistake” made in the case and “not a mistake with the policies.”^{Footnote 2757} They also both repeatedly testified it was never a policy, practice or procedure “not to give a suicide note to a family.”^{Footnote 2758} As a result, LCol Sansterre explained this “wasn’t a practice that had to be changed. It was a situation that occurred.”^{Footnote 2759}

211. Only Maj Dandurand appeared to believe retaining the suicide note was in line with the policies or practices applicable at the time of the investigation.^{Footnote 2760} In testimony, he explained he initially thought the applicable policy or appropriate practice was to retain the note as evidence for a lengthy period after the investigation.^{Footnote 2761} For this reason, and based on his discussions with WO Ross during the conduct of the QA review, he was not convinced the Detachment had done “anything wrong” in this case, and was adamant disciplinary measures would have been “completely inappropriate,” because he thought there was nothing to suggest the investigators had gone “outside the norm” or wilfully failed to follow normal practices for the handling of evidence.^{Footnote 2762} However, Maj Dandurand’s understanding of the applicable policies and practices eventually changed, and he recognized the failure to release Cpl Langridge’s suicide note at an earlier time was a “mistake.”^{Footnote 2763} Even before he developed this new understanding about the release of the original note, it does appear he was always of the view the failure to disclose the existence of the note was a mistake. Early on, he had written to Col Hammond that he agreed the family “should have at least been told.”^{Footnote 2764}

212. In order to address what was perceived as the true problem – i.e., to ensure further mistakes were not made – the most important measure put in place was related to case management on a case-by-case basis. Having heard the discussions in the OC Conferences and conference calls about the CO’s displeasure with the failure to disclose Cpl Langridge’s suicide note and his clear direction this should not happen again, it was expected the Detachment OCs, MWOs and case managers would monitor the files closely and manage the cases in order to ensure the disclosure of suicide notes was not unnecessarily delayed.^{Footnote 2765} To ensure this was done, CFNIS HQ decided to get directly involved. LCol Sansterre, either directly or through Maj Bolduc, contacted the Detachment OC every time a new sudden death investigation was opened and asked whether a suicide note was found and what would be done about its disclosure.^{Footnote 2766} This practice continued until December 2011, for as long as Maj Bolduc remained the CFNIS DCO, even if LCol Sansterre had already moved on to a new position in April 2011.^{Footnote 2767} As a result, as LCol Sansterre explained, any CFNIS members tasked to investigate a suicide – whether or not they knew about the Langridge case, the directives issued by the CO or the SOP being drafted and later promulgated – would know about the importance of disclosing suicide notes because of the questions they would be receiving from their chain of command.^{Footnote 2768}

213. However, as ultimately recognized by Maj Bolduc himself when he added the passage about suicide notes in the SOP, the case monitoring alone could not address the issue permanently. Eventually, the individuals in charge would change, and might not be aware of the issue. Hence, it was necessary to set out the procedure to be followed and to disseminate the knowledge. Most importantly, whether the CFNIS was able to ensure suicide notes were disclosed at the appropriate time would in turn depend on its ability to determine when that was. The CFNIS would then have to ensure the members involved in deciding when to disclose suicide notes in particular cases – or those in charge of monitoring their actions – had a common understanding of how the appropriate time for disclosure should be determined. In this last respect, the evidence before this Commission has shown there were different – and at times inconsistent – views among the members of the CFNIS and its chain of command. It is not clear to what extent this changed after the failure to disclose Cpl Langridge’s suicide note was discovered.

What Were the Old Procedures?

214. The CFNIS members who testified before this Commission all agreed at the time when the investigation into Cpl Langridge’s death was conducted, there were no written policies or procedures specifically relating to the disclosure of suicide notes.^{Footnote 2769} There was a general MP policy about evidence handling, which required that evidence be kept “until it is no longer required and/or authority for its disposal has been received.”^{Footnote 2770} The policy set out various waiting periods prior to seeking authority to dispose of exhibits seized where court proceedings were involved, or where the owner of the items could not be identified, and also stated: “physical evidence collected in the course of an investigation and not used as exhibits at a subsequent trial need not be retained with the status of evidence.” ^{Footnote 2771}

215. While the CFNIS members who testified in this hearing were generally aware of this policy, their views on whether and how it would apply to suicide notes varied widely. Some thought the policy would always apply and suicide notes always had to be treated like other evidence,^{Footnote 2772} while others thought the policy would only apply under certain circumstances or for a certain period of time, such as if a suicide note “became evidence,” or while a crime was being investigated.^{Footnote 2773} One member commented because of the benefit of releasing them to the family, suicide notes did not necessarily have to be treated like other evidence.^{Footnote 2774} Where the policy was thought to apply – or to apply for a certain period of time – the members had different views about when the note had to be released. Some thought it was at the end of the investigation or once it was decided not to proceed with charges,^{Footnote 2775} while others thought it was at various earlier points, including: when the note “went from being evidence to being information,”^{Footnote 2776} when the information received made it clear the death was a suicide,^{Footnote 2777} when it was determined the note was no longer relevant or necessary for the investigation,^{Footnote 2778} when foul play was ruled out,^{Footnote 2779} or when the note no longer had evidentiary value in relation to indications of foul play.^{Footnote 2780}

216. Aside from their views about the applicability of the evidence policies to decisions about the release of original suicide notes, the members also had different understandings about what the practice or procedure was for determining when to disclose the existence and contents of the notes. LCol Garrick, the CFNIS CO at the time, thought the existence of the note would be disclosed “immediately.”^{Footnote 2781} He thought the contents or copy of the note would also generally be disclosed “right away,” unless the information in the note was relevant to an ongoing investigation.^{Footnote 2782} He did not think the mere fact of not having received official confirmation of the cause of death would have been sufficient to withhold disclosure if the information in the note was not directly relevant to the investigation.^{Footnote 2783} MWO Watson, the Acting Detachment OC at the time, thought the existence and contents of the note could be disclosed within days of the death, even if the original was still being held as evidence.^{Footnote 2784} Maj Bolduc believed the practice was to disclose the existence and contents of suicide notes once it was determined the death was a suicide and the note was no longer necessary for the investigation.^{Footnote 2785} Maj Dandurand and Sgt Bigelow thought the appropriate time was when foul play had been ruled out.^{Footnote 2786} WO Tourout, for his part, testified based on “experience and training,” the appropriate procedure was to disclose the existence and contents of the suicide note only once a “positive determination” about the cause of death had been made.^{Footnote 2787}

217. In their testimony, LCol Sansterre and Maj Bolduc both insisted the determination of the appropriate time to disclose or release suicide notes always depended on the particular circumstances of the case, on the experience of the investigators and case managers and on their view of the relevance of the note to the investigation.^{Footnote 2788}

218. Some of the discrepancies in the members’ views appeared to be related to their understanding of what would be required in order to “rule out foul play.” In their closing submissions, counsel for the subjects of the complaint maintain the CFNIS policy in 2008 “directed foul play could not be ruled out until the ME report was received.”^{Footnote 2789} The Commission has found no documentary evidence or testimony confirming such a policy existed. Based on their testimony, it does appear at least MCpl Ritco and WO Tourout believed foul play was only ruled out in this case at the very end of the investigation.^{Footnote 2790} However, nothing indicates this was because of any policy in existence at the time.

What Were the New Procedures?

219. The 2011 SOP provided the existence of suicide notes was to be disclosed “as soon as it is practicable to do so,” and the notes were to be released “as soon as [they were] no longer required for the investigation” or “upon conclusion of the investigation.”^{Footnote 2791} Previously, LCol Sansterre had directed the disclosure be done “as soon as possible without jeopardizing the investigation.” ^{Footnote 2792} Maj Bolduc believed the language in the 2011 SOP reflected this same direction.^{Footnote 2793}

220. The views about the appropriate time for disclosing suicide notes continued to differ after these new procedures were put in place.

221. Maj Bolduc believed the procedure was to disclose the existence and contents of the note as soon as the possibility of a crime had been eliminated or once it was determined the death was a suicide and the note was no longer required for the investigation.^{Footnote 2794} He also indicated his understanding was the note was to be disclosed once all the circumstances surrounding it had been established and it was determined the disclosure could be done “without prejudicing the investigation.”^{Footnote 2795} According to him, it was always necessary to wait until foul play had been ruled out even before telling the family about the note in order “to protect the integrity of the ongoing criminal investigation.”^{Footnote 2796} In his view, a clear comment by the coroner at the scene indicating everything was consistent with suicide would not be sufficient to lead to the immediate release of the note, as it should only be released “when the investigator is satisfied that there was no foul play.”^{Footnote 2797} His views on when the original suicide note was to be released were less clear. He indicated the general MP policy on evidence handling could still apply where the note was viewed as evidence.^{Footnote 2798} He stated his intent in drafting the 2011 SOP paragraph was to provide for the original note to be returned at the end of the investigation, but also said once foul play was ruled out, it was possible it could be released soon after or at the same time as the family was advised about the note.^{Footnote 2799}

222. Maj Dandurand still believed the appropriate time to disclose the note and to release the original was when foul play was ruled out, which in his view required receiving at least informal or preliminary reports from the Coroner’s office about the cause of death.^{Footnote 2800} He thought disclosure would not occur immediately upon finding the note, but could take place “within a few weeks of the investigation commencing,” provided foul play – or the involvement or significance of the note in this respect – was ruled out.^{Footnote 2801}

223. MS McLaughlin thought the procedure was not to disclose notes when foul play was suspected.^{Footnote 2802} Where there was no suspicion, he thought the note could be disclosed early on, without having to wait for the ME report confirming the cause of death.^{Footnote 2803} He also thought, even where there was suspicion, the determination would mostly depend on whether the disclosure would benefit or hinder the investigation.^{Footnote 2804}

224. MCpl Ritco believed that, pursuant to the new procedures, the suicide note had to be disclosed once it was not deemed a “major piece of evidence” or once it was “no longer required” for the investigation.^{Footnote 2805} He believed as long as the possibility of foul play was not ruled out, revealing the existence of a suicide note could pose a risk to the investigation.^{Footnote 2806}

225. LCol Sansterre thought the note would be disclosed when it was no longer necessary for the investigation, which he believed would generally be when there was “no suspicion” the note was written by anybody else.^{Footnote 2807} He indicated, where there was no suspicion a crime had been committed following a thorough examination of the scene in consultation with the ME, the existence and contents of the note should be disclosed immediately.^{Footnote 2808} However, in his view, there should be no disclosure “if there is any doubt, any little bit of suspicion.”^{Footnote 2809}

226. LCol Delaney, who was the CFNIS CO for over a year after the new procedure was put in place, testified the practice was to advise the family about the note and provide a copy “very quickly.”^{Footnote 2810} He indicated this was generally done before the end of the investigation, while the original note was often retained until the conclusion of the file.^{Footnote 2811} He also explained, if the case was “a classic suicide,” the original could be released sooner, but would not be released right away if foul play was suspected.^{Footnote 2812} LCol Frei, who became the CFNIS CO in 2012, thought the proper timing for disclosing the existence and contents of the note would depend on a number of factors, including the contents of the note, the circumstances of the death, whether the note could have evidentiary value and whether its authenticity needed to be investigated.^{Footnote 2813} He thought the note would be disclosed earlier where it had no evidentiary content, and believed the intent of the new procedure was to allow for the disclosure to take place before the ME report was received where there was otherwise no suspicion about the circumstances of the death or the authenticity of the note.^{Footnote 2814} In his view, the determinations about when to disclose the existence and contents and when to release the original note were completely separate.^{Footnote 2815}

227. As they had done when discussing the previous practices or procedures, LCol Sansterre and Maj Bolduc both repeatedly insisted the determination of the appropriate time to disclose the note under the new procedures would be very case-specific.^{Footnote 2816} Ultimately, it would be for the investigators and their case managers, based on their experience, to determine when the best time was in each case, with oversight by the chain of command and the understanding strong justification would have to be provided for any decision to delay disclosure.^{Footnote 2817} Maj Bolduc could not provide an estimate of the time it would take for the CFNIS to disclose suicide notes under the new procedures, because the variations were too great.^{Footnote 2818} He insisted there could be no “magic formula” and no fixed timelines, as too narrow a directive would “put obstacles in the way of the investigator’s work” and would prejudice the investigation.^{Footnote 2819} LCol Frei agreed entirely the determination would be “very case specific.”^{Footnote 2820} He thought it would involve the entire investigative team and likely the CO himself as well.^{Footnote 2821}

228. In the end, no clear definition of the terms “as soon as it is practicable” or “as soon as possible” could be provided.^{Footnote 2822} Different members had different – and at times inconsistent – understandings of what was provided for in the “new” procedure.^{Footnote 2823}

What Changed?

229. In light of this evidence, a question arises as to what substantive change, if any, was made when the CFNIS procedures were “revised.” Both before and after the revision, the CFNIS members agreed the appropriate time for disclosing suicide notes depended on the circumstances of each case and disagreed or had different and inconsistent views about how the determination was to be made.

230. In most cases, the individual members’ views about what criteria had to be used to determine when to disclose suicide notes under the old procedures and the new procedures were the same. The revision did not appear to change their opinion about how the appropriate time for disclosure was to be determined. Maj Bolduc thought the appropriate time under the new procedures was once it was determined the death was a suicide and the note was no longer required for the investigation and testified “that was also my understanding of the policies we had before.”^{Footnote 2824} Maj Dandurand thought the appropriate time to disclose the note under both the old and the new procedures was when foul play was ruled out.^{Footnote 2825} In this respect, he testified the old policy was “exactly the same as the new policy.”^{Footnote 2826}

231. LCol Garrick testified the 2011 SOP was not a departure from the practice he would have expected to be followed when he was the CFNIS CO in 2008.^{Footnote 2827} LCol Sansterre thought the SOP itself was a “new policy” because there was never a written policy on this topic before.^{Footnote 2828} However, he testified:

Would the procedures be different? I don't think so. I think the procedures are what we are detailing now. I don't know of any other suicides where we withheld the note for that long a period of time without advising so.^{Footnote 2829} [Emphasis added]

232. Maj Dandurand believed what changed was not so much the actual procedures but “the way in which we apply it.”^{Footnote 2830} He also indicated having a written SOP was a new development, and added the CFNIS’ understanding of the process for seizing and disposing of evidence had “evolved.”^{Footnote 2831}

233. Maj Bolduc, for his part, explained the main difference was the CFNIS had not previously had this experience with failing to disclose a suicide note.^{Footnote 2832} Now that this had happened, the lesson was passed on that there had been a mistake and this should not happen again.^{Footnote 2833}

Were the Statements Made about the Procedures Accurate?

234. The statement most often made by the CFNIS after the failure to disclose Cpl Langridge’s suicide note was discovered – and included in the CDS’ public statement on the issue – indicated the CFNIS “has revised its procedures to ensure such a situation does not happen again.”^{Footnote 2834} LCol Sansterre testified he was “extremely” and “absolutely” satisfied “this was a true and accurate statement.”^{Footnote 2835} He explained:

I brought it up at every one of those conferences, and that's why I brought these documents with me. There is a perception that there are people that are lying, whether the CDS or myself, and I take that very seriously. That's why I came here today outside of my testimony later to say that's not the case.^{Footnote 2836} [Emphasis added]

235. As the evidence in these proceedings has shown, the substantive understanding of the CFNIS members about the “procedures” for disclosing suicide notes had not really changed, and no new written procedure existed until over two years after the failure to disclose the note was discovered. However, on the basis of the evidence, it is also clear LCol Sansterre and the CFNIS chain of command did believe they had revised the procedures when the public statements were made.

236. In testimony, LCol Sansterre, Maj Bolduc and Maj Dandurand explained the statements about the procedures having been revised were meant to refer to the discussions about the issue and the “practical procedure” or “best practice” reflected in the direction provided by the CO at the time, rather than to any written policies or procedures.^{Footnote 2837} There is no doubt the issue was discussed extensively and the CO made it clear to all he did not want this failure to happen again. Most importantly, as LCol Sansterre testified, in practice, “the procedures were changed from the moment that we knew,” because from this moment on, in every case, the CO got personally involved to ask about suicide notes and their disclosure.^{Footnote 2838} This monitoring by HQ, more than the SOP development and any directives or discussions about the appropriate time for disclosure, was what the chain of command viewed as the revision of the procedures. It was the method they chose to ensure the failure to disclose the note would not happen again, and it was the reason they did not see the need to include a specific mention of suicide notes in the first version of the SOP.

237. Further, as explained by LCol Sansterre, although there was not necessarily a change in the substance of the procedures for determining the appropriate time to disclose suicide notes – or even a perception such a change was needed – there certainly was an “emphasis” on making sure the notes were disclosed as soon as possible and this was viewed as the revision of the procedures.^{Footnote 2839} As a result, the Commission finds there was no dishonesty in the public statements made by the CFNIS about revising their procedures.

238. Similarly, although they could have been clearer on this point, the MRLs were not meant to imply the failure to disclose Cpl Langridge’s suicide note had resulted from a problem with the policies rather than from a mistake. While they did not state this directly, LCol Sansterre testified the message the MRLs “very subtly” conveyed when stating the CFNIS had “unfortunately” initially not disclosed the note was that this failure had been the result of a mistake.^{Footnote 2840} The PAOs did understand this message, and both the LFWA and the CFNIS PAOs transmitted it to the media during interviews.^{Footnote 2841}

239. However, there were other statements included in the MRLs and made to the Fynes that created confusion and failed to convey a complete and accurate picture of the situation.

240. First, the statements in the initial versions of the MRLs about access to information policies having prevented the release of the suicide note were clearly not accurate and not related to the facts of this case.^{Footnote 2842} LCol Sansterre, Maj Bolduc and Maj Dandurand all recognized these statements were the result of confusion about the relevant policy area and were “blend[ing] together several issues” and “mixing apples and oranges.”^{Footnote 2843} At the time, Maj Bolduc had expressed doubts about their accuracy and had asked they be verified.^{Footnote 2844} LCol Sansterre had also inquired about the issue.^{Footnote 2845} In the end, the information was not provided to the media because a new version of the MRLs was created at LCol Sansterre’s request before the first interview with the media took place.^{Footnote 2846}

241. The statement indicating a copy of the note should have been provided to the family “right away”, which was delivered to the media and published,^{Footnote 2847} is more problematic. While it was in line with what some of the CFNIS members thought should have been done, it did not represent any consensus within the CFNIS about what would or should be done with suicide notes and hence, would not have been a fair representation of what members of the public could legitimately expect the CFNIS to do in the future. In particular, it was not consistent with the views of the members of the chain of command at the time – LCol Sansterre, Maj Bolduc and Maj Dandurand – who were consulted when the MRL was prepared.^{Footnote 2848}

242. In testimony, LCol Sansterre noted instead of the words “right away”, it would have been preferable to say, “as soon as we determine that it wouldn’t jeopardize the outcome of the investigation.”^{Footnote 2849} He added, in reality, each time a suicide note was seized by the CFNIS, there were discussions and at times debates “on when is the ‘right away’.”^{Footnote 2850} Maj Dandurand explained his perspective:

[R]ight away does not, in my mind, necessarily mean upon receipt of the note It's immediately, without delay, transferred to the person to which it's addressed or to the executor of the estate.^{Footnote 2851} [Emphasis added]

243. Instead, Maj Dandurand thought “right away” would mean “within a few weeks of the investigation commencing, provided that foul play has been ruled out.”^{Footnote 2852}

244. Maj Bolduc thought “right away” would be “when it is possible to do it and it will not have an impact on the integrity of the investigation.”^{Footnote 2853} He explained the term “right away” was “really the media response, not that was managed but it was at that point, the person who wrote that line thinking it was the thing to do.”^{Footnote 2854} He did not think the words fully or accurately reflected the direction provided by the CO or the procedures to be followed.^{Footnote 2855}

245. The language used by Maj Dandurand during his November 2009 meeting with the Fynes also did not present an entirely accurate picture. While his assertion indicating the CFNIS used to have a policy not to divulge suicide notes^{Footnote 2856} was likely the result of his own initial erroneous perceptions about the evidence handling policies applicable, it left the Fynes with the impression the failure to disclose their son’s suicide note was not viewed as a mistake but rather as appropriate behaviour under the policies then in place.^{Footnote 2857} It also created confusion and further undermined the Fynes’ already shattered confidence in the CFNIS. Mr. Fynes testified:

[W]hen I hear a suggestion that there was a policy not to divulge suicide notes I get an absolute chill that other families may have never been told that their loved ones left a note for them if that was indeed a practice within the NIS.^{Footnote 2858}

246. Finally, the response provided through Col Blais in January 2011 was also not ideal. Its description of what should have been done – releasing the note at the end of the investigation or when foul play or the note’s relevance was ruled out – was not clear as to exactly when it was believed the note should have been disclosed.^{Footnote 2859} The lack of consensus within the CFNIS on this point also meant the response would not necessarily be accurate, depending on who was asked to make the determination. More importantly, the response stated the failure to disclose Cpl Langridge’s suicide note had led to the “revision and ‘tightening’ of the [SOP] associated with this topic.”^{Footnote 2860} However, whatever other revision of the procedures may have taken place, it is clear there was no SOP in January 2011 about the disclosure of suicide notes that had been revised or tightened.

247. In testimony, Maj Dandurand indicated he thought the SOP may have been in the process of “being drafted” when this response was provided.^{Footnote 2861} However, the evidence has shown it was not until July 2011 that the SOP paragraph about the disclosure of suicide notes was drafted. In January 2011, there was no plan to add a reference to the SOP then in force.

Were the Measures Taken Sufficient?

248. When the failure to disclose Cpl Langridge’s suicide note was discovered, significant amounts of time, energy and resources were invested in preparing the CFNIS and the CF’s public response. Hundreds of pages of correspondence and numerous drafts of MRLs were created. Meanwhile, not a single piece of paper or even one electronic communication appears to have been created about the appropriate procedure to follow for the disclosure of suicide notes until a single paragraph was added to the SOP over two years later. Even then, it was done almost as an afterthought, when a suggestion was received from an administrative officer. Previously, the only written document discussing the issue of the failure to disclose Cpl Langridge’s suicide note outside the context of the media response or responses to the Fynes was the QA report about the 2008 investigation.

249. There is no doubt extensive discussions about the issue did take place within the CFNIS chain of command, and the CO became personally involved in monitoring actual cases. However, many issues were left unaddressed.

250. In their testimony, LCol Sansterre and Maj Bolduc made it clear significant reliance would be placed on the experience and assessments of the investigators and case managers with first-hand knowledge of the case when making the determination about the appropriate time to disclose the note.^{Footnote 2862} Indeed, no amount of monitoring by the chain of command could be sufficient if the investigators on the ground did not report the issue in a timely manner and provide the information and preliminary assessments necessary to make the determination. In order to do this, the investigators needed to be aware of the nature and importance of the issue and to have at least some understanding of the factors relevant to making the determination. Yet, very limited steps were taken in this case to make the investigators on whose information these important determinations would ultimately be based aware of the issue and the different considerations at stake.

251. While most of the CFNIS members who testified in this hearing were aware there had been issues with the disclosure of a suicide note in this case,^{Footnote 2863} and were aware of the revised SOP ultimately developed in 2011,^{Footnote 2864} many did not recall being advised about any new directives on this issue before the finalized SOP was circulated.^{Footnote 2865} Some had not even seen the 2011 SOP prior to these proceedings, although they had received instructions in specific cases.^{Footnote 2866} Even Sgt Shannon, who participated in drafting the initial 2010 SOP, was not aware the failure to disclose Cpl Langridge’s suicide note had been an important part of the impetus to elaborate the SOP in the first place, and had no knowledge about the applicable CFNIS procedures for the disclosure of suicide notes.^{Footnote 2867}

252. Meanwhile, the CFNIS chain of command had ordered a QA analysis of the investigation in order to begin addressing the issue. The report did not reveal what actually caused the failure to disclose the note in this case, but it did discuss the issue. It provided views about when the note should have been disclosed in this case and it highlighted the need to make “a cognizant and informed decision” about the disclosure of suicide notes.^{Footnote 2868} In testimony, LCol Sansterre, Maj Bolduc and Maj Dandurand explained the QA report and its recommendations formed part of the discussions held within CFNIS leadership about developing procedures on the disclosure of suicide notes for the future.^{Footnote 2869} They also explained the report could be used to communicate “lessons learned” to the CFNIS members and Detachments.^{Footnote 2870} Indeed, while the views it contained about the appropriate time for disclosure did not necessarily correspond to the views ultimately adopted by all members of the chain of command,^{Footnote 2871} circulating the brief report throughout the organization would have been a convenient way to ensure all members were aware there had been an issue, and knew the procedures were being examined by the chain of command.

253. However, the extent to which the report was circulated is not clear. Most of the members involved in the investigation had never seen the report prior to these proceedings and were not aware of the recommendations it contained.^{Footnote 2872} LCol Sansterre recalled the HQ CWO, who was responsible for coordinating with Detachment MWOs, was aware of the report, but neither he nor Maj Bolduc could confirm whether the report was circulated to the Detachments^{Footnote 2873} Maj Dandurand, for his part, believed within his Detachment, any “lessons learned” from the report were communicated to investigators verbally, through periodic meetings at the Detachment, as well as by ensuring case managers had received the report.^{Footnote 2874}

254. In a section entitled “Action Taken to Rectify Procedural Problems Discovered,” the QA report stated:

Resultant of the complaint brought forward by the family of Cpl LANGRIDGE [with respect to] the delay in disclosure of the suicide note; the CFNIS WR Chain of Command has become extremely cognizant of the issue of disclosure of any suicide notes left by the deceased at the scene. Additionally, in depth analysis/discussions have occurred regarding best practices concerning the requirement to engage families of the deceased members in concert with the respective AOs and have in fact ensured that a more proactive approach is being taken [with respect to] ongoing files being investigated by CFNIS WR.

In addition to the foregoing, a full debrief of the [subject] QA shall be incorporated in a Professional Development day for all investigators and Case Manager (TTBD). In the interim more stringent monitoring/case managing concerning these types of issues have/will be implemented. Finally, CFNIS WR is anxiously awaiting the proposed new Victim Services Annex, currently being drafted, which upon receipt will be disseminated by means of a PD session.^{Footnote 2875} [Emphasis added]

255. LCol Sansterre testified he had “no doubt that if [WO Ross] wrote it in his recommendations, that training day took place.”^{Footnote 2876} However, Maj Dandurand testified there were no PD days devoted to the report or to the new policy directives for the handling of suicide notes.^{Footnote 2877}

256. There is also no indication the issue of the disclosure of suicide notes was incorporated into any training materials for new or existing members. For the period between 2009 and 2011, the CFNIS records were searched, and no educational or training materials discussing the issue were located.^{Footnote 2878} The only reference to the issue was found in a presentation Maj Bolduc made to new members of the CFNIS in September 2009.^{Footnote 2879} However, it does not appear the substantive issues were discussed. In testimony, Maj Bolduc recalled he used Cpl Langridge’s case – along with other cases “where we got very bad media coverage about things we had done or things we were said to have made mistakes” – as an example of why it was important to have Quality Assurance programs and to “make sure we do our job properly.”^{Footnote 2880} He spoke about the media coverage surrounding the failure to disclose the suicide note to convey the message “be sure that if we make mistakes, that is going to make the news a little bit more…” and “there are consequences for everything we do. And we are accountable in all the cases we investigate.”^{Footnote 2881}

257. In addition to the insufficient steps taken to make members aware of the issues, it is clear the discussions held also failed to produce the necessary common understanding – even among the members who were aware of them – about the appropriate criteria to use for determining when to disclose suicide notes and about how these criteria should be applied to specific cases. As a result, when they testified before this Commission over three years after the failure to disclose Cpl Langridge’s suicide note was discovered, the members of the CFNIS and its chain of command still had different understandings. If they had to make a determination as of the date of this hearing about when to disclose a suicide note, it is clear they would not all come to the same answer.

258. Further, even the issues the CFNIS witnesses themselves identified during this hearing as still needing to be addressed were not promptly addressed.

259. During his testimony in June 2012, Maj Bolduc explained the paragraph added to the SOP in 2011 might need to be further revised during the July 2012 annual SOP review because it was not entirely clear about who the suicide note should be provided to.^{Footnote 2882} In the initial discussions, LCol Sansterre had directed the note be provided to the NOK, as determined through CF administrative processes.^{Footnote 2883} Initially, the CFNIS advised the AO assigned to the family and waited until a determination was made about who should receive the note prior to providing it.^{Footnote 2884} Subsequently, the CFNIS provided the note directly to the estate, which Maj Bolduc thought was the most appropriate procedure.^{Footnote 2885} He noted that, as a result, there were discussions about the SOP paragraph – which refers to the NOK and the person to whom the note is addressed – and this aspect was being verified.^{Footnote 2886}

260. During his testimony in October 2012, LCol Frei noted other issues with the SOP. He explained it was being reviewed “yet again,” this time to provide for greater involvement of the ME or coroner in discussions, to be held on a case-by-case basis, about “how and when” to disclose the contents of suicide notes to family.^{Footnote 2887}

261. Yet, in July 2013, the SOP had still not been revised and it remained exactly as updated in July 2011.^{Footnote 2888} Considering how long it took to create the SOP and add the paragraph about suicide notes in the first place, this is not entirely surprising.

What Should Have Happened?

262. As could be expected, considering the different views they expressed about the procedures to be followed for the disclosure of suicide notes generally, the CFNIS witnesses who testified before this Commission also had different views about when Cpl Langridge’s suicide note should have been disclosed to his parents. As recognized by counsel for the subjects of the complaint, there was “considerable debate” amongst the CFNIS members about when the note could reasonably have been disclosed.^{Footnote 2889}

263. Some thought the disclosure could have been done at a very early point. LCol Garrick testified he was not aware of any reason in this case preventing the investigators from being able to advise the family about the note right away.^{Footnote 2890} MWO Watson was of the view a copy of the note should have been provided to the family in the early days, before the funeral was held (March 26, 2008), and the original should have been returned at the end of the investigation.^{Footnote 2891} LCol Sansterre also believed the family should have been made aware of both the existence and contents of the note before the funeral, although the original note might not have been released as quickly.^{Footnote 2892} He explained there was no reason not to disclose the note early on in this case, since the investigators had examined the scene in consultation with the ME and there was no suspicion a crime had been committed.^{Footnote 2893}

264. Others had more difficulty pinpointing an exact time. MCpl Ritco testified he believed revealing the existence of the note before foul play was ruled out could have compromised the investigation, and indicated he did not think foul play could be ruled out until he concluded his investigation (end of May 2008).^{Footnote 2894} He stated, as long as foul play remained a possibility, it was also possible the note may have been forged.^{Footnote 2895} He testified:

Potentially, it could be he didn't write it. I'd feel really, really bad if -- and horrible if I had told the family, "Yeah, we found a suicide note, and this is what your son had said", only to find out my investigation had showed that it was foul play and somebody else had written that. Then, I have to go back to the family and say, "You know what, I made a mistake. It wasn't your son's writing. It wasn't your son's suicide note".

So I have to -- as a police officer, it's a judgement call.^{Footnote 2896}

265. However, MCpl Ritco also testified he did not think, in hindsight, it would have compromised anything in the investigation to tell the family about the contents of the note while advising them its authenticity had not yet been confirmed.^{Footnote 2897} In the end, he indicated he believed at least if the “new” procedures detailed in the 2011 SOP had applied, he should have disclosed the note to the Fynes and provided them a copy when he had his telephone conversations with them (May 5 and May 9, 2008), and should have released the original at the end of the investigation.^{Footnote 2898} He could not identify a specific point in time when the note became “no longer required,” but thought the combination of all the information he had learned by early May 2008 would have been sufficient to conclude the existence of the note could be disclosed to the family.^{Footnote 2899}

266. Sgt Bigelow, for his part, was initially of the view the appropriate time to disclose the suicide note would have been either when information was received from the ME indicating most tests had been performed and the death would likely be ruled a suicide (April 9, 2008) or once the final ME certificate was received (May 15, 2008).^{Footnote 2900} Upon further questioning, he indicated it may have been possible to have “some sort of communication to the next of kin” about the funeral wishes contained in the note earlier, particularly in light of the ME’s comments at the scene and the absence of any other indications of foul play.^{Footnote 2901} He did remain steadfast in insisting the aspects of the evidentiary value of the note and whether foul play was ruled out had to be resolved prior to disclosure.^{Footnote 2902}

267. Yet others did have a specific time in mind that would have come later in the investigation, after Cpl Langridge’s funeral was held on March 26, 2008. Maj Dandurand believed the appropriate time to disclose the note was once foul play was ruled out which required, in his view, obtaining some information from the ME.^{Footnote 2903} In this case, he believed April 9, 2008, when the preliminary information was received from the ME, would have been the appropriate time.^{Footnote 2904} Maj Dandurand testified that prior to this date, the possibility the suicide note may have been falsified and may not have contained Cpl Langridge’s true wishes was a realistic consideration.^{Footnote 2905} Likely referring to Cpl Langridge’s addiction issues, Maj Dandurand explained, considering Cpl Langridge’s history during the last year of his life, he would not have dismissed the possibility of an untoward situation being staged.^{Footnote 2906} However, he was unable to point to any evidence at all uncovered in this case, during the processing of the scene or after, indicating the death was anything other than a suicide.^{Footnote 2907} He was also unable to point to any steps taken by the investigators to rule out or investigate the possibility the death was staged or the suicide note forged.^{Footnote 2908} He did testify he would have fingerprinted the note and would have had a handwriting analysis done if he was conducting this investigation today.^{Footnote 2909}

268. Maj Bolduc was also of the view the “right way” to proceed in this case would have been to release the note when informal confirmation was received from the ME the death would be ruled a suicide (April 9, 2008).^{Footnote 2910} Similarly, in the QA report, WO Ross had expressed the view the existence and contents of the note should have been disclosed when the information was obtained from the ME (April 9, 2008), although he had added the receipt of the final ME certificate (May 15, 2008) would have also been an appropriate time.^{Footnote 2911} WO Tourout, for his part, believed the note could not have been revealed until the cause of death was determined.^{Footnote 2912} He explained the investigators had to keep an open mind until it was “proven 100 percent that it’s an actual suicide” and indicated receipt of the ME report (May 15, 2008) would provide confirmation and determine the cause of death.^{Footnote 2913}

269. Not surprisingly in light of the lack of agreement amongst the CFNIS witnesses, counsel for the subjects of the complaint take the position this Commission should not attempt to determine when Cpl Langridge’s suicide note should have been disclosed in this case. In their closing submissions, they indicate, “this is a dangerous exercise to undertake because it is done from the vantage of hindsight.”^{Footnote 2914} It should be noted if the CFNIS members cannot even agree after-the-fact – and on the basis of the most complete knowledge of the case – about when a suicide note should be disclosed, it is difficult to see how they will be able to come to the appropriate determination in ongoing cases where reliance must be placed on imperfect and incomplete knowledge.

270. On the basis of the evidence heard about what the CFNIS investigators knew at the time of the events, the Commission finds the existence and contents of Cpl Langridge’s suicide note should have been disclosed to his family within days if not hours of his death, and certainly before his funeral. In this case, there was simply no indication at all from the scene, the body, or any of the other information available to the investigators on March 15, 2008, giving rise to any suspicion the death was anything other than a suicide.^{Footnote 2915}

271. As immediately recognized by the ME investigator who attended at the scene, there were no signs of foul play.^{Footnote 2916} The information received by the CFNIS investigators during the hours and days that followed further confirmed what was already evident from the scene and the body, as it indicated clearly Cpl Langridge had repeatedly spoken about and attempted suicide during the previous weeks and months.^{Footnote 2917}

272. As pointed out by Mr. Fynes in testimony, the need to investigate or rule out foul play may have been an acceptable justification for not disclosing the note immediately if there had been “a legitimate concern that there was something other than a classic straightforward suicide.”^{Footnote 2918}

273. In this case, it is the Commission’s opinion there was no cause for such concern. The evidence gathered by March 19, 2008 overwhelmingly supported the conclusion Cpl Langridge had died as a result of suicide, and there were no contrary indications from any sources.^{Footnote 2919}

274. Further, the steps taken (or not taken) by the CFNIS members during the investigation were not consistent with the notion that foul play was being actively investigated or that the suicide note was seen as having any evidentiary value.^{Footnote 2920} No steps were taken to ascertain whether another person might have been present when Cpl Langridge died or whether the death may have been staged. Very few steps were taken to confirm whether the scene of the death had been disturbed prior to the arrival of the CFNIS, and similarly limited steps were taken to determine Cpl Langridge’s whereabouts during the days immediately preceding his death.^{Footnote 2921} After March 19, 2008, the investigative steps and witness interviews were not generally even related to the possibility of foul play, as the investigation then focused on the suicide watch issue.^{Footnote 2922} The suicide note itself was not used for any purpose during the investigation.

275. If the investigators had a real concern the note may not have been written by Cpl Langridge or the death may not have been a suicide – to the point where they felt the note could not be disclosed for these reasons – then they would have had to take immediate steps to have the note analysed to confirm its authenticity. Clearly, there were no such concerns in this case nor any reason for such concerns. To the extent they thought about it at all, the CFNIS members were simply keeping the original note “just in case” information would come to light later making it necessary to have it tested.

276. Since everything is almost always “possible,” the mere abstract possibility of unspecified information casting doubt about the cause of death or the authenticity of the note coming to light at a later time could not constitute an acceptable justification for not advising the Fynes about their son’s suicide note in this case. It may have been acceptable to retain the original note to ensure it was available for testing if new information came to light, but without concrete information indicating there was cause for suspicion, it was not acceptable to keep the Fynes in the dark about their son’s last communication.

Could This Happen Again?

277. It seems unlikely there will ever be another case where the CFNIS withholds a suicide note for 14 months. The accumulation of errors and the extreme inattention observed in this case are attributes of the type of situation that can happen only once. For the time being at least, there continues to be heightened awareness within the CFNIS about the importance of disclosing suicide notes, and there is an SOP paragraph directing disclosure as soon as possible and release of the original note at the end of the investigation, at the latest.^{Footnote 2923} However, the measures in place remain insufficient to prevent the recurrence of one of the most serious impacts endured by the Fynes: the inability to fulfill the funeral wishes their son had expressed in his suicide note.^{Footnote 2924}

278. As has been seen, the members and chain of command of the CFNIS do not share a universal view about when suicide notes should be disclosed and how the determination should be made. In their closing submissions, counsel for the subjects insist “All of the NIS witnesses agreed no policy could dictate the exact time when a note could be provided to the NOK and that this was ultimately [a] matter of investigatory discretion in each instance.”^{Footnote 2925} In the exercise of this “discretion,” it does not appear the CFNIS members have received any guidance about whether and how funeral wishes contained in the note should be taken into account. On the basis of the evidence before this Commission, there is cause for concern many CFNIS members would not disclose suicide notes in time to ensure funeral wishes were known before the funeral.

279. As with views about the procedures applicable before and after this case, the CFNIS witnesses’ views about the importance of making funeral wishes known varied.

280. In testimony, Maj Bolduc was steadfast in maintaining the note could never be disclosed before foul play was ruled out, regardless of the timing of the funeral and of any funeral wishes in the note.^{Footnote 2926} He indicated, “it is possible that it will happen quickly, but it is possible that it will take longer than people want.”^{Footnote 2927} He testified:

Puis je ne veux pas dire qu'on n'a pas de sentiments envers ce que la famille ressent, mais notre objectif c'est vraiment de trouver est-ce qu'il y a un crime qui a été commis, si oui, bien, il faut l'enquêter le crime. Mais si c'est un suicide, puis on détermine après les funérailles que c'était un suicide, c'est malheureux, mais je pense que l'objectif de la police, c'est vraiment de faire ce travail-là.^{Footnote 2928}

[TRANSLATION]

And I don’t want to say that we don’t have feelings about what the family is feeling, but our objective is really to find out whether a crime has been committed, and if so, then we have to investigate the crime. But if it was a suicide, and we determine after the funeral that it was a suicide, that is unfortunate, but I think the objective of the police is really to do that job.^{Footnote 2929}

281. He noted there are no special rules or procedures providing for early disclosure of funeral instructions, as all would depend solely on whether foul play was suspected.^{Footnote 2930} If there were such a suspicion, the information in the note might not be passed on before the funeral.^{Footnote 2931} Maj Bolduc explained the CFNIS would not “do the family justice” by “run[ning] through the steps too fast” and risk providing information in a manner which would later prevent it from solving the case.^{Footnote 2932} As an example, he referred to the possibility a person having committed the crime would write a note indicating the deceased wished to be cremated in order to destroy evidence.^{Footnote 2933}

282. Maj Dandurand also testified that whether the note would be disclosed before the funeral would depend on whether foul play was ruled out.^{Footnote 2934} In the explanations he had provided to the Fynes and to Maj Parkinson, he had hinted the note would rarely, if ever, be disclosed prior to the funeral. He had told the Fynes suicide notes could never be disclosed until foul play had been ruled out, and had specifically commented this might not happen “until well after the funeral.”^{Footnote 2935} He had described the appropriate procedures as involving preliminary determinations being made by the CFNIS, and the note then being presented to the family for handwriting verification “within weeks” of the death.^{Footnote 2936} To Maj Parkinson, he had said Cpl Langridge’s suicide note “would have had no bearing on the funeral dealings” because foul play had not yet been ruled out when the funeral took place.^{Footnote 2937} In testimony, he denied the need to rule out foul play prior to disclosure would make it “highly unlikely,” in practice, for a suicide note to be disclosed prior to the funeral.^{Footnote 2938} Instead, he maintained the note could be disclosed before the funeral if the ME provided a “swift return” on the information necessary, depending on when the funeral was held.^{Footnote 2939} However, he also testified receiving information from the ME is necessary in order to rule out foul play, and he admitted he had never seen a case where the ME was able to return the information less than a week after the death, which is generally when funerals are held.^{Footnote 2940}

283. Sgt Bigelow testified he had never received any direction on how to address funeral wishes contained in a suicide note.^{Footnote 2941} He believed there should be “some sort of communication to the next of kin” about funeral wishes in a suicide note, but still thought this could only be done where foul play or the note’s evidentiary value were ruled out.^{Footnote 2942} MCpl Ritco, for his part, insisted the note could not have been disclosed before the funeral in this case. He explained: “I was still right at the [...] beginning of the investigation. I still didn’t know what was going on, whether it was a suicide, whether it was foul play, it was only days afterwards.”^{Footnote 2943} WO Tourout agreed. He indicated it had “certainly crossed [the investigators’] mind” it would have been important for the family to know about the funeral wishes in the note, but was steadfast the note could still not have been released.^{Footnote 2944} He believed the note could not have been released before the funeral even if fingerprinting had confirmed its authenticity. He stated:

[...] it would still have been the same, it still would have been held as evidence and it wouldn't have undoubtedly [been] determined prior to the funerals. But again, it's unfortunate and we are sorry for that, but it just wasn't possible at the time.^{Footnote 2945} [Emphasis added]

284. MWO Watson, on the contrary, was insistent the note should have been disclosed before the funeral.^{Footnote 2946} About the funeral wishes contained in the note, he testified: “It would have been nice to know and it would have been even better for the family to know that.”^{Footnote 2947} LCol Garrick also thought information about funeral wishes should be disclosed “immediately.”^{Footnote 2948} Similarly, LCol Sansterre believed the funeral wishes should have been transmitted to the family in this case.^{Footnote 2949} In general, he thought disclosure of the existence and contents of suicide notes should be done immediately if no suspicion of foul play existed after the scene examination.^{Footnote 2950}

285. LCol Frei, who was the CFNIS CO when the testimony before this Commission concluded, could not provide specifics about how funeral wishes contained in suicide notes would be addressed. He testified there would be cases where disclosing the note before the funeral would be possible and others where it would not, depending on the “particular circumstances.”^{Footnote 2951}

286. On the whole, it is clear that if a suicide note containing funeral wishes is found by the CFNIS in the future, depending on the individual members making the determination and monitoring the case, the note may or may not be disclosed to the family before the funeral.

287. A large part of the problem stems from the different members’ understanding of what level of suspicion would justify withholding disclosure and of what, precisely, the term “ruling out foul play” means. It appears some of the members tend to focus on the need to disprove any potential suspicious circumstances or foul play, whether or not there is any positive reason for suspicion in the first place. As such, they will want to obtain some positive evidence or confirmation the death was indeed a suicide prior to disclosing even the existence of a note. Their default position appears to be not to disclose the note until it is shown disclosure will have no possible impact, and this will in turn happen only once sufficient confirmation has been obtained the death was a suicide. In practice, this type of approach may lead to delayed disclosure. Many of the members involved in this investigation did not believe they had ruled out foul play until the very end of the investigation, even if there was no reason to suspect it in the first place.^{Footnote 2952} For other members, the analysis appears more focused on the reverse question of whether any of the evidence indicates there is reason to suspect foul play may have been involved. Their default position appears to be to disclose the note without needing to disprove all potential scenarios, unless there is a specific reason to believe it should not be disclosed right away.

288. In general, it appears the inclusion of funeral wishes in a suicide note and the timing of the funeral are not viewed by most CFNIS members as important considerations in determining when to disclose the note. No official instruction or direction has been provided in this respect.

289. There will be no true assurances the CFNIS has taken all necessary measures to ensure what happened to the Fynes in this case never happens again until its members develop a common understanding of the appropriate criteria to apply in determining when suicide notes must be disclosed and until knowledge of these criteria is appropriately disseminated throughout the organization, including to the investigators on the ground. While the evidence from the members of other police forces who testified before this Commission has demonstrated it would not be a realistic goal to specify uniform or strict policies dictating the exact time when suicide notes need to be disclosed in all cases – as circumstances can and do vary, and the determinations are more often than not made on the basis of simple common sense^{Footnote 2953} – certain principles do need to be observed by the CFNIS in establishing the appropriate procedures.

290. The default position should always favour early disclosure of the existence and contents of suicide notes. The analysis should then focus on whether there is a reason not to disclose. The determination should be made on the basis of concrete facts and evidence rather than abstract possibilities. Rather than asking whether it has been determined the death was a suicide, the question to ask should be whether there is any actual, realistic reason for suspicion in the case. As appears to be the practice among at least some coroners and MEs, there should be early disclosure in all non-suspicious cases.^{Footnote 2954} Even where realistic suspicion is found to exist, the CFNIS members should remain focused on whether disclosing the existence of the note could harm the investigation. Wherever a realistic harm to the investigation cannot be identified, there should be no reason to withhold disclosure. Where funeral wishes or other time-sensitive information is contained in the note, this should be taken into account in the determination. In such cases, if suspicion does exist and disclosure is delayed as a result, all available measures should be taken to conduct testing of the note immediately. While it may not be possible to obtain absolute confirmation of the note’s authenticity prior to the funeral, preliminary testing such as handwriting comparison could provide at least the necessary indications to determine whether the level of suspicion is sufficient to deprive a family of the opportunity to fulfill what may well be their loved one’s last wishes.

291. It should also be noted it is not the role of CFNIS members to protect the family from the potential “harm” that could result from early disclosure of a suicide note if it later turned out the note was not authentic, a rationale invoked on several occasions in testimony before this Commission and in explanations provided to the Fynes. If the CFNIS members believe disclosure cannot hinder the investigation, but nevertheless for one reason or another have doubts about the authenticity of the note – or fear subsequent information may reveal the case to be otherwise than it appears at first – the proper procedure will be to disclose the existence and contents of the note to the family, and to advise them final confirmation of the cause of death or authenticity of the note has not yet been obtained. Under such circumstances, families should be allowed to make their own decisions about whether to honour any wishes contained in the note.

292. Once the family has received a copy of the note, the CFNIS may have reason to retain the original for a certain period of time. The level of suspicion required to justify retaining the original will not be as great as what would be required to justify not telling the family about the note at all. If releasing the original could hinder the investigation – including by making it unavailable for testing or use as evidence if subsequent information revealed this was necessary – there will be justification for not proceeding immediately.

293. Another aspect to address is the process for disposing of evidence. Under the policies and procedures applicable at the time of the investigation into Cpl Langridge’s death, the suicide note should, at a minimum, have been returned at the end of the investigation. However, there were no adequate processes in place at the Detachment to ensure evidence was disposed of in a timely manner, and it often ended up being retained for years simply because no one attended to the disposal process. The 2011 SOP does provide clearly for the original note to be released at the end of the investigation at the latest. However, it is not known whether the actual practices of the CFNIS Detachments for disposing of their evidence have improved. Should a suicide note again “fall through the cracks” during the course of an investigation, or the members not determine it could or should be disclosed, the final safeguard to ensure the family learns of the note at least before a year or more has passed, is to ensure there are adequate processes in place to return items seized when investigations are closed. The history of this case has shown written procedures or instructions are not sufficient. The CFNIS must ensure all of its Detachments have the necessary resources and processes in place for disposing of evidence in a timely manner.

294. Until these issues are addressed properly by the CFNIS, no one, including this Commission, can be certain what happened to Mr. and Mrs. Fynes will never happen again.

4.3 The 2009 PNOK Investigation

Introduction

1. One significant portion of the Fynes’ overall complaints to the MPCC involves their dissatisfaction with the 2009 investigation. The genesis of this investigation was the Fynes’ unhappiness with the decision to grant Ms. A decision-making authority with respect to Cpl Stuart Langridge’s funeral. The Fynes felt that, as a result of the PEN form completed by Cpl Langridge, which named them as primary and secondary next-of-kin (NOK),^{Footnote 2955} the regiment should instead have recognized their entitlement to make funeral decisions.

2. The Fynes have two different types of complaints regarding this matter. The first involves their underlying dissatisfaction with the conduct of the CF, which, in their view, improperly gave this authority to Ms. A. This dissatisfaction led to their complaint to the CFNIS alleging the CF members involved were negligent in appointing Ms. A as the primary next-of-kin (PNOK) and therefore guilty of a service offence. The second aspect of their dissatisfaction regarding this matter involves the manner in which the CFNIS conducted its investigation into their complaint. This second aspect constitutes their complaint to this Commission alleging various defects and inadequacies in the 2009 investigation.

3. While related, the Fynes’ complaints to this Commission about the 2009 investigation are distinct from their complaints about the CF’s actual decisions about the PNOK and the authority to make funeral planning decisions. This report attempts to respond directly only to the Fynes’ complaint to this Commission that the CFNIS investigation was inadequate. To assess this issue it is necessary to look at the nature of the Fynes’ complaint to the CFNIS about what became known as the “PNOK decision” made by the CF regiment.

4. The Commission has reviewed documents and testimony relating to the PNOK issue and looked into the relevant law. While the Commission concludes the underlying issue of who is entitled to plan a military funeral is one of considerable legal complexity, it also concludes the CFNIS investigation into the Fynes’ complaint was wholly inadequate. This chapter addresses the following elements that compromised the 2009 investigation:

Improper interpretation of the complaints;
Weak planning;
Lack of focus;
Insufficient supervision;
Failure to interview potential key witnesses;
Failure to seek outside legal advice;
Poor recordkeeping; and
Poor decision-making.

The Complaint

The Ombudsman Investigator’s Complaint

5. The issues forming the basis of the 2009 investigation first came to the attention of the CFNIS on November 17, 2009, when Lt(N) Michael Amirault of the CFNIS Central Region was contacted by Patrick Martel, an investigator from the CF Ombudsman’s Office.^{Footnote 2956} Mr. Martel told Lt(N) Amirault he had received a complaint from Shaun and Sheila Fynes that LDSH had represented Ms. A as the common-law spouse of Cpl Langridge at the time of his death and, as a result, she became entitled to certain rights and benefits^{Footnote 2957} including authority to plan Cpl Langridge’s funeral.^{Footnote 2958} Mr. Martel suggested there was a possibility a service offence may have been committed in the determination of Cpl Langridge’s PNOK.^{Footnote 2959} Lt(N) Amirault conveyed this information to Maj Daniel Dandurand in a phone call that same day.^{Footnote 2960} He also forwarded the documentation provided by the Ombudsman’s Office supporting the allegations with respect to what Maj Dandurand described as “the PNOK issue”^{Footnote 2961} Mr. Martel was contacted by the CFNIS WR on December 4, 2009, to set up a time to meet. At that time, he faxed additional documents to Maj Dandurand in support of the allegations.^{Footnote 2962} Following this, Maj Dandurand and MS Eric McLaughlin met the Ombudsman’s investigators Mr. Martel and Phillipe Joly on December 18, 2009. During that meeting, Mr. Martel provided further documentation in support of the allegations, which MS McLaughlin catalogued in the General Occurrence (GO) file.^{Footnote 2963}

6. In the initial stages of the investigation, the complaints were characterized by the CFNIS as having originated with the Ombudsman. The tasking of MS McLaughlin by WO Blair Hart on December 7, 2009, states MS McLaughlin will “conduct an investigative assessment into the Ombudsman’s complaint”^{Footnote 2964} The File Status Report from December 10, 2009, similarly states, “An allegation has been brought forward by the CF Ombudsman.”^{Footnote 2965}

7. On February 12, 2010, Maj Dandurand decided the CFNIS would conduct an investigation into the allegations of negligent performance of duty following the “review of the documentation provided to the CFNIS WR investigators by the CF Ombudsman’s office.”^{Footnote 2966} In a phone call on the same day, Maj Dandurand notified Mr. Fynes of the investigation and advised him, “Investigators from CFNIS WR met with Ombudsman investigators who provided documentation leading CFNIS to initiate this investigation.”^{Footnote 2967} In his meeting with the Fynes on March 3, 2010, Maj Dandurand explained the Ombudsman’s office was looking at many issues and had brought the allegation concerning the PNOK to the attention of the CFNIS, which is why the CFNIS was speaking with them.^{Footnote 2968} Indeed, during his initial conversations with Lt(N) Amirault, Mr. Martel stated he had yet to notify the Fynes he was speaking to the CFNIS.^{Footnote 2969}

8. In some respects the CFNIS members treated the Ombudsman as the complainant. MCpl David Mitchell contacted Mr. Martel on February 18, 2010, shortly after being assigned to the file, to advise him of the change in personnel and to gather further information on the allegations.^{Footnote 2970} The CFNIS committed at that time to keep Mr. Martel informed regarding what was transpiring in the investigation and to contact him for more information as the need arose.^{Footnote 2971} In other respects, the investigators did not treat the Ombudsman as the complainant. After MCpl Mitchell’s initial contact they did not contact Mr. Martel again, nor keep him informed about the investigation.^{Footnote 2972} The CFNIS did not advise Mr. Martel of the conclusion of the investigation or provide him with a final briefing letter on the investigation.^{Footnote 2973}

The Fynes’ Complaint

9. On November 28, 2009, the Fynes met with Maj Dandurand and MS McLaughlin. The intended purpose of the meeting was to provide the Fynes with a briefing on the 2008 investigation.^{Footnote 2974} While Maj Dandurand had received the documents from the Ombudsman’s investigator prior to the meeting, he had not reviewed them in detail. MS McLaughlin did not believe he was aware of all of the initial information from the Ombudsman’s investigator at the time of the meeting with the Fynes.^{Footnote 2975}

10. The Fynes did raise issues at the meeting relevant to the subject matter in the documentation provided to the CFNIS by Mr. Martel. They specifically expressed concerns they had had no decision-making authority over Cpl Langridge’s funeral even though they had been named as PNOK and SNOK on his PEN form.^{Footnote 2976} They also alleged Ms. A was not Cpl Langridge’s common-law spouse at the time of his death. In their view, it should have been Mrs. Fynes who was entitled to dispose of Cpl Langridge’s remains.^{Footnote 2977}

11. It is difficult to know the extent of the discussion about these issues because at least an hour of the interview was not audio recorded.^{Footnote 2978} The transcripts of the recorded portions of the interview relevant to these allegations are relatively short and comprise only a few pages of text.^{Footnote 2979}

12. The allegation concerning the PNOK issue is reflected in MS McLaughlin’s complaint synopsis^{Footnote 2980} written on January 12, 2010, a month and a half after the meeting with the Fynes.^{Footnote 2981} The complaint synopsis is a summary of the November 2009 meeting with the Fynes and it does not refer to the Ombudsman Investigator’s complaint. As such, it tends to indicate the Fynes were viewed as the complainants.

13. In the synopsis, MS McLaughlin states he has been tasked with conducting an investigation into the allegation the LDSH Adjutant was negligent by failing to appoint Mrs. Fynes as NOK. Maj Dandurand’s notebook entry for the meeting similarly reflects the allegations concerning the determination of the PNOK and indicates the CFNIS would investigate the allegations.^{Footnote 2982}

14. The Fynes were not contacted again by the CFNIS about the 2009 investigation until February 12, 2010, when Mr. Fynes was contacted by Maj Dandurand who advised him of the departure of MS McLaughlin and told him the CFNIS would be investigating the PNOK allegation.^{Footnote 2983} The Fynes heard nothing further from the CFNIS about their allegations until their March 3, 2010, interview, which was intended as an opportunity for the Fynes to supply information regarding their PNOK complaint.

Who Was the Complainant?

15. The CFNIS did not keep a clear record of who was officially viewed as the complainant and whose allegations were being investigated. The Fynes would eventually complain the written briefing they received at the end of the investigation failed to recognize that the PNOK issue had also been brought to the CFNIS’s attention by the Ombudsman’s Office, and not just by the Fynes.^{Footnote 2984}

16. In their testimony, the CFNIS members involved in the investigation explained they regarded the Ombudsman as a third party complainant or a conduit for the Fynes’ complaint to come to the CFNIS.^{Footnote 2985} MS McLaughlin described the Ombudsman’s Office as “the investigative body that initially was looking into [the allegations] for the Fynes.”^{Footnote 2986}

17. Maj Dandurand testified the initial notations in the file identifying the Ombudsman as the complainant should not be viewed as determinative of who was, in fact, viewed and treated as complainants by the investigators.^{Footnote 2987} He believed nothing turned on this fact.^{Footnote 2988} To some extent, this may be true.

18. The Ombudsman’s investigator did bring the allegation concerning Ms. A’s entitlement to certain benefits to the attention of the CFNIS in the first instance. The issue was then discussed by the Fynes in their meeting with Maj Dandurand and MS McLaughlin and was more fully expanded on in the subsequent meeting with the Ombudsman’s investigators. The launch of the investigation seems to have been primarily premised on the information and documents received from the Ombudsman, as comparatively little information was given to the CFNIS by the Fynes about the issues under investigation prior to March 2010.

19. At the same time, the Fynes clearly had a vested interest in the outcome of the investigation. They brought the complaint to the attention of the Ombudsman’s investigator who, on his own initiative, took it to the CFNIS.^{Footnote 2989} Most of the information Mr. Martel passed on to the CFNIS originated from the Fynes or their Assisting Officer Maj Stewart Parkinson.^{Footnote 2990}

20. The lack of clarity in the file notations about the identity of the complainant likely had little practical impact on the actual investigation since the allegations were largely the same. However, proper recordkeeping by MP is always important. As certain entitlements are attached to the status of a complainant,^{Footnote 2991} it would have been preferable for the CFNIS to establish a clear identity for the complainant in the investigative file.

21. The initial confusion surrounding the identification of the complainant only intensified as the investigation progressed and the CFNIS members sought to understand the issues at stake.

The Investigative Assessment

Purpose of an Investigative Assessment

22. Prior to launching an investigation, the CFNIS often carries out an investigative assessment of the allegations (also referred to as the “preliminary investigation”) to determine whether there are sufficient grounds to proceed with a full criminal investigation.^{Footnote 2992} An assessment entails conducting initial steps for an investigation, including file research and/or preliminary interviews, to determine whether the complaint may involve the commission of a service or criminal offence.^{Footnote 2993} An assessment is not necessarily completed in every investigation and each completed assessment varies in length and complexity.^{Footnote 2994} There are several possible outcomes of an assessment:

The evidence supports the belief an offence may have been committed, in which case a complete and thorough investigation is conducted;
There is no evidence an offence has been committed, in which case the investigation is concluded at that stage; or
Advice of a technical or subject matter expert is sought; or, the complaint is turned over to another body (for example, an internal CF administrative body).^{Footnote 2995}

Investigative Assessment of the 2009 Complaint

23. There is inconsistency in the 2009 GO file about whether the first step in pursuing the allegations was an investigative assessment, and, if so, when this was completed. Both the complaint synopsis completed on January 12, 2010,^{Footnote 2996} and Maj Dandurand’s notes of the meeting with the Fynes on November 28, 2009,^{Footnote 2997} indicate an investigation was being launched. Maj Dandurand’s notebook entry following the meeting with the Ombudsman’s investigators on December 18, 2009, reflects his “assessment that enough suspicion exists to merit an investigation.”^{Footnote 2998} This suggests that, at some point in December, the investigators believed no further investigative assessment was necessary before launching an investigation. On the other hand, the initial tasking of MS McLaughlin dated December 7, 2009, indicates an investigative assessment was to be undertaken as a first step.^{Footnote 2999} MS McLaughlin confirmed this in testimony.^{Footnote 3000} The results of the investigative assessment were recorded in the GO file by Maj Dandurand in February 2010.^{Footnote 3001}

24. It appears any investigative assessment conducted was based almost entirely on information received from the Ombudsman’s investigator, both at his initial meetings with the CFNIS and in the documentation he provided. Other than a few comments by the Fynes in their November 28, 2009, meeting with Maj Dandurand and MS McLaughlin, the Fynes did not provide any substantive information on the allegations prior to the assessment being recorded as completed.

25. Mr. Martel provided the CFNIS with three batches of documents he felt were relevant to the allegations he had brought to the CFNIS: one batch on November 17, 2009;^{Footnote 3002} a second on December 4, 2009;^{Footnote 3003} and a third on December 18, 2009.^{Footnote 3004} The documents were catalogued by MS McLaughlin and scanned into the GO file by investigators.^{Footnote 3005} The documents received from Mr. Martel comprised approximately 175 pages.^{Footnote 3006} They included a copy of Cpl Langridge’s completed and valid PEN form from 2006 naming the Fynes as his primary and secondary NOK;^{Footnote 3007} extracts from military policy, procedures and guides regarding the recognition of common-law partnerships, casualty coordination and the personal emergency notification;^{Footnote 3008} and the military statutory declaration of the common-law relationship of Cpl Langridge and Ms. A.^{Footnote 3009}

26. In addition to receiving the documents, MS McLaughlin and Maj Dandurand met with the Ombudsman’s investigators on December 18, 2009. Despite reference in Maj Dandurand’s notebook to MS McLaughlin as the “primary note taker” for the meeting,^{Footnote 3010} no minutes exist of the meeting. Maj Dandurand made brief notes in his notebook, likely after the meeting.^{Footnote 3011} But there are no contemporaneous notes, audio recording, video recording or transcript of the meeting.

27. The December 18, 2009, meeting lasted approximately two and a half hours.^{Footnote 3012} Mr. Martel reviewed extensive documentation with Maj Dandurand and MS McLaughlin.^{Footnote 3013} Maj Dandurand testified Mr. Martel pointed out areas of the Code of Service Discipline worthy of consideration by the CFNIS in addition to the document review. Mr. Martel also provided a list of individuals involved.^{Footnote 3014} As well, they discussed how Cpl Langridge’s marital status at the time of his death affected the determination of his NOK.^{Footnote 3015}

28. After the meeting with the Ombudsman’s investigators, MS McLaughlin and Maj Dandurand met to discuss what to do with all the information they had received to date on the allegation.^{Footnote 3016} MS McLaughlin testified the next step in the investigative assessment would have been to secure copies of the documents actually used in making the NOK decision as well as assessing the documents already provided.^{Footnote 3017} He then would have tried to determine if there was some validity to the complaint.^{Footnote 3018}

29. MS McLaughlin did not have the opportunity to complete the steps he identified because he was deployed to Haiti in mid-January 2010.^{Footnote 3019} At that time, he had catalogued all the documents received from Mr. Martel^{Footnote 3020} but had not read any of them. He had simply organized the documents by title for the purpose of drafting a list.^{Footnote 3021} He testified his goal in cataloguing the documents was to make sense of what had been given by the Ombudsman’s investigator, not to determine how the material provided would impact the investigation.^{Footnote 3022} As well, MS McLaughlin had not read the 2008 GO file or other relevant documents.^{Footnote 3023}

30. MS McLaughlin stated, with respect to the interviews with the Fynes and the Ombudsman’s investigators, he had summarized what had been told to the CFNIS during the meetings.^{Footnote 3024} Presumably this refers to two documents in the GO file – the synopsis of the Fynes’ complaint as well as the short synopsis of the information obtained from the meeting with Mr. Martel and Mr. Joly.^{Footnote 3025} MS McLaughlin had not come to any preliminary conclusions prior to leaving the file, but he stated he had an understanding of what needed to be investigated.^{Footnote 3026}

31. Like MCpl Mitchell, who subsequently took his place on the investigation, MS McLaughlin never did identify as significant the issues of who was entitled to make decisions about a military funeral nor of the role of the PEN form in identifying such person.

32. For a period of about a month after the departure of MS McLaughlin, Maj Dandurand was the only investigator assigned to the investigation. During that time, there was nothing on the file to indicate Maj Dandurand did any work on the investigation.

33. Nevertheless, on February 17, 2010, Maj Dandurand recorded the outcome of the investigative assessment in the GO file.^{Footnote 3027} The entry is backdated to February 12, 2010,^{Footnote 3028} presumably the date the decision regarding the assessment was reached. Maj Dandurand’s entry reads:

Following a review of the documentation provided to the CFNIS WR investigators by the CF Ombudsman’s office, it is determined that CFNIS will conduct an investigation into allegations of Negligence in the Performance of Duties. The specifics of the allegation centre on the Chain of Command’s decision that Cpl Langridge’s spouse and not his parents were the Primary Next of Kin […] Maj Dandurand, OC CFNIS WR, will assume responsibility as lead investigator.^{Footnote 3029}

34. He also advised Mr. Fynes in a telephone call on February 12, 2010, of the decision to proceed with the investigation and the assignment of MCpl Mitchell to replace MS McLaughlin.^{Footnote 3030}

35. Maj Dandurand’s GO file entry specifically states a review of the documents from Mr. Martel led to the decision to initiate a full investigation. However, it is unclear whether any CFNIS investigator had actually read the documents prior to the decision to launch the investigation and, if so, when. MS McLaughlin had not reviewed the documents before leaving the file. MCpl Mitchell did review the documents and did discuss some of the documents with Maj Dandurand, but it is uncertain when this occurred.^{Footnote 3031} It may have happened during their first meeting on February 12, 2010, though there is no record of any document review.^{Footnote 3032} It is unlikely MCpl Mitchell had time to review all of the documents prior to the February 12, 2010 assessment, considering the number of documents involved and the fact he began working on this file on February 12th.^{Footnote 3033}

36. Maj Dandurand, for his part, could not recall reading the first batch of documents in great detail, but stated it was not uncommon for him to open the envelope containing the documents and leaf through them.^{Footnote 3034} There is no evidence in the GO file he read the other two batches of documents from Mr. Martel before writing the investigative assessment.

37. Some of the documents were reviewed in the meeting with Mr. Martel, but the step of CFNIS investigators independently reading, understanding and identifying important documents does not appear to have been taken as part of the investigative assessment. In fact, it seems likely very few of the documents had actually been read by anyone prior to the assessment being recorded as completed.

38. Maj Dandurand’s approach in documenting the process and outcome of the investigative assessment is in sharp contrast with the investigative assessment performed by Sgt Scott Shannon when he took over as lead investigator on the file in September 2010.^{Footnote 3035} Sgt Shannon’s assessment is very detailed and comprehensive and contains a timeline of significant events, as well as the identification of significant policies, regulations and documents. It also contains notes on the specific steps Sgt Shannon undertook to complete the assessment.^{Footnote 3036} This variance in the execution and documentation of the two assessments clearly highlights the lack of attention devoted to the completion of the initial investigative assessment of the 2009 complaint.

The Mitchell Investigation

39. MCpl Mitchell was assigned to the 2009 investigation in mid-February 2010, after the deployment of MS McLaughlin.^{Footnote 3037} Because MCpl Mitchell was an intern at the time, Maj Dandurand was designated as the lead investigator.^{Footnote 3038} In practical terms, this meant MCpl Mitchell was to do the legwork on the file,^{Footnote 3039} while Maj Dandurand would provide oversight and direction as the file progressed.^{Footnote 3040} MCpl Mitchell completed his internship as a CFNIS investigator in late March 2010.^{Footnote 3041}

Understanding of the Issue in the Allegation

40. In commencing the investigation, both MCpl Mitchell and Maj Dandurand overlooked a vital step in their understanding of the issue to be investigated. The focus of the Fynes’ frustration with the PNOK process was that, although Ms. A had not been named on the PEN form,^{Footnote 3042} she was recognized as PNOK by the Regiment and given final decision-making authority for Cpl Langridge’s funeral.^{Footnote 3043}

41. In investigating this issue, a logical first step would have been to examine whether it was Ms. A, the Fynes or someone else (for example, the executor of Cpl Langridge’s will) who was entitled to have final decision-making authority for the funeral. The investigation needed to determine whether the PEN form afforded the Fynes any rights with respect to the funeral or whether other documentation, legislation or CF orders might have indicated who was entitled to make funeral decisions. A legal opinion would have been helpful to understand these issues, and to determine who could legally be granted authority to make the funeral decisions and how the determination could be made. If the Fynes were correct about their entitlement to make decisions regarding the funeral, a logical next step would have been to determine who made the decision that Ms. A was entitled to plan the funeral and why.

42. Instead of adopting this approach, MCpl Mitchell and Maj Dandurand simply assumed the Fynes, as the PNOK and SNOK named on the PEN form, were entitled to decision-making authority for the funeral. As a result, the initial focus of the investigation was solely on the question of who had made the PNOK determination at a meeting involving senior LdSH officers and the Assisting Officers assigned to the Fynes and to Ms. A held two days after Cpl Langridge’s death (the “casualty coordination meeting”).^{Footnote 3044} MCpl Mitchell stated his task was to determine who at that meeting made the decision Ms. A was Cpl Langridge’s NOK, on the basis of what information this decision was made and how it was justified.^{Footnote 3045} He was focused on the decision-makers and their actions because he thought identifying them would allow him to determine whether a service offence had been committed.^{Footnote 3046}

43. However, if the initial assumption was incorrect that the PEN form was determinative of who was entitled to plan the funeral (which turned out to be the case), then the investigative steps based on this assumption would be unlikely to assist in resolving the complaint unless the assumption was revisited along the way.

44. MCpl Mitchell’s investigation was interrupted part way, before it could come to any conclusions.^{Footnote 3047} Neither MCpl Mitchell nor Maj Dandurand revisited their assumption about the impact of the PEN form.

Investigation Plan

45. One of MCpl Mitchell’s first tasks was to prepare an investigation plan (IP).^{Footnote 3048} As listed in his IP, a primary task was to “determine who made the NOK decision.”^{Footnote 3049}

46. MCpl Mitchell’s IP listed the interviews he intended to conduct.^{Footnote 3050} He listed Maj Parkinson, the AO for the Fynes, to corroborate the Fynes’ story.^{Footnote 3051} He also planned to interview 2Lt Adam Brown, the AO for Ms. A, because he had attended the casualty coordination meeting.^{Footnote 3052} He listed Capt Mark Lubiniecki (the Unit Adjutant) and LCol Pascal Demers (the CO LDSH) as interviewees because he believed they had been in attendance at the casualty coordination meeting.^{Footnote 3053} He intended to interview everyone who was at the casualty coordination meeting to get a clear picture of what happened during the meeting^{Footnote 3054} He also wanted to interview Ms. A to clarify her marital status with Cpl Langridge.^{Footnote 3055} MCpl Mitchell testified he had also considered, but not listed, many more interviews, including: MCpl William Fitzpatrick (the Stables NCO who had found additional paperwork for Cpl Langridge after his death); MCpl Dianne Birt (a HQ squadron clerk who had reportedly been involved in discussions about Cpl Langridge’s common law paperwork and possible intent to dissolve the common law relationship); Mr. Dirk Velthuizen (the funeral director present when Ms. A and Regiment members attended at the funeral home); and Cpl Jon Rohmer (a friend of Cpl Langridge, also present at the funeral home).^{Footnote 3056}

47. MCpl Mitchell also listed in his IP the task of obtaining all relevant documentation.^{Footnote 3057} However, other than the BOI report specifically,^{Footnote 3058} the IP did not identify what documents or sorts of documents were considered to be relevant.

Witness Interviews

48. The interviews conducted by MCpl Mitchell, in line with his IP and his general approach to the issues, all appeared to be focused on identifying the decision-maker or decision-makers involved in naming Ms. A as PNOK.

Maj Parkinson interview

49. The first interview was with Maj Parkinson,^{Footnote 3059} who explained he was told the Fynes were PNOK and SNOK for Cpl Langridge in his initial tasking as AO.^{Footnote 3060} However, in later conversations with 2Lt Brown, Capt Lubiniecki and Maj Earl Jared, he was informed Ms. A was the PNOK.^{Footnote 3061} Maj Parkinson described the Fynes’ reaction to being told they were not Cpl Langridge’s NOK as being “crushed like a grape.”^{Footnote 3062}

50. Maj Parkinson also provided Maj Dandurand and MCpl Mitchell with information on who made the decision about the PNOK.^{Footnote 3063} Specifically, he identified the position of the person who made the PNOK decision.^{Footnote 3064} In his oral testimony, MCpl Mitchell stated Maj Keith Reichert was the AJAG for the regiment and had been identified as the decision-maker by either Maj Parkinson or Capt (formerly 2Lt) Brown.^{Footnote 3065} This was further confirmed by Maj Parkinson when he testified the source of the NOK decision was the AJAG.^{Footnote 3066} However, this reference, along with several others, was redacted by counsel for DND in the interview transcript for Maj Parkinson’s interview with the CFNIS that was made available for the Public Interest Hearing.^{Footnote 3067}

Capt Brown interview

51. The second interview was with Capt Brown, who had been the AO for Ms. A,^{Footnote 3068} and had attended the casualty coordination meeting.^{Footnote 3069} He identified several of the other participants in the meeting including Maj Trevor Cadieu, Maj Jared, Capt Lubiniecki and the Regimental Quartermaster, MWO Remi Mainville. There was an additional participant whose name was redacted from the transcripts by counsel for DND,^{Footnote 3070} but identified by MCpl Mitchell in his testimony as the AJAG, Maj Reichert.^{Footnote 3071} Capt Brown said he asked during the meeting who would have ultimate say for funeral arrangements and he was told, “for the funeral it was [Cpl Langridge’s] common-law wife.”^{Footnote 3072} Capt Brown recalled there was no discussion about the basis for that decision at the meeting and no one asked for justification.^{Footnote 3073} Capt Brown further stated, it had been stressed there should be an attempt to make decisions regarding the funeral collectively between the Fynes and Ms. A.^{Footnote 3074} He also mentioned Cpl Langridge’s will had not yet been found and a copy was not at the meeting.^{Footnote 3075}

WO (Ret’d) Doucette interview

52. The third interview conducted was with WO (Ret’d) Caroline Doucette, the chief clerk at LDSH at the time of Cpl Langridge’s death. She had little information to provide concerning the casualty coordination meeting, which she had not attended.^{Footnote 3076} She had been on leave when the information was assembled from Cpl Langridge’s personnel file and given to Capt Lubiniecki.^{Footnote 3077} She had no knowledge of who made the decision that Ms. A should be the PNOK or how the decision was made.^{Footnote 3078} MCpl Mitchell did not ask WO (Ret’d) Doucette about her email communication in December 2008 with the then Adjutant, Capt Eric Angell, in which she said the PEN form had always stated the Fynes were the PNOK and SNOK. MCpl Mitchell was in possession of the email^{Footnote 3079} and he stated in testimony he considered the email to be significant.^{Footnote 3080}

Incomplete and Inadequate Document Review

53. While the purpose of MCpl Mitchell’s interviews – both completed and proposed – is relatively clear, the purpose of the document review he conducted is less so.

54. When MCpl Mitchell became involved in this investigation, the GO file included only the documents received from the Ombudsman’s investigator.^{Footnote 3081} In accordance with his IP,^{Footnote 3082} MCpl Mitchell obtained a copy of the more than 100-page BOI report from Land Force Western Area (LFWA).^{Footnote 3083} Maj Dandurand stated in his testimony the BOI report was, in his view, relevant to the investigation to provide background information on Cpl Langridge’s life.^{Footnote 3084} In fact, the report provided no information relevant to the NOK allegation and MCpl Mitchell himself did not think it was relevant to the 2009 investigation.^{Footnote 3085}

55. MCpl Mitchell also requested from LFWA the Summary Investigation (SI) into the administrative actions taken by the Unit after Cpl Langridge’s death.^{Footnote 3086} MCpl Mitchell received the annexes to the SI, which comprised over 575 pages and contained the questions asked of witnesses and their responses, as well as all the documentary evidence collected as part of the SI.^{Footnote 3087} Missing from the GO file is a copy of the SI report itself, though it appears MCpl Mitchell did receive it.^{Footnote 3088} Also missing are the references, which do not appear to have been obtained by MCpl Mitchell.^{Footnote 3089} The references contain a collection of 41 policy documents, some related to the PNOK allegation,^{Footnote 3090} the vast majority of which were not already part of the GO file.

56. MCpl Mitchell did not ask for Cpl Langridge’s complete personnel file, which may have contained other forms relevant to the PNOK determination. Even with the file, he would not have had any way of becoming aware of yet another PEN form completed by Cpl Langridge as part of a Primary Leadership Qualification (PLQ) course he took in March 2007. This form, designating Ms. A as the PNOK,^{Footnote 3091} as a matter of course would have been retained separately from the personnel file, in a different geographic location. This form post-dated the PEN form that formed the basis for the PNOK allegations. MCpl Mitchell stated in his testimony this document would have been relevant and something he would have explored.^{Footnote 3092}

57. MCpl Mitchell did not obtain or review the 2008 GO file, other than the excerpts contained in the documents received from the Ombudsman.^{Footnote 3093} As a result, relevant materials contained in the 2008 file – such as a note by Capt Lubiniecki written prior to the casualty coordination meeting asking whether Cpl Langridge had a will,^{Footnote 3094} and officer notes reporting a March 15, 2008, conversation where Capt Lubiniecki told the MP he was aware Cpl Langridge and his spouse “had separated for some time”^{Footnote 3095} – were never considered during the PNOK investigation.

58. MCpl Mitchell testified he reviewed all the material in the 2009 file – both the material received from the Ombudsman^{Footnote 3096} and the documents he had collected.^{Footnote 3097} However, he did not make any notes nor otherwise identify any documents or information he considered relevant in this material. For example, as part of the SI annexes, MCpl Mitchell had obtained a copy of the Supplementary Death Benefits (SDB) form^{Footnote 3098} and Cpl Langridge’s will,^{Footnote 3099} as well as emails between the chain of command both immediately before and shortly after the casualty coordination meeting,^{Footnote 3100} but it is not known if or how these were used by MCpl Mitchell.

59. MCpl Mitchell also reviewed additional documents not scanned into the file. As a result, it is uncertain exactly what documents were obtained and reviewed during the investigation. For example, MCpl Mitchell conducted policy research on July 16, 2010, but the documents he lists in his GO file entry, namely the Casualty Notification Manuals and CFAO 24-1, do not form part of the file.^{Footnote 3101} In his testimony, he identified these documents as relevant and significant.^{Footnote 3102} As well, MCpl Mitchell stated he likely reviewed other policy documents referenced in the Casualty Notification Manuals, but there is no list of these documents, and they are not scanned into the file.^{Footnote 3103}

60. The overall result of the incomplete recordkeeping for this part of the investigation was that a new investigator starting work on the file or even a supervisor reviewing the investigation would not have known what documents were obtained, what documents were reviewed, and what documents were considered relevant. MCpl Mitchell candidly acknowledged policy review was not his strength.^{Footnote 3104} Nevertheless, it may have been helpful to other investigators who worked on the file to have a better sense of what documents had been reviewed, and which, at least in the opinion of MCpl Mitchell, were worthy of further consideration. It appears MCpl Mitchell did not receive further assistance and guidance from his own supervisors in this respect.

Status of the Investigation in September 2010

61. MCpl Mitchell left the investigation in September 2010.^{Footnote 3105} By then, he had obtained information about who had attended the casualty coordination meeting^{Footnote 3106} and had learned there was no copy of Cpl Langridge’s will at the meeting.^{Footnote 3107}

62. However, the actual issue MCpl Mitchell had set out to investigate remained outstanding. He had gathered some evidence on the issue of the PNOK decision^{Footnote 3108} but he testified he had not reached a conclusion about who ultimately had made the decision.^{Footnote 3109}

63. In addition, some issues had not been examined, as they were not part of what Maj Dandurand and MCpl Mitchell understood to require investigation. MCpl Mitchell had not come to a conclusion as to who was entitled to make decisions concerning Cpl Langridge’s funeral, how the PNOK decision should have been made or how the decision was made.^{Footnote 3110} The meaning of the term “PNOK” was not properly resolved, nor was the purpose of the PEN form understood. No legal opinion was sought about any of these issues. The issue of whether Cpl Langridge had been in a common-law relationship at the time of his death also remained an open question^{Footnote 3111}

64. Overall, after six months of investigation, little had been uncovered that could substantiate or refute the complaint. Despite any shortcomings in his investigation, the Commission was impressed by MCpl Mitchell’s forthright testimony, and it was clear from the evidence he made an honest effort to carry out the tasks assigned to him. However, he received little help or guidance from anyone in his chain of command.

Supervision of the Mitchell Investigation

65. Although he was formally in charge of the investigation, at least while MCpl Mitchell was on his internship, and was to provide direction to MCpl Mitchell, Maj Dandurand’s involvement in actual investigative activity was limited to attending the meetings with the Fynes^{Footnote 3112} and the interview with Maj Parkinson.^{Footnote 3113} He met with MCpl Mitchell when he was assigned to the file,^{Footnote 3114} met with him to discuss the documents received from the Ombudsman^{Footnote 3115} and again to brainstorm a list of potential witnesses to be interviewed.^{Footnote 3116} There is no evidence he took any steps to ensure the issues to be investigated were properly identified and that legal advice was sought where necessary. In terms of contributions by other supervisors to the investigation, WO Hart reviewed MCpl Mitchell’s investigation plan,^{Footnote 3117} and MCpl Mitchell’s notebook was reviewed by WO Sean Bonneteau.^{Footnote 3118} While these supervisors testified they discussed ongoing investigations with investigators throughout the course of each week,^{Footnote 3119} and MCpl Mitchell stated he had an open door with Maj Dandurand,^{Footnote 3120} there is no record of the supervisors providing any additional direction or input to MCpl Mitchell, despite his situation as a new member of the CFNIS.

The Shannon Investigation

66. Sgt Shannon officially became the lead investigator on the 2009 investigation on September 7, 2010, following MCpl Mitchell’s departure.^{Footnote 3121} Maj Dandurand maintained a limited supervisory role on the file, despite being the only investigator with continuous involvement from the outset of the investigation in November 2009. Sgt Shannon did not discuss the investigation with Maj Dandurand until November 2010, almost two months into his tenure as lead investigator.^{Footnote 3122} Sgt Shannon also did not discuss the investigation with MCpl Mitchell prior to his departure.^{Footnote 3123} Rather, Sgt Shannon’s entire initial understanding resulted from his own review of the file as it existed on SAMPIS.^{Footnote 3124} Sgt Shannon began the investigation fresh.^{Footnote 3125}

Sgt Shannon’s Approach

67. Sgt Shannon adopted a very literal approach to the complaint. As reflected in his investigation plan, he was investigating an allegation that Capt Lubiniecki had designated the incorrect NOK.^{Footnote 3126} This is all Sgt Shannon attempted to investigate – who was the proper PNOK. He was quite clear he was not investigating the allegation as to who had authority to make funeral decisions.^{Footnote 3127}

Personal Emergency Notification form

68. Given the Fynes’ emphasis on the PEN form, an obvious place to begin the analysis of whether the Fynes were Cpl Langridge’s PNOK and SNOK would seem to be to examine that form. The Fynes and previous investigators had simply assumed that the PNOK and SNOK, as named on the PEN form signed September 26, 2006,^{Footnote 3128} were entitled to be recognized as NOK by the regiment and therefore to plan the funeral.

69. Sgt Shannon examined the PEN form and the attached instructions. The form states at the bottom, “This is not a legal document”^{Footnote 3129} presumably meaning the PEN does not create any rights in and of itself. It simply identifies individuals to be contacted in an emergency.^{Footnote 3130} Sgt Shannon also consulted CFAO 26-18 which specifically addresses personal emergency notification.^{Footnote 3131} The order confirms “the purpose of the PEN is to ensure that when a member dies, is injured, becomes seriously ill or is reported missing, the appropriate persons are notified.”^{Footnote 3132} It also states the term “next of kin” as used in the order is not a legal term and should not be confused with heir-at-law.^{Footnote 3133}

70. Sgt Shannon concluded the PEN form had no legal effect in terms of entitlement to the status of PNOK and was only relevant to the issue of notification in case of death or serious injury.^{Footnote 3134}

Alternative definitions of NOK

71. Having rejected the utility of the PEN form in determining PNOK, Sgt Shannon relied instead on his own research to determine the proper PNOK. In researching the issue, Sgt Shannon looked at the definition set out in CFAO 26-18 as well as in the instructions accompanying the PEN form.^{Footnote 3135} As well, Sgt Shannon looked at the CO and AO guides containing examples of who can be considered NOK.^{Footnote 3136} Sgt Shannon rejected all of these definitions. He dismissed the definitions in the PEN form and CFAO 26-18 because he saw them as merely “suggestions on the manner in which next of kin should be selected for the purpose of that form.”^{Footnote 3137} Similarly, the definitions in the CO and AO guides were rejected as being too flexible and not providing a definitive method of determining NOK.^{Footnote 3138}

72. Sgt Shannon did not identify any other definitions of PNOK in the military orders or instructions he consulted. In his investigative assessment, Sgt Shannon proclaimed he had “conducted a formal review of all relevant Canadian Forces policies, regulations and documents that pertain to the subject matter of this investigation.”^{Footnote 3139} In testimony, he stated categorically:

There is no such thing in any other body of law as primary next of kin and secondary next of kin except in the Canadian Forces Administrative Order [CFAO] related to the PEN form. [...] I was not able to identify any other legal reference [to] the term ‘primary next of kin’ and ‘secondary next of kin.’^{Footnote 3140}

73. Sgt Shannon’s research into the meaning of PNOK also included sources external to the CF and military law, and incorporated other federal statutes as well as provincial law. Sgt Shannon described his research as being based on “all available bodies of law.”^{Footnote 3141} In his testimony, he stated he was not able to find a “conclusive one-page document that the Government of Canada or any province has come up with a bona fide list or set of rules that defines NOK.”^{Footnote 3142}

74. Sgt Shannon testified he researched the common law and civil law (specifically, the law of torts).^{Footnote 3143} From this research he “was able to determine that there is no definitive rule or process in defining NOK.”^{Footnote 3144}

75. Having concluded there was no legal definition of PNOK or NOK, Sgt Shannon turned to a completely different source – societal customs. From his research, he determined the process for defining NOK relied heavily on such customs.^{Footnote 3145} He said the customs of society dictate the spouse is the person responsible in situations when a member of someone’s family is in difficulty or requires assistance.^{Footnote 3146} The spouse is the person who should make any decisions or take responsibility for the individual.^{Footnote 3147} In his testimony, Sgt Shannon explained:

Our society determines who the family representative would be, which is the spouse based on our customs. If you go and speak to a married person they have a spouse. If you have issues with that family and something happens to the husband you’re not going to go and try to find his parents. The spouse is right there.^{Footnote 3148}

76. In arriving at this conclusion, Sgt Shannon did not rely on any external resource. He believed his own personal assessment of societal customs to be an adequate basis for answering a legal question.^{Footnote 3149} He did state in testimony it is ultimately up to a judge to make “that legal determination” if there is any conflict about who is NOK because there is no substantive definition or process for determining NOK.^{Footnote 3150} However, for the purpose of this investigation, Sgt Shannon relied exclusively on his own interpretation of societal customs.

77. Sgt Shannon stated such customs depend on how society defines family. As an example, in a primarily Anglo-Saxon Christian society, family would be spouse, parents, brothers, sisters, stepsisters, stepbrothers, etc. Other cultures in present day Canada accept only a male as the NOK.^{Footnote 3151} He agreed, regardless of which community is being examined, NOK can comprise more than one individual.^{Footnote 3152} However, he believed the spouse would take precedence as NOK in 99 percent of cultures within Canada.^{Footnote 3153}

78. In his opinion, the customary understanding of “spouse” includes “common-law spouse.” In this situation, hence, there is no difference between those who are legally married and those who complete a CF common law statutory declaration.^{Footnote 3154} In either case, no other family member takes precedence over the spouse.^{Footnote 3155}

79. Sgt Shannon believed a common-law spouse is equivalent to a spouse, which is equivalent to NOK.^{Footnote 3156} Using this formulation for the meaning of NOK, the only issue under investigation necessarily became whether Cpl Langridge and Ms. A were in a common-law relationship, as the military defined it, at the time of Cpl Langridge’s death.^{Footnote 3157} If so, then Ms. A was properly Cpl Langridge’s PNOK. Sgt Shannon saw no difference between alleging the NOK had been improperly designated and alleging the common-law spouse had been improperly identified.^{Footnote 3158}

Marital status of Cpl Langridge and Ms. A

80. In addressing the issue of Cpl Langridge’s marital status, Sgt Shannon considered only whether a common-law relationship existed based on military rules and regulations.^{Footnote 3159} In his investigative assessment,^{Footnote 3160} Sgt Shannon identified the policy and regulations relevant to the issue of Cpl Langridge’s common-law status at the time of his death. He identified two different orders stipulating when a common-law relationship was no longer deemed to be valid by the CF. The first states the relationship will be considered terminated when there has been a three-month period of separation between the CF member and the common-law spouse, and imposes an obligation on the CF member to advise the CO when the relationship no longer meets the conditions for recognition by the CF.^{Footnote 3161} Sgt Shannon also identified a second Instruction, stating the only method of terminating a common-law relationship was for the CF member to advise the CO in writing using a specified form.^{Footnote 3162} Both of these provisions existed at the time of Cpl Langridge’s death, so, at that time, a common-law relationship could have been ended by either set of actions.^{Footnote 3163} Sgt Shannon was satisfied that Cpl Langridge continued to be in a common-law relationship with Ms. A at the time of his death because they had not been separated for three months, nor had Cpl Langridge filed any paperwork advising the CO of the end of the relationship.

81. Sgt Shannon found “the record is quite clear”^{Footnote 3164} that Cpl Langridge and Ms. A had a temporary separation at the time of his death but had not been separated for more than three months.^{Footnote 3165} Sgt Shannon determined the date of separation primarily based on one document, described by him as a statutory declaration of the landlord stating Cpl Langridge and Ms. A ceased to have co-financial responsibility for their joint residence on February 11, 2008.^{Footnote 3166} He considered financial responsibility for a residence in which the couple had lived to be evidence of continuing cohabitation.^{Footnote 3167} Since February 11, 2008 was within three months of the date of Cpl Langridge’s death on March 15, 2008, he concluded Cpl Langridge and Ms. A had not been separated for a period of three months or greater as required by the CF Order.^{Footnote 3168} It was not of concern to him whether Cpl Langridge or Ms. A had actually been living in the residence until February 11, 2008. He believed this was legally their joint residence until the day they mutually ceased being responsible for their shared property.^{Footnote 3169} For him, this fact, along with the fact their personal effects were located in the residence, was enough to establish the continuation of the common-law relationship within three months of Cpl Langridge’s death.^{Footnote 3170}

82. By establishing that Cpl Langridge and Ms. A were in a common-law relationship at the time of his death, Sgt Shannon believed he had determined who the PNOK was. He had answered the allegation as he had interpreted it.

“New” allegation by Mrs. Fynes – lack of involvement in funeral planning

83. Well into his investigation, Sgt Shannon added on his own accord an allegation concerning the Fynes’ role in the funeral. He testified:

[...] However, I will add that the November [2010] press conference by Mrs. Fynes she made a public allegation that the Canadian Forces allowed other members to plan her son’s funeral. Upon hearing that public allegation, I expanded the scope of my investigation and I incorporated that new allegation into my investigation.^{Footnote 3171}

84. This “new” allegation specifically addressed the Fynes’ concern about Ms. A’s role in planning the funeral.^{Footnote 3172} Sgt Shannon understood Mrs. Fynes to be complaining she had not been involved in the planning of her son’s funeral.^{Footnote 3173}

85. Of note, this particular allegation is not mentioned in Sgt Shannon’s investigation plan,^{Footnote 3174} investigative assessment^{Footnote 3175} or in his PowerPoint presentation to the chain of command at the conclusion of the file.^{Footnote 3176} He testified, by the time he prepared the presentation, he had already determined to his own satisfaction that this allegation was not founded, so there was no need to address it.^{Footnote 3177} In fact, the first mention of this specific allegation being part of Sgt Shannon’s investigation came during his testimony. It is unusual to investigate an allegation without making note of it anywhere in the file and without recording any conclusions. It is also perplexing an investigation of “new” allegations would be attempted on the basis of a press conference without ever contacting the person making the allegation.

86. Sgt Shannon testified Mrs. Fynes had communicated with Ms. A, both by phone and through her AO, to make decisions concerning the funeral prior to the regiment recognizing Ms. A’s decision-making authority over the funeral. Sgt Shannon interpreted this as Mrs. Fynes having “made statements that she was going to be co-planning the funeral with [Ms. A].”^{Footnote 3178} He stated Mrs. Fynes had, on the first day after Cpl Langridge’s death, made the same decision as the regiment about who could give instructions regarding the funeral.^{Footnote 3179} It was his opinion Ms. A, because she was the spouse, received communications from Mrs. Fynes and an agreement was reached concerning how the funeral service would transpire.^{Footnote 3180} He explained:

If you look at the totality of the circumstances in this case, Mrs. Fynes, on the very first day, when she became aware that her son had passed, provided her wishes on what would happen at the funeral through her assisting officer to [Ms. A] as the next of kin. So even before she was advised of that decision by the Canadian Forces, she had instinctively realized that her son’s spouse would be the person that would be dealing with these matters. That is the only logical assumption that you can draw from the fact that she identified her wishes and communicated them in a diplomatic and polite manner to the spouse of her son.^{Footnote 3181}

87. Sgt Shannon was also of the opinion the Fynes had a significant input into the funeral and, in his view, all the wishes of the Fynes concerning the funeral were accommodated by Ms. A.

The record is also very clear, the documentary record, especially the personal notes of the Assisting Officer of Mrs. Fynes, that there is not one wish of Mrs. Fynes in regards to the final remembrance of her son that was not agreed to by [Ms. A]. [Ms. A] then communicated the wishes of the family to the Regiment through her Assisting Officer. The Regiment responded to those wishes.^{Footnote 3182} [Emphasis added]

88. On the narrow question of the Fynes’ involvement in funeral planning, Sgt Shannon concluded there was no basis for the allegation they had been excluded.^{Footnote 3183}

Problems with Sgt Shannon’s Investigation

Misunderstanding of the allegation

89. During their respective interviews with the CFNIS, the Fynes and the Ombudsman’s investigators raised many different issues. However, the issue to be investigated, as identified by Maj Dandurand in the investigative assessment, was the decision confirming Ms. A and not the Fynes as Cpl Langridge’s PNOK.^{Footnote 3184} There was no explicit definition of the terms “primary next of kin” and “next of kin” when the complaint was formulated, nor was there a test of the connection between being recognized as PNOK and the ability to plan the funeral. Yet, it seems likely that all those involved in the investigation prior to Sgt Shannon shared the belief the person recognized as PNOK was entitled to plan the CF member’s funeral.^{Footnote 3185} The terms NOK and PNOK had been used by the investigators, the regiment and the complainants to mean the individual who had final decision-making authority over the funeral.

90. The Fynes were upset about the designation of PNOK because of the consequences it had on funeral planning.^{Footnote 3186} In their second interview with the CFNIS, Mrs. Fynes explained the issue in this way, “When we went to the funeral, because she [Ms. A] was the primary next of kin, and she got to call the shots, she closed the casket, she arrived... she chose everything.”^{Footnote 3187} The Ombudsman’s investigators and Maj Dandurand confirmed there was discussion in their meeting about who the appropriate PNOK for the purposes of funeral planning would have been.^{Footnote 3188}

91. Members of the chain of command of the regiment established in their testimony that in their view “the next of kin is entitled to plan and coordinate the funeral”^{Footnote 3189} and the implications of the NOK decision “are significant in terms of having influence over funeral proceedings.”^{Footnote 3190} This understanding of the role of the PNOK is supported in the QR&Os, which state a military funeral will be accorded to a deceased member of the CF where the next of kin so desires.^{Footnote 3191} As a result of the regiment’s recognition of Ms. A as PNOK, members of the chain of command testified the regiment would have defaulted to the wishes of Ms. A had there been a discrepancy between what the Fynes and Ms. A had wanted at the funeral.^{Footnote 3192}

92. The CFNIS, at least prior to Sgt Shannon’s involvement, also had this understanding of the role of the PNOK. The initial complaint found in the investigation file states Ms. A had been appointed as NOK and “this decision denied the Fynes the right to make arrangements for their son’s funeral.”^{Footnote 3193} MCpl Mitchell explained his understanding of PNOK as “the person best suited in order to ensure that what I want done as regards to funeral or estate.”^{Footnote 3194} MS McLaughlin was a little more circumspect about the exact role of the NOK, stating he did not know the consequences of being named NOK,^{Footnote 3195} though the result in this case had been to allow Ms. A to make the funeral arrangements.^{Footnote 3196} Maj Dandurand also believed one consequence of the NOK designation was to allow Ms. A to make decisions about the funeral.^{Footnote 3197} Maj Dandurand described the NOK decision as the decision from which everything else flowed, including the ability to plan the funeral.^{Footnote 3198} In fact, Maj Dandurand had not even asked for the meaning of “next of kin” with respect to funeral planning to be determined given that, for him, the consequences of the PNOK decision seemed so obvious in this case.^{Footnote 3199} Up until this point in the investigation, no investigator had seriously questioned the connection between the PNOK and funeral planning. It was also clear funeral planning was the issue of concern for the complainants.

93. However, the essence of the allegation is not reflected in the GO file. While the initial complaint synopsis does include the allegation that Ms. A’s appointment as NOK “denied the Fynes the right to make arrangements for their son’s funeral,”^{Footnote 3200} the subsequent summary of the meeting with the Ombudsman’s investigators,^{Footnote 3201} the investigative assessment prepared by Maj Dandurand^{Footnote 3202} and MCpl Mitchell’s investigation plan^{Footnote 3203} all refer only to investigating possible negligence in the making of the PNOK decision. The Fynes’ allegation concerning who was entitled to plan the funeral was not included.

94. Sgt Shannon’s understanding of the allegations came from his review of documents relevant to the investigation. However, if the allegation concerning funeral planning was implied but not specifically stated, Sgt Shannon could not readily have been able to determine what should have been under investigation. Despite this, it was Sgt Shannon’s responsibility, as the new lead investigator, to clarify what should have been under investigation.

95. Sgt Shannon informed himself about the file only by conducting what he considered to be a thorough review of its contents. While he insisted he was required, as part of the file handover process, to read all the documentation on the file and that he had done so,^{Footnote 3204} there were some notable exceptions to his purported comprehensive file review. This may have contributed to his imperfect understanding of the allegations.

96. Sgt Shannon testified he was required to review all the material on the file including all audio and video recordings.^{Footnote 3205} However, he did not review recordings of the three interviews with the Fynes.^{Footnote 3206} Instead, he simply reviewed interview summaries and notes.^{Footnote 3207} Notably, from the second and third interviews with the Fynes, there are over five hours of audiotape comprising 360 pages of transcripts.^{Footnote 3208} Yet there are only four pages of summaries for these interviews in the GO file.^{Footnote 3209} The written summaries are far less comprehensive than the audio recordings; many specifics are not included and would not have been known to Sgt Shannon. All audio recordings should have been reviewed to ensure the Fynes’ actual allegations were understood. In addition, consideration should have been given to conducting a fresh interview with the Fynes.

97. No audio recording or contemporaneous notes existed for the December 2009 meeting with the Ombudsman’s investigators, so Sgt Shannon could not have reviewed a complete account of what occurred at that meeting. However, it would have been possible to contact Mr. Martel to discuss the allegations made during his meeting with the CFNIS, or to discuss it with the CFNIS members who were present. Instead, the decision was made not to contact Mr. Martel who, at least on paper, was identified as the complainant.

98. Sgt Shannon did not meet with Maj Dandurand until some two months into his investigation,^{Footnote 3210} at a briefing Sgt Shannon provided to the command team sometime after he had already reached conclusions about the allegations. Sgt Shannon testified he was of the firm belief, when he began the meeting, he “had failed to cross the threshold of a mere suspicion that any individual of the Canadian Forces had committed any offence defined by the Criminal Code of Canada or by the Code of Service Discipline.”^{Footnote 3211} While he testified he kept an open mind and was inquisitive,^{Footnote 3212} it is questionable whether this meeting had any impact on Sgt Shannon’s understanding of the allegations. The conclusions reached in the investigation suggest it did not.

99. Rather than seeking out primary sources to clarify or verify his understanding of the allegation, Sgt Shannon relied on his own reading of relevant documents to form his understanding of the allegations. He framed the issue under investigation simply as determining whether Ms. A, as the common-law spouse of Cpl Langridge, was his NOK at the time of his death.^{Footnote 3213} Admittedly, the Fynes themselves often expressed their complaint simply in terms of PNOK status. However, the fact remains the essence of the complaint was about funeral planning and that should have been the focus of the investigation.

100. The allegation concerning who was entitled to plan the funeral was not considered. It does not matter if the common-law spouse was the equivalent of PNOK, if the PNOK was not entitled to plan the funeral. However, no one ever asked if the PNOK was entitled to plan the funeral. The link between the PNOK and the authority to plan the funeral was never made. Nor was it considered important. Maj Dandurand testified that at the time he viewed the ultimate question as what factors went into the CO’s decision as to who was the NOK.^{Footnote 3214} However, if the PNOK does not have the authority to plan the funeral, then determining who is the PNOK is not responsive to the allegation made by the Fynes and the Ombudsman’s investigator. There was no analysis completed about whether Ms. A was the correct person to plan the funeral and whether the regiment was negligent in recognizing that entitlement.

101. The addition of the “new” allegation by Sgt Shannon also reflected his misunderstanding of the Fynes’ primary concern. Sgt Shannon’s formulation of the “new” allegation still did not address the central issue of who was entitled to plan the funeral. Sgt Shannon focused narrowly on whether the Fynes had any input into the funeral, not on whether they had been deprived of their rightful decision-making authority in the matter. This was an inadequate understanding of the actual allegations made by the complainants and the issues in need of investigation.

Incomplete and faulty legal analysis

102. The investigation of the issue of who was entitled to plan Cpl Langridge’s funeral was a legally complex one. Meticulous research should have been conducted to find all the relevant CF orders, policies and directives potentially applicable to the issue of funeral planning and the recognition of common-law relationships. In addition, research should have been done on whether any provincial or federal law existed on either of these issues. A careful analysis had to be conducted to determine what law applied in the circumstances. This type of detailed evaluation of the PNOK allegation required the specialized training of a lawyer. However despite his lack of training, Sgt Shannon undertook the legal analysis himself.

103. It is the Commission’s opinion Sgt Shannon’s purported comprehensive review of the relevant law was incomplete and incoherent. He missed a number of relevant CF orders and policies, in part because he did not recognize the relevance of regulations dealing with funerals. He also improperly dismissed the relevance of provincial law by focusing on the general principle that the military has no duty to enforce provincial law and the CFNIS has no power to investigate breaches of provincial law.

104. Sgt Shannon’s central thesis in the investigation – that common-law status was the equivalent of NOK – is likely not supportable in law. This central assumption, around which his investigation was based, was never tested by legal counsel. If it was incorrect to conclude that a common-law spouse, as defined by the CF, and PNOK are equivalent, then the entire investigation was faulty.

Incomplete understanding of the PEN form

105. Sgt Shannon’s investigation began with the PEN form. While he was convinced the purpose of the form was straightforward and easy to determine,^{Footnote 3215} a careful review shows there are conflicting messages about the status of the PNOK as named on the PEN form.

106. Sgt Shannon failed to identify the anomalies in the PEN form. The form is not clear. It allows for separate identification of the PNOK and SNOK, and the personal emergency notification contact,^{Footnote 3216} but it does not describe the purpose or role of the NOK. If the form was primarily for the purpose of emergency notification, why identify the PNOK and SNOK on it at all? Why designate the NOKs on the form if they have no status?

107. Sgt Shannon also failed to identify as relevant the portion of CFAO 26-18 stating, “The person designated as PEN contact or NOK should be capable of making decisions in an emergency, especially in respect of funeral and burial.”^{Footnote 3217} Clearly, in this order it was assumed funeral arrangements would be the purview of the PNOK or PEN contact as designated on the PEN form.

108. Given this lack of clarity, CF members can be excused for not having as clear an understanding of the PEN form as Sgt Shannon had developed. There was a widespread understanding that the PNOK, as named on the PEN form, were entitled to plan a deceased member’s funeral. This understanding was even shared by members of the CFNIS,^{Footnote 3218} in particular Maj Dandurand, who had believed throughout his entire career that the PNOK as named on his PEN form would have an impact on things “such as planning of my funeral, should anything untoward happen.”^{Footnote 3219} For this reason, it seems at least plausible the PEN form could be of some value in determining the intentions of Cpl Langridge concerning who would have decision-making authority over his funeral.

109. Sgt Shannon did not account for the anomalies in the PEN form and in CFAO 26-18 indicating the NOK do have a role different from the emergency contact and, specifically, some responsibility with respect to funeral and burial arrangements. As a result, his analysis of the PEN form was incomplete. Assistance from legal counsel should have been sought in developing a complete analysis of the PEN form.

Failure to seek legal advice on PNOK research

110. The Commission is of the opinion Sgt Shannon should have sought legal advice to ensure the research he conducted concerning the role of the NOK was complete. Despite his assertions to the contrary, Sgt Shannon did miss identifying some CF orders containing a definition of PNOK. For example, Sgt Shannon did not identify CFAO 24-5 on “Funerals, Burials and Graves Registration” which provides a definition of NOK to be used in connection with that order.^{Footnote 3220} DAOD 7011-0 on service estates and personal belongings also supplies a definition of NOK.^{Footnote 3221} It may be that PNOK is a particular term of art within the military legal context. Sgt Shannon sought no legal advice to confirm that the PNOK definitions in military orders could all be safely ignored or to verify whether his conclusions concerning the utility of the definitions of PNOK contained in military orders were supportable.

111. The exact sources consulted in the investigation are not listed in the GO file and it is not known which specific pieces of federal legislation, provincial legislation or case law were accessed for Sgt Shannon’s research. It is, therefore, not known whether, in the course of this research, Sgt Shannon became aware of Fasken v. Fasken,^{Footnote 3222} a 1953 Supreme Court of Canada case that considered the meaning of the term “next of kin.” That case, the Court’s most recent statement on this subject, suggests that at common law, and in the absence of statutory provisions to the contrary, blood ties are determinative of status as next of kin and, if there are no children, surviving parents constitute next of kin, even if there are living siblings.

Lack of recognition of the role of the executor in funeral planning

112. Significantly, while acknowledging the executor had an important role to play after the death of an individual, Sgt Shannon completely dismissed the role of executor as relevant to his investigation because he was not investigating who was in charge of planning the funeral.^{Footnote 3223} He failed to consider CF orders and policy concerning the executor as well as those relevant to the issue of funeral planning. Notably, in testimony Sgt Shannon acknowledged missing DAOD 7011-1 in his research.^{Footnote 3224} This is a substantial omission given that the text of the order reads, “The executor or liquidator of the succession named in a will is, subject to provincial law, entitled to the custody of the remains. The executor or liquidator of the succession is not necessarily the deceased’s NOK.”^{Footnote 3225} The Casualty Admin Guide also refers to the role of the executor, stating “the Assisting Officer with the assistance of the chaplain, will discuss with the Estate Executor with respect [sic] to interment.”^{Footnote 3226}

113. Contrary to the belief of the regiment, the Fynes, and the earlier investigators, these directives suggest the PNOK was not entitled to make decisions about interment of Cpl Langridge’s remains. However, other CF policy documents suggest the NOK are entitled to plan the funeral and still others suggest there is a role in funeral planning for both the NOK and the executor.^{Footnote 3227} However, because Sgt Shannon’s research was incomplete, and he did not understand the allegations centred on funeral planning, he did not consider how this variety of CF policies fit together.

114. Interestingly, the question of the role of executor did surface in the investigation, but not as a result of any research or legal conclusions reached by Sgt Shannon. Rather, it was raised as an issue at the CFNIS command team meeting in early November 2010. As a result of the meeting, Sgt Shannon was asked to investigate “the role of the Executor of a CF Will in the planning process of a funeral of a CF member” in the follow up interviews with the subject matter experts, Sgt Carole Pelletier and LCdr Charles Gendron.^{Footnote 3228} MS Tania Gazzellone, who assisted Sgt Shannon in conducting the interviews, did ask questions with respect to the role of the executor, and both experts thought the executor would play some role in funeral planning.^{Footnote 3229} However, given a hypothetical situation very similar to Cpl Langridge’s, the subject matter experts advised such matters were best addressed to the JAG.^{Footnote 3230} Apparently, Sgt Shannon did not feel it was necessary to act on that advice.

Applicability of provincial law

115. Sgt Shannon rejected the applicability of provincial law to the issues under investigation. Specifically, he rejected the use of provincial law as a potential basis for establishing a breach of a military duty, a necessary element for the Code of Service Conduct offence of negligent performance of a military duty.^{Footnote 3231} In his assessment, he had “no jurisdiction or interest in provincial law and it has no bearing on the actions or conduct of members of the Canadian Forces.”^{Footnote 3232} While Sgt Shannon agreed part of the Fynes’ allegation was that a decision concerning the appointment of PNOK had been made without reference to provincial statutes, he testified it would not be appropriate to hold the potential suspects up to the standard of knowing and having to abide by provincial statutes.^{Footnote 3233} He stated he was very clear and concise in identifying the military rules, regulations and orders applicable to this case and in concluding the provincial statutes could not be the basis for imposing a duty related to military operations.^{Footnote 3234}

116. The assertion provincial law was not relevant to the investigation is questionable. Under the Constitution Act 1867, matters of property, wills and estates, as well as marital status, all fall under provincial legislative jurisdiction.^{Footnote 3235} Prima facie, therefore, provincial legislation and case law interpreting the common law may be potentially relevant, if not determinative, with respect to those issues. Valid federal (including military) law will prevail over valid provincial law in cases of conflict. However, whether there is a conflict, whether the respective laws are validly enacted from a constitutional point of view, and whether any apparently conflicting laws can be reconciled, are all subtle and complex legal questions. The categorical statement in the final briefing letter to the Fynes that “the investigation did not consider any provincial legislation as a source of reference owing to the fact the NDA hold[s] legal precedence over provincial legislation”^{Footnote 3236} is based on a great over-simplification.

117. The Fynes had raised the issue of the relevance of provincial law to the funeral planning allegation in their discussions with the CFNIS.^{Footnote 3237} The Ombudsman’s investigator had provided copies of what was believed to be relevant provincial legislation to the CFNIS.^{Footnote 3238} Provincial law should not have been dismissed out of hand.

118. Sgt Shannon’s rejection of provincial law meant he did not consider two potentially relevant pieces of Alberta legislation – the Funeral Services Act^{Footnote 3239} and the Adult Interdependent Relationship Act.^{Footnote 3240} The Funeral Services Act is the provincial statute concerning the disposition of human remains in Alberta. While there is nothing in the legislation concerning who is entitled to plan the deceased’s funeral, the regulation does contain direction concerning who is entitled to dispose of the remains of the deceased. The first person with the right to dispose of the remains is the personal representative designated in the will of the deceased.^{Footnote 3241} The term “personal representative” is neither defined in the Act nor in the regulation but most likely refers to the executor as named in the will. Mr. Fynes was eventually recognized by the CF to be Cpl Langridge’s executor.^{Footnote 3242} This legislation, and this section in particular, were brought to the attention of the CFNIS early in the investigation and included in the documents received from the Ombudsman.^{Footnote 3243}

119. The Adult Interdependent Relationship Act defines the entitlement to status as adult interdependent partners for residents of Alberta.^{Footnote 3244} Though different language is used, “interdependent partner” appears to be another term for “common-law spouse.” Under the provisions of the Act, Ms. A and Cpl Langridge were not interdependent partners, not having fulfilled any of the necessary pre-conditions (living together for a period of three years, having children or having entered into an adult interdependent agreement under the Act).^{Footnote 3245} According to the Fynes, if Ms. A was not Cpl Langridge’s interdependent partner under the provincial legislative scheme, she was not his spouse.^{Footnote 3246} If the Fynes were correct, even with Sgt Shannon’s conclusion that NOK equals spouse equals common-law spouse, Ms. A could not be his PNOK.

Failure to investigate who in the Chain of Command made the PNOK decision

120. Sgt Shannon’s failure to investigate the issue of who named or recognized Ms. A as PNOK was the result of his faulty conclusion that she was clearly the correct NOK and also his opinion Cpl Langridge himself determined his NOK simply by entering into a common-law arrangement.^{Footnote 3247}

121. Sgt Shannon testified the military relies on administrative documents completed by members to disclose the individual family circumstances of each member.^{Footnote 3248} In this case, Cpl Langridge had completed a CF common-law statutory declaration with Ms. A in December 2007. Since it was Sgt Shannon’s thesis that PNOK was the equivalent of spouse and common-law spouse, he concluded the military had no role to play in placing Ms. A in a position where she could exercise the duties, privileges and responsibilities associated with PNOK. It was his opinion Cpl Langridge had already made such a determination^{Footnote 3249} and all the military did was support those wishes.^{Footnote 3250} Thus, Sgt Shannon did not find it relevant to his investigation to determine who in the regiment actually made the decision regarding PNOK or how the decision was made.

122. This conclusion is difficult to understand and involves a measure of circular reasoning. For Sgt Shannon, the only relevant decision was Cpl Langridge’s decision to enter into a common-law relationship with Ms. A. This decision led to Ms. A being his PNOK. However, this line of reasoning seems to ignore that the relevant “decision” was the decision to recognize Ms. A as PNOK, not the decision of Cpl Langridge to make Ms. A his common-law spouse. Someone in the military had to decide whether Cpl Langridge’s declaration of common-law did indeed make Ms. A his PNOK. Someone had to recognize Ms. A’s entitlement to PNOK status in order for the status to be meaningful.

123. It would seem precisely such a decision was conveyed in the email sent by LCol Demers prior to the casualty coordination meeting on March 17, 2009, stating “given the docs on file, it seems [Ms. A] is PNOK, so we need to follow her wishes.”^{Footnote 3251} Sgt Shannon testified this was not a decision about who was PNOK, but a direction from the CO.^{Footnote 3252} Whether it was a direction or decision, this email clearly seems to constitute evidence relevant to determining who in the regiment had made the PNOK decision. However, Sgt Shannon completed his inquiry into the matter with the conclusion the PNOK decision was Cpl Langridge’s alone.

Failure to interview key players

124. Having attributed the PNOK decision to Cpl Langridge, Sgt Shannon failed to interview the key players in the actual decision-making process. In his investigation plan, Sgt Shannon identified four interviews to be conducted concerning the NOK allegation – Maj Cadieu, LCol Demers, Maj Reichert and Capt Lubiniecki.^{Footnote 3253} With the exception of Maj Reichert, Sgt Shannon considered each of these officers to be suspects in his investigation^{Footnote 3254} However, Sgt Shannon interviewed none of them.

125. In his testimony, he stated the “reasonable suspicion model” led to his decision not to interview anyone identified as a suspect.^{Footnote 3255} He explained that, to invoke his authority and power as a police officer, he must have a reasonable suspicion the individuals to be interviewed had committed a crime. Since at no time did he establish a reasonable belief an offence had occurred, he did not interview anyone identified as a suspect.^{Footnote 3256}

126. This logic is flawed. Sgt Shannon concluded the officers identified as potential suspects did not need to be troubled with interviews because he did not believe they had a role in any possible offence. However, interviewing these officers may have clarified if they did in fact have a role or useful information that would have cleared up any errors of fact about what occurred at the casualty coordination meeting and how the PNOK decision was made.

127. Furthermore, Sgt Shannon’s interpretation of his authority to interview suspects was not one shared by other members of the CFNIS. MCpl Mitchell was prepared to interview all those who had attended the casualty coordination meeting, including identified suspects.^{Footnote 3257} When he learned, during the course of his interview with Capt Brown, that Capt Brown had attended the casualty coordination meeting, he administered a caution.^{Footnote 3258} Sgt Shannon could have proceeded in the same manner when interviewing other subjects.

128. As interviews with police are always voluntary in any event, there was no issue about Sgt Shannon not being able to exercise his “authority” absent sufficient suspicion.

129. Sgt Shannon could have relied on factual evidence gathered from interviews as well as factual evidence gathered from documents. However, with the exception of two interviews with subject matter experts, Sgt Shannon’s entire investigation focused on a review of documents. He chose not to interview the witnesses identified in his investigation plan because he viewed the records and documents to be much more accurate than witness interviews taking place years after the events occurred.^{Footnote 3259} It was Sgt Shannon’s belief, in this particular case, the documents spoke louder than words^{Footnote 3260} and, while the witnesses provided many different versions of events, the documents eliminated the “static.”^{Footnote 3261} According to Sgt Shannon, the information in the documents was very black and white and explained the story so there could be no contesting what had happened.^{Footnote 3262} Sgt Shannon assumed the documents made it obvious who did what and when. He rejected witness interviews as a potentially valuable source of information, even though significant and otherwise unavailable information could have been gained from speaking to some of those involved in the events under consideration.

Insufficient investigation of the status of the common-law relationship

130. Regarding his investigation of whether Cpl Langridge was in a common-law relationship at the date of his death, Sgt Shannon would have benefitted from conducting interviews with fact witnesses prior to reaching his conclusion there was evidence of cohabitation. There were many interviews that could and should have been undertaken. Sgt Shannon did not interview Ms. A, even though it seems entirely likely an interview with her would have yielded important information on the status of her relationship with Cpl Langridge at the time of his death, and when (or even if) they had ceased to cohabit. A brief interview with Mrs. Fynes could have been useful in confirming when she helped move Cpl Langridge out of his joint accommodation with Ms. A. Sgt Shannon rejected the need to interview Mrs. Fynes because she had already been interviewed several times,^{Footnote 3263} though not on the topic of Cpl Langridge’s marital status. Likewise, an interview with Padre William Hubbard, who helped move Cpl Langridge’s belongings out of his and Ms. A’s shared residence, may have proven useful.^{Footnote 3264}

131. Sgt Shannon relied only on prepared summaries of interviews with the Fynes.^{Footnote 3265} As a result, he missed information the Fynes gave concerning the status of Cpl Langridge’s common-law relationship with Ms. A. The audio tapes contained a number of potentially relevant allegations by Mrs. Fynes, notably: the chain of command was aware Cpl Langridge and Ms. A had broken up because they had made a verbal declaration before Maj Jared;^{Footnote 3266} Ms. A had asked for a restraining order on Cpl Langridge;^{Footnote 3267} Veterans Affairs had deemed Cpl Langridge to be single at the time of his death;^{Footnote 3268} and the relationship had ended when Cpl Langridge left the residential treatment centre in early January 2008.^{Footnote 3269} None of this information appeared in the summaries prepared by MCpl Mitchell, but all of it might have been relevant to the issue of Cpl Langridge’s cohabitation with Ms. A.

132. Sgt Shannon found there was no statutory declaration ending the common-law relationship as per CF policy in the unsigned documents found behind the filing cabinet after Cpl Langridge’s death (discussed in more detail below). To Sgt Shannon, the absence of this document meant Cpl Langridge had not been contemplating ending his relationship with Ms. A.^{Footnote 3270}

133. However, there was evidence to suggest such a document may have existed. In her interview with MCpl Mitchell as part of this investigation, WO (Ret’d) Doucette said that after Christmas 2008, MCpl Fitzpatrick had told MCpl Birt Cpl Langridge wanted to dissolve his common-law relationship and, as a result, MCpl Birt put together a package containing the necessary forms and gave it to MCpl Fitzpatrick for Cpl Langridge.^{Footnote 3271} In testimony, MCpl Fitzpatrick confirmed Cpl Langridge had told him he and Ms. A had split up and MCpl Fitzpatrick provided him with blank forms to update. It is not clear from his testimony if the dissolution form was included, but he did provide Cpl Langridge with a package of forms.^{Footnote 3272} Four partially completed forms, not including the form dissolving the common-law relationship, were found by MCpl Fitzpatrick behind his filing cabinet after Cpl Langridge died. While the forms should have been returned to the clerk,^{Footnote 3273} MCpl Fitzpatrick stated Cpl Langridge also had the option of returning the completed forms directly to him or someone he knew in the office because Cpl Langridge was transferred to the Regimental Quarter Master’s shop from MCpl Fitzpatrick’s office shortly after receiving the forms.^{Footnote 3274}

134. Sgt Shannon simply accepted that since no form had been found, none existed. He did not investigate further. It is entirely possible Cpl Langridge decided not to formally end his relationship with Ms. A, and therefore never completed a dissolution form. However, in all the other forms found, Cpl Langridge had indicated the benefits were to be given to his parents. Given the importance of the dissolution form to the whole issue of Cpl Langridge’s common-law status, Sgt Shannon should arguably have undertaken some effort to satisfy himself no such form existed. This could have included reviewing the interview of WO (Ret’d) Doucette^{Footnote 3275} and interviewing MCpls Birt and Fitzpatrick.

135. Sgt Shannon could have spoken to members of the regiment concerning where Cpl Langridge’s original will was found as it was not discovered for the first few days after his death.^{Footnote 3276} Given the CFNIS and the regiment had both misplaced important documents in this and the 2008 investigation, it would have been prudent for Sgt Shannon to investigate to ensure no dissolution form existed.

136. Ultimately, it may be Sgt Shannon was correct in his conclusion that under military law a common-law relationship still existed at the time of Cpl Langridge’s death. The CF requirements necessary to terminate the relationship may not have been met. However, in arriving at that conclusion, Sgt Shannon ignored many sources of relevant evidence. His factual inquiry into the common-law relationship was cursory. While Sgt Shannon’s conclusion may have been correct, it was supported by incomplete evidence.

Inadequate investigation of the Fynes’ intentions for funeral planning

137. Similarly, Sgt Shannon did not conduct a thorough factual investigation of the Fynes’ involvement in funeral planning. His conclusions were based on very significant assumptions about Mrs. Fynes’ intentions regarding Cpl Langridge’s funeral and about her actual role in making decisions about the funeral and the disposition of Cpl Langridge’s body. These assumptions were without basis in anything the Fynes had said and unsupported by the facts.

138. It is difficult to understand how Sgt Shannon could possibly know what Mrs. Fynes’ intentions were concerning who would plan the funeral since he had never talked to her about her involvement in the funeral planning or listened to the interviews conducted with the Fynes by the CFNIS. The Fynes had never expressed any intention that Ms. A should be the one to plan the funeral. Rather they acquiesced to what they understood to be Ms. A’s authority to plan the funeral when they were told the regiment had recognized her as PNOK. They felt they had no choice in who planned the funeral.^{Footnote 3277}

139. Furthermore, Sgt Shannon’s interpretation of the facts concerning Mrs. Fynes’ intentions for funeral planning is questionable. For example, the telephone call from Mrs. Fynes to Ms. A in the days following Cpl Langridge’s death was likely not viewed by Mrs. Fynes (or Ms. A for that matter) as Mrs. Fynes agreeing with Ms. A’s authority to plan the funeral. Indeed the phone call was motivated, at least in part, by a desire of the Fynes to reassure Ms. A that Cpl Langridge’s debts would be paid.^{Footnote 3278}

140. Sgt Shannon was also not correct that all of the Fynes’ wishes concerning the funeral were met. They clearly conceded to Ms. A several matters of importance. The most significant concessions involved negotiations concerning the flag to be placed on Cpl Langridge’s casket and whether his remains would be buried or cremated. The Fynes had wanted the regimental flag to be used.^{Footnote 3279} In communications between the AOs, Ms. A’s preference for cremation had been conveyed. However, Ms. A was willing to budge on cremation if the Canadian flag was used on the casket instead.^{Footnote 3280} Since the issue of how the remains would be disposed was an emotional one for Mrs. Fynes,^{Footnote 3281} she agreed with Ms. A’s request in order to avoid having Cpl Langridge’s remains cremated.^{Footnote 3282} When the flag was removed from the casket at the funeral, it was presented to Ms. A.^{Footnote 3283} The Fynes felt strongly they should have received it.^{Footnote 3284} Ms. A also had a viewing of the body prior to the funeral, which the Fynes would not have had^{Footnote 3285} and Ms. A closed the casket.^{Footnote 3286}

141. The evidence shows Mrs. Fynes compromised on issues about which she felt very strongly. These facts would have been available to Sgt Shannon had he met with the Fynes to discuss the allegations, reviewed their previous interviews, and thoroughly reviewed the documents which were part of the GO file.

Conclusion Regarding the Investigation of the PNOK Complaint

142. In the end, the command team agreed with the conclusions Sgt Shannon had reached on the file.^{Footnote 3287} They were satisfied with his investigation and analysis of the allegations and were confident Sgt Shannon had come to proper conclusions.^{Footnote 3288} WO Hart summed it up, in responding to the Fynes’ allegation to the MPCC that both the 2009 and 2010 investigations were inadequate and failed to address the issues to be investigated:

I am fully satisfied that these investigations were conducted thoroughly. There are always going to be difference [sic] in opinion from people as to what they want to see done. However, when we looked at this file, when we looked at the circumstances around here, these matters in a neutral way, not looking to cast blame one side or another and view them on the face as the allegations that were made, I’m comfortable with how these investigations played out. I have no reservations about it at all.^{Footnote 3289}

143. Sgt Shannon and the command team were completely confident in reaching the conclusion the investigation should be closed and no charges were to be laid. Even if this conclusion was correct, fundamental errors were made in the handling of the investigation.

144. While Sgt Shannon correctly identified the need to examine assumptions concerning the use of the PEN form made by the previous investigators and the complainants, he failed to identify the central issue of the complaint. Rather, he focused his investigation very narrowly on whether Ms. A was Cpl Langridge’s common-law spouse at the time of his death. The entitlements associated with being recognized as PNOK, particularly whether this included the entitlement to plan the funeral, were not investigated. Though they did not state their complaint particularly clearly and though they based the complaint on the assumption the PEN form was central to the determination of the issue, the Fynes were ultimately concerned the role of planning the funeral had been given to someone who was not entitled.

145. After the investigation was well under way, Sgt Shannon did consider the additional allegation about funeral planning. The investigation of this allegation focused only on the Fynes’ participation in funeral planning, and still missed the central issue of who was entitled to plan the funeral.

146. As a result of not understanding the complaint, relevant questions were not asked in the investigation. The role of the executor was not considered to be relevant to the issues being investigated. Nor was the identity of the person or persons who actually made the PNOK decision. Neither issue formed part of the investigation.

147. Understanding the complaint and the full range of questions that needed to be investigated was a difficult and complex task. However, it would have been important to properly identify the allegation concerning who was entitled to plan Cpl Langridge’s funeral.

148. A fundamental flaw in the investigation was the failure to seek legal advice.^{Footnote 3290} Once the core of the allegation had been identified, it should have been apparent legal advice was required. The issues of who can be recognized as PNOK, the entitlements associated with that status, as well as who is entitled to plan the funeral are all complex legal questions involving the interplay of multiple military orders and policies as well as consideration of provincial and possibly case law. Those issues required legal input.

149. Instead, all the analysis done was by Sgt Shannon. Even without legal training, Sgt Shannon was convinced he had the experience and expertise necessary to be able to draw legal conclusions with respect to the investigation.^{Footnote 3291} He testified:

I made the determination not to consult legal aid or legal advice because I didn’t believe it was necessary. I believed my assessment of the wording of the orders and the regulations was accurate and logical and clearly articulated and then my articulation of those were supported by the in-depth review by Major Dandurand, [and] the command team.^{Footnote 3292}

150. Legal advice was available had the investigators requested it. MCpl Mitchell had sought and obtained a legal opinion on the 2010 investigation.^{Footnote 3293} There was a dedicated JAG officer in the office of the CO CFNIS who was available to provide opinions and answer questions concerning cases.^{Footnote 3294} Maj Dandurand confirmed investigators were aware of these resources and, if they believed they were delving into areas outside of their expertise, they would not have hesitated to access the available resources.^{Footnote 3295} No acceptable justification was provided for the failure to seek legal advice in this case.

151. The investigation also suffered from other shortcomings. In conducting the investigation about the common-law relationship and the input the Fynes had into funeral planning, there was a failure to conduct interviews with fact witnesses. Assumptions were made that were not supportable on the actual facts.

152. Ultimately, it may well be that Sgt Shannon was correct there was no conduct of members of the CF amounting to a service offence. However, this outcome was not because Ms. A was the correct PNOK. Rather, the underlying military law on PNOK and funeral planning and its interplay with provincial law may have been so murky and complex that a decision-maker coming to a wrong conclusion could not be seen as negligent in the performance of a military duty.

153. To the extent the CF decision-makers took legal advice in making the decision, then even if the decision was arguably wrong in law, it is unlikely it would constitute a service offence since acting on legal advice might well negate negligence. On the other hand, if a legal advisor determined Ms. A should be given decision-making authority over the funeral, he or she might have been guilty of negligent performance of their military duty in the provision of that advice. This possibility was never appreciated, let alone pursued.

154. The fact there might not have been grounds to lay a charge with respect to the decision to name Ms. A as PNOK and to give her authority over the funeral does not absolve those who carried out the investigation of responsibility for the substandard way in which the investigation was carried out. The Fynes’ complaint against the chain of command may not have been sustainable at law, but their allegation against the CFNIS for the way their complaint was investigated is well-founded.

Additional Complaints to the CFNIS

155. In addition to the general complaint about Ms. A being recognized as Cpl Langridge’s PNOK, and the impact of that recognition on decision-making related to Cpl Langridge’s funeral, the Fynes raised with the CFNIS three additional concerns that could support criminal or service offence charges:

Potential offences committed by Ms. A and by the two CF members who accompanied her during her visit to the funeral director, including conduct that may have amounted to fraud in the form of providing false information for the purpose of obtaining benefits;^{Footnote 3296}
Potential criminal conduct or service offences associated with Cpl Langridge’s misplaced paperwork found after his death but prior to his funeral;^{Footnote 3297} and
An allegation that a JAG officer gave an opinion about the status of the relationship between Cpl Langridge and Ms. A based on an outdated policy document.^{Footnote 3298}

156. The Fynes’ complaint to the MPCC alleges the CFNIS failed to properly address issues requiring investigation and failed to investigate issues specifically brought to their attention.^{Footnote 3299}

157. The Fynes were correct to believe these allegations were given, at best, cursory attention. Given Sgt Shannon’s conclusion Ms. A was properly Cpl Langridge’s PNOK, this is not surprising. It may be none of these additional complaints to the CFNIS was capable of supporting criminal or service offence charges. That result does not justify a failure by the CFNIS to inform the Fynes in a timely manner of the basis for a decision not to investigate the first two additional allegations nor, for the third allegation, does it excuse a failure to ensure the complaint was properly analyzed, which in fact corresponded to the essence of the Fynes’ concerns.

The Registration of Death

158. From the time they received the first Proof of Death Certificate, the Fynes were consistent in raising concerns with the CF about the Registration of Death for Cpl Langridge.^{Footnote 3300} When given a Proof of Death certificate following the interment, the Fynes complained the information on that form concerning Cpl Langridge’s residence, marital status and NOK was all incorrect.^{Footnote 3301} Some changes were made to subsequent Proof of Death certificates by the funeral director after consultation with Capt Brown.^{Footnote 3302} The Fynes believed that Mr. Fynes, in his capacity as executor, could not proceed to deal with the administration of Cpl Langridge’s estate as a result of inaccuracies in the Registration of Death Certificate.^{Footnote 3303} The Fynes also complained it was disrespectful for Cpl Langridge to have been buried while paperwork was incorrect.^{Footnote 3304} Because of their intense concern about this issue, they eventually sought and obtained an ex parte order amending the Registration of Death to remove the designation of Ms. A as Cpl Langridge’s common-law spouse, to change the permanent residence address, and to change the identity of the informant for the information contained in the Registration of Death from Ms. A to Mrs. Fynes.^{Footnote 3305}

159. With respect to the Registration of Death Certificate, the Fynes alleged the CF had played a role in providing inaccurate information to the funeral director (or allowing it to be provided). Specifically, they claimed Ms. A provided false information and the two CF members accompanying her just stood by while she said things that were “clearly and obviously untrue.”^{Footnote 3306} They claimed offences may have been committed by Ms. A when she gave incorrect information,^{Footnote 3307} and offences may also have been committed by the two CF members in attendance when the information was given.^{Footnote 3308} They maintained, had Mr. Fynes been sent to the funeral home instead of Ms. A, the issues concerning the Registration of Death would have been avoided.^{Footnote 3309} In addition, there was some suggestion by the Fynes that Ms. A had provided incorrect information, particularly with respect to her marital status, to support her eligibility for monetary benefits as a result of Cpl Langridge’s death.^{Footnote 3310} They also alleged the funeral director had attempted to provide them with a copy of the first, and as it turned out, inaccurate Proof of Death certificate at the funeral, but was stopped by someone in uniform and told not to provide it until after the Fynes had returned to Victoria.^{Footnote 3311}

Misplaced Paperwork

160. The Fynes raised separate concerns with the CFNIS about the administrative documents relating to Cpl Langridge, which were found behind MCpl Fitzpatrick’s filing cabinet after Cpl Langridge’s death. There were four documents: a will;^{Footnote 3312} a Designation of Memorial Cross Recipients form;^{Footnote 3313} a Personal Emergency Notification form;^{Footnote 3314} and a Supplementary Death Benefits form.^{Footnote 3315} Each document related to the administration of Cpl Langridge’s affairs after his death. While none of the documents was fully completed, each named the Fynes as the intended recipients of the particular benefits or responsibilities being conferred. Of particular importance was the will found behind the filing cabinet, in which Cpl Langridge had changed the executor from his friend David White to his stepfather, Shaun Fynes. The CF eventually deemed this will to be valid under provisions in the Alberta Wills Act,^{Footnote 3316} but Mr. Fynes was not advised there was any change in the estate executor until almost two months after the second will was found.^{Footnote 3317}

161. The Fynes alleged the explanations of how and where the documents were found did not “even pass the giggle test,”^{Footnote 3318} perhaps suggesting they believed the documents had been deliberately suppressed for some reason related to the PNOK decision, but certainly alleging some misconduct in connection with their initial disappearance and subsequent discovery.^{Footnote 3319}

No Investigation of These Two Issues

162. Neither the Registration of Death nor the misplaced paperwork allegations were investigated as part of the 2009 investigation. The allegations did not form part of the synopsis of the initial complaint, of either investigative assessment, of either MCpl Mitchell’s or Sgt Shannon’s investigative plans, nor of the concluding PowerPoint presentation. There are brief references to both issues in the GO file in the context of notes regarding a phone call with the Ombudsman’s investigator,^{Footnote 3320} and some documents from the Ombudsman’s investigator which are included in the file.^{Footnote 3321} There is also mention of the Registration of Death issue as part of the complainants’ statement.^{Footnote 3322} In contrast, the issues were discussed at some length by the Fynes and the CFNIS on multiple occasions during the course of the investigation^{Footnote 3323} and were brought to the attention of the CFNIS by both the Ombudsman’s investigator^{Footnote 3324} and Maj Parkinson.^{Footnote 3325} The CFNIS investigators should have been aware of these issues.

163. It may be the allegations were not part of the investigation because they were viewed simply as consequences of the PNOK decision. Both the Fynes and the investigators had identified the NOK decision as the “nexus” because “so much was hinging on that one decision on the administrative side.”^{Footnote 3326} Maj Dandurand explained the issues under investigation this way:

My interpretation of what it was we were going to investigate was the negligent performance of duty with respect to the primary - - determination of primary next of kin, which from there, at the time, our understanding was everything else was a consequence thereof.^{Footnote 3327}

164. Since the investigation reached the conclusion that Ms. A was the correct PNOK and therefore no error had been made in her appointment, it appears the investigators concluded there was no need to investigate the other follow-on allegations.

165. During initial interviews with the Fynes, Maj Dandurand stated other agencies and administrative processes were dealing with the full range of their administrative concerns. He suggested the Ombudsman’s office,^{Footnote 3328} the BOI, and the SI^{Footnote 3329} were looking into the full spectrum of issues. He used the analogy with the Fynes that the CFNIS was only investigating about five centimetres of the metre stick of issues they had raised.^{Footnote 3330} However, he did assure them the CFNIS would investigate any criminal issues.^{Footnote 3331}

166. In testimony, the investigators raised other reasons for not investigating these particular allegations. Sgt Shannon dismissed the death certificate issue because, in his view, there was no causal relationship between CF members’ actions and the effective operations of the CF, a necessary element to found a service offence.^{Footnote 3332} With respect to the misplaced paperwork, MS McLaughlin stated he would not have pursued the issue because MCpl Fitzpatrick did not deliberately misplace the documents and therefore he did not see any indication that a service offence had been committed.^{Footnote 3333} Sgt Shannon did not consider the misplaced documents to be relevant because they were not fully completed and, in his view, none affected the status of Cpl Langridge’s common-law relationship.^{Footnote 3334} MCpl Mitchell, it should be noted, did conduct some preliminary investigation into both issues, asking questions concerning both the death certificate issue and the misplaced paperwork during the witness interviews he conducted.^{Footnote 3335}

167. It would appear failure by the CFNIS to investigate and reach conclusions about the allegations concerning the death certificate and the misplaced paperwork was in large part a consequence of the flawed investigation into the PNOK issue. Had the issue been understood as relating to funeral planning, the Fynes’ additional allegations would have been a more obvious component of the overall investigation. Issues concerning the information Ms. A provided for the Registration of Death arose because the CF designated Ms. A to attend at the funeral home, accompanied by CF members, to make decisions about the funeral. The facts concerning the misplaced documents may not have been investigated, in part because the documents were not viewed as relevant, but the contents of the new will would have had a direct impact on funeral planning, while other documents may well have been evidence of Cpl Langridge’s intentions regarding who should make decisions about his funeral.

The Question of Jurisdiction

168. The investigators also justified the failure to investigate the additional allegations by stating they were beyond the jurisdiction of the CFNIS.^{Footnote 3336}While this may be true for some of the allegations, the allegations related to the CF’s role in assisting in the provision of any alleged misinformation would appear, at least prima facie, to fall within the potential scope of CFNIS jurisdiction. If allegations do fall outside of the mandate or jurisdiction of the CFNIS, the complainants should be informed of that fact. Maj Dandurand did advise the Fynes during their final interview that, for the investigation to come to a timely conclusion, the investigation was staying focused on the allegation of negligence.^{Footnote 3337} However, the Fynes were never informed there would be no investigation of the death certificate and misplaced documents allegations. Sgt Shannon noted, with respect to the allegations concerning the death certificate, if he were the one receiving the complaint, he would have advised the Fynes to contact the Edmonton Police Service.^{Footnote 3338} When dealing with these types of allegations by a complainant, Sgt Shannon suggested the following course of action:

[…] in many situations the police receive reports from citizens, and right from the very, very initial contact, it is clear that what the citizen is reporting to the police is not a crime, or it is not a matter that is within the purview of the police. Then it is incumbent on the professionalism of the police officer to advise the citizen, and then to provide potential avenues where that person can gain the assistance that they require.^{Footnote 3339}

169. If the CFNIS was not going to investigate allegations beyond the PNOK issue, the Fynes ought to have been clearly informed. In the case of the issues concerning Ms. A and the death certificate, being so informed may have allowed them to pursue the matter in a different, perhaps more appropriate, forum.

170. The CFNIS should not rely on other agencies or processes to investigate or resolve issues properly falling within its jurisdiction or mandate. The CFNIS should determine independently whether an allegation merits criminal investigation of issues or persons within its jurisdiction, regardless of other investigations being conducted and their results.

171. The issue of the potential involvement of CF members in providing incorrect information for the death certificate and the issue of the misplaced documents were reviewed as part of the SI into administrative matters. However, this did not relieve the CFNIS from the obligation to conduct its own investigation into any criminal aspects of these complaints or from a requirement to inform the Fynes in a timely manner of the reasons for any decision not to investigate.

Issue of JAG Legal Advice on Cpl Langridge’s Marital Status

172. Almost at the outset of the 2009 investigation, there was a complaint concerning a decision allegedly made in a letter from LCol Bruce King, a senior JAG officer, regarding Cpl Langridge’s marital status. As recorded in the investigative file, the complaint synopsis reads:

Lastly, [the Fynes] were concerned with a decision rendered by a JAG officer which formally advised that Cpl Langridge and [Ms. A] were in fact still in a common-law relationship at the time of death. The Fynes believe that the JAG officer quoted a repealed policy when rendering his decision.^{Footnote 3340}

173. On its face, this complaint has several obvious defects. LCol King’s involvement with the Fynes matter did not begin until the convening of the BOI, for which LCol King acted as legal advisor.^{Footnote 3341} The discussions that affected the CF’s recognition of Ms. A as Cpl Langridge’s common-law spouse occurred many months before the BOI was convened. LCol King did write a letter to the Fynes’ lawyer, in part, as a response to the Fynes’ allegations about the consequences to them of the inaccurate information in the proof of death certificate. The letter, however, was dated March 20, 2009,^{Footnote 3342} more than a year after the military’s decision to recognize Ms. A as Cpl Langridge’s PNOK. The March 2009 letter is clearly marked “without prejudice,” indicating it was sent in the context of potential settlement discussions. As such, based on “settlement privilege,” neither the letter nor its contents could be relied upon for any purpose outside of settlement discussions.

174. It is difficult to see how LCol King’s letter could be characterized as a decision about Cpl Langridge’s common-law status or how, in view of the timing, any such decision could be factually linked to any consequences suffered by the Fynes.

175. Aside from these incongruities, there may be reason to question the accuracy of the formal complaint as recorded in the GO file. No mention is made in the initial record of the identity of the JAG officer involved nor, more importantly, of when the alleged incorrect legal opinion was given or in what context^{Footnote 3343} Following the CFNIS meeting with the Ombudsman’s investigator, the complaint was refined to identify a specific JAG officer – LCol King – and also to identify a letter from LCol King to the Fynes’ lawyer as a “copy of the decision rendered by LCol King [with respect to] Cpl LANGRIDGES’S [sic] common law status.”^{Footnote 3344}

176. It is not possible to know precisely what complaint about the JAG officer the Fynes made directly to the CFNIS. The only discussion of the issue between the Fynes and the CFNIS was not recorded. That discussion took place in the context of a lengthy conversation following the Fynes’ first interview with the CFNIS, but the parties to the discussion had left the room where the interview was taking place and the recording device had been turned off. MS McLaughlin testified that, in the unrecorded discussion, the Fynes did not give any names nor was there any other real information other than the fact a JAG officer had quoted a repealed policy.^{Footnote 3345}

177. Maj Dandurand explained in his testimony that the issue galvanized for him after the meeting with the Ombudsman,^{Footnote 3346} and he understood the issue under investigation was whether bad advice had been provided by a legal officer (assumed to be LCol King) during the casualty coordination meeting or to the CO.^{Footnote 3347} He thought it was as a result of this advice that the PNOK decision was made, and the Fynes were denied final decision-making authority over Cpl Langridge’s funeral. This seems to be a reasonable understanding of the complaint given the Fynes’ concern with the funeral planning issue.

178. Maj Dandurand’s understanding of the nature of the Fynes’ complaint makes a good deal more sense than the formal complaint as recorded in the GO file. There was a casualty coordination meeting. A JAG officer (not LCol King) was in attendance.^{Footnote 3348} Legal advice was presumably given.^{Footnote 3349} Following that meeting, the decision to recognize Ms. A as PNOK was ratified.^{Footnote 3350} This series of facts appears to leave open the possibility that there might have been a plausible case for a charge of negligent discharge of a military duty by the person providing the legal advice. If the legal advice was the basis for the PNOK decision, if it was incorrect and caused harm to the Fynes, and if it was found to fall markedly below the standard to be expected by a legal officer in the circumstances, it is possible an offence could have been made out. However, no such investigation was ever carried out, making it impossible to speculate further about any such possible charge.

179. As noted by Maj Dandurand in his testimony, when a complaint comes to the attention of a member of the CFNIS, that person should “at the least validate whether the individual is formally complaining. We pose the question: Is this what you’re complaining about?”^{Footnote 3351} This seems like sensible advice, especially when facts about a case raise questions as to whether the complaint as formulated makes any sense. In this investigation, the investigators did not seem to appreciate the importance of this basic step. Instead, the initial investigators seem to have relied on information coming from the Ombudsman’s investigator to clarify the complaint^{Footnote 3352} rather than attempting to verify the allegation with the Fynes, in circumstances where, as far as the CFNIS was concerned, the Ombudsman was not the true complainant.

180. At all times, the investigation appears to have relied exclusively on the formal complaint as set out in the GO file. Sgt Shannon’s approach to his investigative task was extremely literal. Sgt. Shannon seems to have never asked how a letter written many months after Ms. A’s status as Cpl Langridge’s common-law spouse was recognized by the CF – a letter expressly stating that it was written “without prejudice” – could be construed as constituting a decision as to her marital status. Instead, he simply investigated the issue of whether the policy upon which this “decision” was allegedly based was repealed at the material time.^{Footnote 3353} Having determined the order had not been repealed as of the date of Cpl Langridge’s death,^{Footnote 3354} Sgt Shannon took no further investigative steps, simply concluding the allegation against LCol King was unfounded.

181. None of the investigators on the file conducted an investigation into the actual focus of the complaint, namely, the legal advice that led to the PNOK decision.

182. Given the incongruities in the formal complaint, some effort should have been made to ensure the complaint being investigated was an accurate reflection of the actual issues troubling the Fynes and of the issues actually raised on the facts. It would also have been useful if the investigators sought legal advice regarding the meaning and consequences of the March 2009 letter.

Conclusion Regarding the Investigation into the Additional Complaints

183. In the course of conducting the 2009 investigation, the CFNIS did not investigate several of the major allegations brought forward by the Fynes. Had there been better clarity in the GO file itself and among investigators as to the importance of the funeral planning issue, the additional concerns raised by the Fynes might have been the subject of a more appropriate investigation. Seemingly incongruous complaints should have been clarified with the Fynes before being dismissed with only superficial investigation. If a decision had been made that certain issues were not going to be investigated, this ought to have been communicated clearly to the Fynes.

Supervision and Recordkeeping

The Importance of Supervision to an Investigation

184. Supervision is an integral part of managing an investigation to a successful conclusion. In any investigation, leadership and oversight are required to ensure that the complainant’s concerns are fully and appropriately investigated. In this case, the supervisors took a hands-off approach. Supervisors may have spoken to investigators and checked SAMPIS regularly, but they allowed the investigators to proceed with the investigation as they saw fit with limited supervisory direction. While such a supervisory approach may be appropriate in certain circumstances, it was not appropriate for this investigation. A complex set of allegations and facts, the lack of continuity on the file and poor recordkeeping required more, rather than less, oversight and control. The central role of the supervisor is to be knowledgeable about the details of the investigation, to give input, and to provide direction.

Responsibility for Supervision of the Investigation

185. Investigators were supervised initially by the Operations WO who acted as the de facto Case Manager.^{Footnote 3355} WO Hart was in this position at the outset of the investigation up to July 2010, during the period MS McLaughlin and MCpl Mitchell worked on the file. WO Bonneteau assumed the position in the summer of 2010 shortly before Sgt Shannon became the lead investigator.^{Footnote 3356}

186. The Operations WO assigned investigators to files and provided the OC updates on investigations in weekly status reports and, in person, at briefings with the command team.^{Footnote 3357} It was also the responsibility of the Operations WO to review and oversee the course of investigations to ensure they were being conducted in a timely and proper manner.^{Footnote 3358}

187. The Operations WO relied, in part, on informal discussion with the investigators to monitor activity in the investigation. During the course of the investigation, both WO Hart and WO Bonneteau regularly spoke with investigators to discuss where things stood and what they were anticipating as their next course of action.^{Footnote 3359} If there were questions about what was being done, the supervisor would speak to the investigator.^{Footnote 3360}

188. Supervisors also relied on the SAMPIS entries made by the investigators to monitor and oversee the file.^{Footnote 3361} Supervisors had complete access to SAMPIS and could enter the system at any time and check the file for information or review it from a quality assurance perspective.^{Footnote 3362} WO Bonneteau testified his initial understanding of the investigation came from reading and reviewing the file.^{Footnote 3363} He also reviewed every ongoing file daily to ensure activity was continuing.^{Footnote 3364}

189. The OC of the detachment throughout the course of the 2009 investigation was Maj Dandurand. While day-to-day activity did not necessarily come to his attention,^{Footnote 3365} he would be made aware of critical or unanticipated developments.^{Footnote 3366} Maj Dandurand, like the Operations WO, relied on informal daily meetings with members of his command team to stay up-to-date on files.^{Footnote 3367} The Operations WO and the command team would sit down weekly with the OC and report on ongoing investigations.^{Footnote 3368} The OC was responsible for taking the information and briefing the chain of command on significant developments.^{Footnote 3369}

190. Maj Dandurand testified command does not generally operate in a strictly linear fashion within the CFNIS and the MP. While orders come down the chain of command, “there is a recognition that command is done by [the] team.”^{Footnote 3370} Nevertheless, Maj Dandurand, as the OC, had ultimate accountability for the conduct of all investigations and the responsibility to evaluate whether the steps taken in an investigation were reasonable.^{Footnote 3371} The final decision to close an investigation also rested with the OC.^{Footnote 3372}

191. The investigators expected oversight and expected to have their work reviewed and checked by the supervisory team.^{Footnote 3373} As MCpl Mitchell noted:

The decisions that we make are always – I wouldn’t say second guessed, but checked and solidified throughout our chain of command…Files are reviewed all the time. They are constantly reviewed by the case manager – sorry, the team leader and the case manager should be reviewing the files from beginning to end.^{Footnote 3374}

192. The role of the command team was to analyze the investigators’ actions and to provide direction.^{Footnote 3375} As noted by LCol Gilles Sansterre, the CO CFNIS, it is the supervisors who should provide leadership and guide the conduct of the investigation.^{Footnote 3376}

Passive Involvement of Supervisors

193. While there was an expectation of supervisory engagement in investigations, the role assumed by the supervisors in this case was not one of ongoing evaluation of the investigation, but rather of somewhat detached observation. Neither WO Hart nor WO Bonneteau liked to micro-manage investigations.^{Footnote 3377} As WO Hart explained in his testimony:

The investigator is the individual who is tasked to conduct the investigation. That is the individual who gets down into, as you say, the nitty-gritty. It is my job just to oversee, from a more global perspective, what they are doing, and to follow the flow of the investigation, to make sure that it’s being conducted. [...] The investigators, when they are initially tasked, will have the job to take a look at the complaint and to draft their initial investigation plan. Once the initial invest plan is drafted, we will review it to make sure that they have a handle on what it is that is expected of them, and then, from that point on, they are allowed to proceed with their investigations.^{Footnote 3378}

194. In practical terms, supervisors do not task the investigators with every step in the investigation, nor do they reinvestigate allegations.^{Footnote 3379} As WO Bonneteau noted in his testimony, it was not the role of the Operations WO to “hold the hand of every investigator,” or else files would never be completed.^{Footnote 3380} More direction would be given to an intern, but an experienced investigator such as Sgt Shannon would simply be allowed to do his job.^{Footnote 3381}

195. Maj Dandurand had a unique role in the supervision of this investigation. At the outset, he was not only the OC of the detachment but also an investigator on the file. Initially, his participation in the investigation was very important, but after May 2010, his involvement, whether investigatory or supervisory, became much more limited. After that point in time, he participated in the command team briefing in early November 2010, the concluding PowerPoint presentation in February 2011, and he reviewed the file and signed the concluding letter sent to the Fynes in May 2011. While he was kept up to date on critical developments in the investigation, he did state that, after an initial briefing, “the investigators have their understanding and the benefit of the totality of the group’s experience in pursuing these investigations and then they go and do their work.”^{Footnote 3382} Maj Dandurand could have served as “the continuity stream for this file,”^{Footnote 3383} a useful role given the personnel turnover in the investigation. But, for a number of reasons, his contributions to the investigation were very limited during the last year the file was active.

196. It is important to note a more hands-off approach to oversight of investigations is not necessarily unreasonable. It does allow experienced investigators to get on with the job of actually conducting the investigation and demonstrates confidence in the investigators’ abilities. Although such a supervisory approach was popular in the CFNIS WR Detachment command team, in this case it was not appropriate. This investigation required a more substantive review of the material under investigation. The allegations were very complicated and any serious review of the conclusions reached by the investigators required an understanding of the allegations and what needed to be done to fully investigate them.

197. On the whole, because of the lack of guidance and oversight from the supervisors, the allegations were never properly understood or identified, relevant facts were not uncovered, appropriate legal advice was not sought and conclusions were not appropriately questioned.

Failure to understand the allegation and the issues under investigation

198. WO Hart, WO Bonneteau and Maj Dandurand all understood the allegation to be about whether the military had appointed the wrong PNOK, resulting in the Fynes not having authority to plan their son’s funeral.^{Footnote 3384} However, this was not investigated because Sgt Shannon’s understanding of the complaint stopped at finding the meaning of PNOK, which he understood to be a complaint about the common-law spouse. These different understandings of the PNOK allegation should have come under the scrutiny of an informed supervisor. To provide meaningful comment on the conduct of the investigation, it was incumbent on the supervisors to first ensure that they understood what the investigators were investigating.

199. WO Hart and WO Bonneteau did not appear to appreciate what was being investigated. They appear to have assumed that issues important to resolving the allegations had been investigated without first checking what the investigators had examined. When asked if Sgt Shannon should have looked into who the executor was, WO Bonneteau testified this “was part of Sgt Shannon’s investigation, so that was part of what he was supposed to do, not myself…I am assuming that he did look into it.”^{Footnote 3385} Similarly, when asked whether the basis for determining if Ms. A was the common-law spouse should have been provincial law rather than the military statutory declaration, WO Hart stated, “That was an area that my investigators were looking into and it was not an area that I investigated.”^{Footnote 3386} While Sgt Shannon did superficially examine both provincial law and the identity of the executor, these issues did not form a substantial part of the investigation. Had the investigation been properly focused on funeral planning, such issues would have been prominent.

Inadequate supervision of investigation plans and lack of follow up

200. The investigation plans compiled by MCpl Mitchell and Sgt Shannon, approved respectively by WO Hart and WO Bonneteau, show two very different approaches. The duties of the Operations WO, along with the OC, included approving or amending the plan and returning it to the investigators for implementation.^{Footnote 3387} MCpl Mitchell’s investigation plan was interview-based, and he testified he wanted to interview anyone who had attended the casualty coordination meeting.^{Footnote 3388} Sgt Shannon’s investigation represented a clear departure from this approach.

201. The command team decided interviews beyond those with the subject matter experts were not necessary,^{Footnote 3389} accepting Sgt Shannon’s conclusion that the documents stood on their own.^{Footnote 3390} However, the command team was unaware Sgt Shannon had not found all the relevant documents,^{Footnote 3391} nor did they have a way of determining if Sgt Shannon had gone far enough in identifying all the available documents.^{Footnote 3392} Potentially important witnesses such as attendees at the casualty coordination meeting, as well as civilian witnesses such as Ms. A and the funeral director, were never interviewed, and important information, such as how the PNOK decision was made and by whom, was never gathered.

202. There was some attempt to provide supervisory direction at the November 2010 command team meeting. At the meeting, the command team appropriately questioned the conclusions reached by Sgt Shannon.^{Footnote 3393} As a result, Sgt Shannon made changes to his investigation plan and added eight issues requiring additional investigation.^{Footnote 3394} On that basis, he and MS Gazzellone conducted interviews with two subject-matter experts in Ottawa to find answers to the outstanding issues and “to determine if his interpretation of the policies, directives and orders was the correct interpretation.”^{Footnote 3395} Sgt Shannon did brief WO Bonneteau after the interviews^{Footnote 3396} and Maj Dandurand received the “Coles Notes” version of the interviews.^{Footnote 3397} However, there does not seem to have been any significant supervisory follow-up as to what exactly had been learned about the issues of concern to the command team. There was no document produced in the GO file or elsewhere setting out the answers to the eight open questions.^{Footnote 3398} Despite Sgt Shannon’s opinion that the final PowerPoint presentation answered all of these questions,^{Footnote 3399} it clearly did not.^{Footnote 3400}

203. Had the supervisors turned their minds to the actual questions, it would have been obvious the question concerning “the role of the Executor of a CF will in the planning process of a funeral of a CF member”^{Footnote 3401} had not been answered. In fact, the subject-matter experts had said that, in similar circumstances to those under investigation, they would have deferred to the expertise of the JAG.^{Footnote 3402} Sgt Shannon’s conclusions needed testing by his supervisors. Passive reception of a slide presentation is not tantamount to actual oversight and review.

Failure to adequately question conclusions

204. The decision to conclude the investigation occurred sometime after subject-matter expert interviews were conducted in November 2010.^{Footnote 3403} In the end, the supervisors accepted the conclusion of Sgt Shannon that PNOK was the equivalent of spouse and common-law spouse. But they did not understand how the conclusion was reached. When asked whether he shared Sgt Shannon’s understanding about NOK being the equivalent of spouse, WO Bonneteau simply replied:

[…] when Sgt Shannon was assigned as lead investigator on this investigation, being the experienced investigator I pretty much had a hands-off on it in that I allowed him to do his job. […] it wasn’t my role to look over his shoulder and look at every little aspect of his investigation.^{Footnote 3404}

205. Maj Dandurand also could not recall where or when Sgt Shannon would have explained the linkage between NOK and common-law spouse,^{Footnote 3405} clearly a critical investigative conclusion. While supervisors do not need to be peering over the shoulders of their subordinates, they do need to ask probing questions and obtain satisfactory answers before determining whether an investigation can be closed. Blind faith in the abilities, professionalism and expertise of the lead investigator is not sufficient.

Failure to seek legal advice

206. While supervisors should not be expected to be subject-matter experts or have intimate knowledge of every detail, they should recognize when an investigation is complex and what appropriate outside expertise may be helpful in investigating the allegations. The Commission is not aware of any evidence indicating supervisors recommended legal advice be sought. Neither WO Bonneteau nor Maj Dandurand thought a legal opinion was necessary at the time.^{Footnote 3406} While WO Hart stated in testimony he would have consulted the regional military prosecutor if he had been lead investigator, this was not a suggestion he made to anyone he was supervising.^{Footnote 3407} Rather than making a recommendation for legal assistance as they were entitled to do,^{Footnote 3408} the supervisors deferred to the investigators’ judgment, stating investigators were always free to seek legal advice.^{Footnote 3409} Neither Sgt Shannon nor any of the supervisors involved in this investigation were lawyers. Yet the conclusions reached concerning the applicability of provincial law, the meaning of NOK based on customs of society rather than on existing law, and the role of the executor were all legal issues. It was the responsibility of the supervisors not simply to deflect the obligation for seeking legal advice to investigators, but to ensure the allegations were fully and properly investigated and engage legal counsel when appropriate.

Role of CFNIS HQ

207. CFNIS HQ was not involved in the actual investigation of the allegations, fulfilling more managerial functions such as coordinating and approving procedures, strategic oversight and quality control.^{Footnote 3410} While it may have been appropriate for the CO not to be involved in the details of each investigation in the CFNIS, this particular investigation was different. It was legally and factually complex with complainants who had a challenging relationship with the CFNIS and the CF in general. Nevertheless, like the other supervisors involved in this investigation, HQ personnel took a hands-off approach to supervision, which meant they were not knowledgeable about the investigation and did not provide guidance or direction in its conduct.

208. LCol Sansterre, who was the CO CFNIS for all but the final month of the 2009 investigation,^{Footnote 3411} explained that from a day-to-day perspective, the CO did not oversee investigations – it was left to the DCO, Maj Francis Bolduc, to brief him on the cases where he needed to know details.^{Footnote 3412} In this investigation, LCol Sansterre was aware of the very basics: the fact the investigation had been opened; monthly status briefings on the file; and when it was concluded.^{Footnote 3413} He could not recall if the DCO had given him any oral briefings on the investigation and he could not recall being apprised of any issues throughout the course of the file.^{Footnote 3414} He had only a very vague understanding of the allegations concerning the PNOK and JAG lawyer, and believed incorrectly that the Fynes’ concerns about false information being given at the funeral home was under investigation.^{Footnote 3415} He understood the decision to close the file was based on the conclusion the NOK had been properly appointed but he did not understand in detail the basis for that conclusion.^{Footnote 3416}

209. LCol Sansterre did acknowledge in testimony that he did not “drill down” into the investigation.^{Footnote 3417} Nevertheless, he denied having a hands-off approach to supervision. Instead, he stated that he did not micromanage investigations but rather “empowered those who worked for me to do their jobs.”^{Footnote 3418} LCol Sansterre explained his lack of involvement and knowledge of this specific investigation as being, in part, a result of having 180 files in the course of a year come through the CFNIS. He also testified he would have had better knowledge of the file if it had resulted in charges being laid, since public affairs would have become involved.^{Footnote 3419}

210. The only supervisory input from HQ in the file was in connection with the SI. LCol Sansterre testified he thought he and Maj Dandurand probably had a discussion in which he advised Maj Dandurand to speak to the President of the SI to ensure the CFNIS investigation would have precedence over the SI.^{Footnote 3420} On a practical level, this meant LCol Sansterre would expect the discussion to include determining if there were witnesses the SI needed to interview and confirming the CFNIS would have access to the witnesses before the SI.^{Footnote 3421} While LCol Sansterre did recall a meeting with the President of the SI, he did not have the “level of detail” to know why the SI was permitted to proceed with interviews of witnesses months prior to the CFNIS, even interviews with some of the same witnesses later named on MCpl Mitchell’s investigation plan.^{Footnote 3422} The CFNIS could have requested the SI be shut down if both investigations were dealing with the same issues. And, in this investigation, there was clearly overlap.^{Footnote 3423}

211. Despite recognizing this as a potential issue and making a specific request to Maj Dandurand concerning the maintenance of a separate investigation, there does not seem to have been any follow up to determine whether the mandates of the two investigative bodies had been “deconflicted” and whether the ability of the CFNIS to conduct an independent investigation was given precedence. While knowledge of the day-to-day activities in ongoing investigations may be beyond the purview of the CO of the CFNIS, this may have been an instance where ensuring investigations were independent from the other CF processes should have engaged the CO’s ongoing attention.

Recordkeeping

212. When a hands-off approach to supervision is adopted, it becomes important to maintain accurate records so supervisors at all levels can monitor and assess developments in the investigation at any time. In addition, with so many personnel changes, accurate records are an absolute necessity for incoming personnel, especially in circumstances where there is little if any overlap between investigators and little evidence of briefings or handover. However, in maintaining acceptably precise and detailed records for this investigation, the CFNIS failed miserably, with events not being recorded and important records being inaccurate or incomplete. Despite their stated reliance on SAMPIS as a source of ongoing information about the file, supervisors did little to ensure complete records were kept, merely making grammatical changes to text box entries.

Failure to record interviews

213. Poor recordkeeping was evident at the outset of the investigation with the incomplete recording of interviews with the complainants and as a result, of the allegations. Only half of the first interview with the Fynes in November 2009 was actually recorded. Estimates of the total length of the interview ranged from three hours to four and a half hours meaning at least an hour and possibly up to two and a half hours of the Fynes interview did not get recorded.^{Footnote 3424} The explanation provided was that after the formal part of the meeting was completed, the interview continued in the hallway outside of Maj Dandurand’s office.^{Footnote 3425} Since MS McLaughlin had gone to make a copy of the recording of the first portion of the interview for the Fynes, this latter part of the interview was not recorded.^{Footnote 3426} There is no obvious reason why Maj Dandurand could not have requested the Fynes return to his office and wait for MS McLaughlin before continuing the discussion. Despite Maj Dandurand’s email assurance to the CFNIS public affairs officer that the meeting had been taped “so nothing was missed or omitted from our end”^{Footnote 3427}, significant discussion did take place off tape, including the Fynes’ allegation concerning the JAG officer.^{Footnote 3428}

214. The meeting with the Ombudsman’s investigator was also not recorded. MS McLaughlin viewed this as simply a meeting between two investigative bodies, discussing information to be passed on to the CFNIS.^{Footnote 3429} As a result, the only contemporaneous records of the meeting are brief notes in Maj Dandurand’s notebook.^{Footnote 3430} MS McLaughlin’s explanation for his failure to take any notes whatsoever during the meeting was that they were simply reviewing documents.^{Footnote 3431}

215. These explanations are not satisfactory. The Ombudsman was considered by the CFNIS not simply to be another investigative body, but in some documents to be the complainant in the investigation. Under the circumstances, a complete audio recording or at least comprehensive notes should have been made of the meeting. The allegations which formed the basis for the investigation, as well as other concerns the CFNIS decided not to investigate, were discussed during the meeting.^{Footnote 3432} Had a more complete record of the meeting been created, it would have been available for review both by investigators and supervisors to ensure the allegations, as recorded in the file and as investigated, corresponded with the concerns brought forward by the complainants.

Failure to identify potential suspects

216. Another example of careless recordkeeping is the failure to identify potential suspects in writing regarding the PNOK allegation. The Fynes were firmly of the opinion Capt Lubiniecki was responsible for the decision which put Ms. A in the position of PNOK.^{Footnote 3433} However, in testimony at the hearing, a number of the investigators stated they knew persons higher in the chain of command were likely responsible for making the final decision about who was NOK.^{Footnote 3434} Nevertheless, the only person ever mentioned as a suspect by name in the GO file was Capt Lubiniecki.^{Footnote 3435} This remained the case even after the interviews with Capt Brown and Maj Parkinson in which they gave evidence about who was in attendance at the casualty coordination meeting and who was involved in making the NOK decision.^{Footnote 3436} In his testimony, Sgt Shannon stated he had identified three suspects (Capt Lubiniecki, LCol Cadieu and LCol Demers) and had pinpointed LCol Demers as having made the NOK decision.^{Footnote 3437} While Sgt Shannon noted all three names (along with Maj Reichert) in his investigative plan as possible interviewees, he only ever identified Capt Lubiniecki in writing as a suspect.^{Footnote 3438} There is no evidence Sgt Shannon or any of the other investigators were deliberately trying to protect the higher ranks and, in fact, their testimony is quite the opposite.^{Footnote 3439} However, the fact remains that despite specifically identifying three suspects, only the lowest ranked member is actually mentioned by name in any documents on the GO file.

Failure to record investigative steps, analysis and plans

217. According to a CFNIS SOP, revised towards the end of the investigation, the text boxes in a GO file should be a reflection of the investigation plan and should be kept up to date as the investigation progresses.^{Footnote 3440} According to the SOP, there is a need to avoid “[v]ague entries or no entries at all in some portions of the investigative activities [because it] lead[s] to misunderstandings, poor thought flow or omissions.”^{Footnote 3441} Yet, despite this clear direction in the SOP, on many occasions investigators did not record steps or analysis they had undertaken. In his testimony, WO Hart candidly acknowledged:

If we were to actually sit and record everything that took place in a file, we would be spending all of our time recording rather than doing the investigation. So, yes, there’s always going to be investigative steps, there’s going to be thought processes that may or may not be captured in the file. It depends on what the investigator feels is relevant to the investigation.^{Footnote 3442}

218. If investigative steps were not all recorded in the file, it is unclear how supervisors or incoming investigators could rely on the GO file to reflect what investigation had actually taken place. For example, WO Bonneteau was not aware Sgt Shannon had added a new allegation to the investigation concerning the Fynes’ involvement in funeral planning based on a press conference given by Mrs. Fynes.^{Footnote 3443} The allegation was not recorded in the GO file for WO Bonneteau to review. In testimony, WO Bonneteau seemed unconcerned he was unaware of an entire avenue of investigation, stating it was simply a different form of the same complaint which was already being investigated.^{Footnote 3444} This attitude demonstrates how unfamiliar WO Bonneteau was with the limited scope of Sgt Shannon’s investigation, focusing as it did only on whether the Fynes had input into the funeral and not on who was actually entitled to plan the funeral.

219. Milestone events were also not recorded in the GO file. The text boxes in the GO file do not state the command team met with Sgt Shannon in early November 2010 to review his conclusions, nor that it was the command team who raised specific questions during the meeting that were to be answered through further investigation.^{Footnote 3445} While Sgt Shannon’s notes indicate he was tasked with preparing a briefing for the chain of command on both the 2009 and 2010 investigations,^{Footnote 3446} there is no indication in the file of the decision to conclude the investigation after the subject-matter expert interviews, nor of the thought process leading to Sgt Shannon’s recommendation to conclude.^{Footnote 3447} Other than a copy of the PowerPoint presentation, there is no record of any other notes taken during the meeting of the command team held in February 2011.^{Footnote 3448}

Incorrect or incomplete records of investigative steps

220. Even when investigative steps were recorded, the information contained in the GO entry was not always accurate. This is particularly evident in the witness statements produced after interviews. While there should have been an increased concern with accuracy, given that neither supervisors nor incoming investigators reviewed the actual audio or video tapes of the interviews, there were many examples of information either not being recorded or being recorded incorrectly.

221. In the witness statement following the interview of Capt Brown,^{Footnote 3449} there was no mention that he stated he may have given what turned out to be incorrect information, which was used to produce the registration of death, when he accompanied Ms. A to the funeral home.^{Footnote 3450} This was precisely a concern of the Fynes, and though MCpl Mitchell had asked questions about the issue during the interview and relevant information had been provided, it was not identified in the witness statement.

222. In the witness statement of the subject-matter expert Sgt Pelletier,^{Footnote 3451} Sgt Shannon failed to record that Sgt Pelletier said she would defer to the JAG when given the hypothetical situation in her interview (no will, parents on PEN form, there is a common-law spouse) and asked to comment on who would have authority to plan the funeral.^{Footnote 3452} When asked if the common-law statutory declaration created any rights for the spouse, Sgt Pelletier responded she did not know and was not expert in the legality of the situation.^{Footnote 3453}

223. In the witness statement for the other subject matter expert, LCdr Gendron, Sgt Shannon overstated LCdr Gendron’s expertise. In his testimony, LCdr Gendron referred to the description of him in the witness statement as “the subject matter expert regarding issues related to casualty support and related administrative actions mandated by CF policies and regulations” as “probably a bit embellished.”^{Footnote 3454} Sgt Shannon also failed to note, in the witness statement he prepared based on LCdr Gendron’s interview, that during the interview, when presented with a hypothetical situation corresponding to the facts under investigation, LCdr Gendron stated, since this situation was not something in which his directorate would get involved, any comment he had would be purely his personal opinion.^{Footnote 3455} He also did not record LCdr Gendron’s statement that if he had been the CO in the hypothetical situation, he would have consulted the JAG.^{Footnote 3456}

Conclusion Regarding Recordkeeping and Supervision

224. Overall, the recordkeeping in this investigation was poor. In reviewing the file, the supervisors do not seem to have been particularly concerned with ensuring consistency, completeness or accuracy in records. On the other hand, they seemed to have been concerned with ensuring GO file entries had proper grammar and were formatted correctly.^{Footnote 3457} To be sure, this is a requirement in the SOPs – “Grammar, content, spelling, thoroughness of investigation, and essential SAMPIS items are all part of [the WO/Ops Sgt/Team Lead’s] vetting process.”^{Footnote 3458} But its importance pales in comparison to the goal of keeping a complete and accurate record. Given the reliance placed on the documents and text entries in the GO file, the supervisors should have made efforts to ensure the record of the investigation was fully maintained.

225. This was a complex investigation. To properly investigate the complaints, there needed to be a complete understanding of the allegations, a thorough legal analysis, and detailed witness interviews. This investigation required supervisors who would provide hands-on oversight based on a thorough knowledge of the investigation as it progressed. Instead, the supervisors chose a much more hands-off approach. Rather than providing the necessary guidance and oversight, the supervisors seemed averse to being perceived as micro-managers. The investigation was made more difficult by personnel changes and poor recordkeeping practices.

226. The consequences are reflected in the unsatisfactory conduct of this investigation. As Maj Dandurand himself noted in one of the interviews with the Fynes, “at the end of the day, you can push responsibility down, but if you’re the person pushing that responsibility down, you are actually accountable for what gets done.”^{Footnote 3459} The supervisors must ultimately accept some of the responsibility for the inadequacies of this investigation.

Timeliness

227. The complaint forming the basis of the 2009 investigation first came to the attention of the CFNIS WR on November 17, 2009, when Lt(N) Amirault of the CFNIS Central Region contacted Maj Dandurand to advise him of a complaint he had received from the Ombudsman’s investigator.^{Footnote 3460} The last activity on the file, other than the transfer of evidence, was a letter sent on May 6, 2011, to Mr. and Mrs. Fynes advising them of the conclusions of the investigation.^{Footnote 3461} The file was active for 535 days or for almost a year and a half. The Fynes complained to the MPCC this was an unreasonably long time to complete the investigation.^{Footnote 3462}

Delays

228. There were three significant periods of delay in the course of the investigation. The first was a period of inactivity of almost two months between the meeting with Ombudsman’s investigators on December 18, 2009,^{Footnote 3463} and Maj Dandurand completing his investigative assessment on the file on February 12, 2010.^{Footnote 3464} MS McLaughlin did compile the documents received from the Ombudsman’s investigators, but little else was accomplished during this time period. This delay was never really explained except to say MS McLaughlin was deployed to Haiti. In his testimony, he explained this meant having to drop everything to get kitted up and ready to go prior to his departure from Edmonton in mid-January.^{Footnote 3465} There was no explanation for the lack of activity from mid-January to mid-February when only Maj Dandurand was assigned to the file.

229. The second period of delay occurred during MCpl Mitchell’s investigation, which proceeded rather slowly. The investigative activity from mid-March to September 2010 involved only three witness interviews^{Footnote 3466} and obtaining and reviewing the SI report.^{Footnote 3467}

230. The Fynes repeatedly expressed their dissatisfaction with the pace of the investigation during their May 5, 2010, interview with MCpl Mitchell and Maj Dandurand.^{Footnote 3468} At about the same time, the CF chain of command was also asking when investigations ancillary to the BOI, including the CFNIS investigation, would be complete.^{Footnote 3469} Maj Dandurand testified the investigation had been featuring on:

[…] [the] Provost Marshal’s watch list as a file that had CF interest in the sense that it was being tracked by the Vice-Chief of Defence Staff and the Provost Marshal as being requested to be able to speak to that at times, which is why the watch list existed. And I would have to say that I believe it was an effort to try and get this investigation concluded. It was perhaps one of the questions that was occurring in the margins with respect to not only this investigation, but others, to say what do you need in order to get this – this moving along at a quicker pace.^{Footnote 3470}

231. In accounting for the delays during MCpl Mitchell’s investigation, it should be noted MCpl Mitchell stated he was unavailable to work on the investigation from May 10 to 21, 2010, while on training.^{Footnote 3471} He also explained he was taken off the file in mid-August so he could leave for a course starting at the beginning of September 2010.^{Footnote 3472} He candidly admitted he was not particularly good at policy review and there was a huge amount of paperwork he had to go through on the file.^{Footnote 3473} Maj Dandurand agreed the investigation was more complex than most^{Footnote 3474} and covered “a myriad of issues.”^{Footnote 3475}

232. There was also a suggestion in connection with this particular delay that the detachment was very busy at this time and was understaffed. Maj Dandurand testified there were about 50 open investigations, divided amongst nine investigators in May 2010.^{Footnote 3476} MCpl Mitchell confirmed there were not many investigators, and they were constantly on the go.^{Footnote 3477} Maj Dandurand stated if direction would have come from HQ to proceed more quickly with the investigation, it would have been necessary to put other files on hold, or it would have been necessary to augment staff for two to six months.^{Footnote 3478}

233. The final period of delay took place between the time when the decision was made to conclude the file and its actual conclusion. There is conflicting evidence about the date the decision was made to conclude the investigation. It is known the decision was made no later than December 10, 2010, when, according to the records in the file, Sgt Shannon was tasked with preparing a PowerPoint briefing for the command team on both the 2009 and the 2010 investigations.^{Footnote 3479} The decision may have been made even earlier. The last interview occurred on November 17, 2010 with LCdr Gendron.^{Footnote 3480} There was no additional investigative activity after that date. In an affidavit produced before the Commission, Mr. Martel from the Ombudsman’s Office indicated he spoke to Maj Dandurand “in the late fall of 2010” and was told the investigation was substantially complete and the file was about to be closed.^{Footnote 3481} The formal conclusion of the file occurred much later, on May 6, 2011, when the Fynes were sent a letter signed by Maj Dandurand explaining the outcome of the investigation.^{Footnote 3482}

234. In the almost five months between when the decision was taken and the actual conclusion of the investigation, Sgt Shannon was responsible for preparing the slide presentation for the command team, as well as drafting the concluding letter to the Fynes.^{Footnote 3483} He completed both of these tasks promptly.

235. The date for the actual briefing to the command team was dependent on the availability of Maj Dandurand.^{Footnote 3484} Once the date had been set, Sgt Shannon completed the presentation over the course of a weekend.^{Footnote 3485}

236. There was an attempt to schedule a verbal briefing with the Fynes, but the decision was quickly made to cancel it when they asked for their lawyer to be present.^{Footnote 3486} When he was then tasked with drafting the concluding letter to the Fynes on February 24, 2011,^{Footnote 3487} Sgt Shannon prepared the draft and sent it to Maj Dandurand for approval on March 3^rd, 2011.^{Footnote 3488}

237. The significant delay at this stage in the investigation occurred principally as a result of Maj Dandurand, both in terms of scheduling the command team briefing and in signing the concluding letter to the Fynes.^{Footnote 3489}

238. By this point, both the CF and the CFNIS leadership were anxious for the investigation to be completed. On February 14, 2011, Col Gerard Blais, who had been tasked with preparing a coordinated CF response to the Fynes’ outstanding concerns, requested the date the CFNIS investigations were expected to be completed, suggesting all the ongoing investigations should be signed off as soon as possible.^{Footnote 3490} On the same date, Maj Bolduc, the DCO of the CFNIS, asked Maj Dandurand to confirm his plans regarding the outstanding investigations, since February 2011 had been set to brief the family.^{Footnote 3491} On February 17, 2011, Maj Bolduc followed up with another email to Maj Dandurand stating they “need to firm up the plan and complete these file[s] with the family brief very shortly. I would suggest that this is one of your high priorit[ies].”^{Footnote 3492}

239. The command team was briefed on February 18, 2011.^{Footnote 3493} By March 8, 2011, the text of the letter to the Fynes had been approved by CFNIS HQ, and it had been decided the letter should go out under Maj Dandurand’s signature.^{Footnote 3494} On April 11, 2011, LCol Robert Delaney, then CO of the CFNIS, emailed Maj Dandurand to ask if the Fynes letter had been signed off and sent.^{Footnote 3495} On April 27, 2011, LCol Delaney again emailed Maj Dandurand to ask if the letter had been sent.^{Footnote 3496} That day the letter was finally mailed, almost two months after having been approved.^{Footnote 3497} The letter was not delivered and was returned to the CFNIS on May 5, 2011, because the mailing address was incomplete. The letter was ultimately sent to the correct address on May 6, 2011.^{Footnote 3498}

240. To explain the delay in the PowerPoint presentation and in concluding the file, Maj Dandurand testified he wanted to do the briefings on the 2009 and 2010 investigations together because the files were intertwined, and he thought the Fynes would want all the answers at the same time.^{Footnote 3499} However, he could not clarify that rationale in light of the fact that according to the weekly file status reports, the 2010 investigation was marked as “to be concluded” the week of August 14, 2010,^{Footnote 3500} several months prior to the decision to conclude the 2009 investigation. Maj Dandurand did state in testimony that medical emergencies in his family in early 2011 prevented him from giving the file his full attention, and he was forced to rely on his second-in-command, MWO Terry Eisenmenger.^{Footnote 3501}

241. Stronger management of the file by Maj Dandurand was needed to bring this investigation to a timely conclusion. With the exception of WO Hart, he was the only CFNIS member consistently involved in the file from its beginning to its conclusion. He had taken the initial complaint call and had conducted both the first interview with the Fynes and the meeting with the Ombudsman’s investigators. As the OC of the detachment, he received the weekly case summaries, which kept a running tab of how many days an investigation had been open. He was aware of the Fynes’ frustration with the pace of the investigation and of his own leadership’s desire to get the file concluded. He was responsible for liaison with his command structure to ensure he had the resources needed to complete ongoing investigations in a timely manner.

242. Even in terms of Maj Dandurand’s own investigative responsibilities on the file, there were significant delays. There was a period of unexplained inaction from mid-January to mid-February 2010 in which he was the only investigator on the file. There were further delays in both the timing of the concluding slide presentation and the mailing of the concluding letter to the Fynes, ultimately requiring the involvement of the CFNIS CO. While there may have been personal circumstances in early 2011 preventing Maj Dandurand from ensuring the matter was concluded in a timely manner, the second-in-command should have been in a position to move the investigation forward.

243. As a supervisor, WO Hart could also have been more proactive in ensuring the investigation progressed more quickly while MCpl Mitchell was leading the file. When he was assigned to the file, MCpl Mitchell was a new recruit to the CFNIS. MCpl Mitchell acknowledged he had difficulty with researching policy and this was a complex investigation with challenging legal and policy questions. WO Hart and Maj Dandurand were the only two supervisors available in the command team at the time.^{Footnote 3502} More support should have been available to MCpl Mitchell which might have helped to speed up the investigation.

Conclusion Regarding Timeliness

244. The consequences of not completing this investigation in a timely fashion were significant. The length of the investigation resulted in five different investigators being assigned to the file at various times. There were three main lead investigators successively in charge of the file, MS McLaughlin, MCpl Mitchell and Sgt Shannon, but there was apparently no direct communication between each departing and each incoming investigator. As a result, the investigation had to be started fresh each time there was a personnel change. While this did allow the new investigators to form their own opinions on the file, it also delayed the actual investigation of the complaints. Maj Dandurand, who could have provided continuity, was not involved in any active investigative activities after the interview with the Fynes in May 2010.

245. The length of the investigation led the complainants to lose faith in the entire investigative process. As Mr. Fynes explained in his testimony, “we got to the point where we just felt like we were being ignored. There was no real activity going on.”^{Footnote 3503} An unnecessarily long investigation made the complainants question the CFNIS’s commitment to the investigative process. This outcome was largely avoidable.

246. Overall, it is the responsibility of supervisors to ensure investigations are completed in a timely manner.^{Footnote 3504} In this situation, that responsibility ultimately lay with Maj Dandurand as the OC of the detachment.

4.4 The 2010 Criminal Negligence Investigation

Allegations

1. Shaun and Sheila Fynes make a number of allegations to the Commission concerning the conduct of the 2010 CFNIS investigation into their complaints against members of the LDSH chain of command and the military medical community for their treatment of Cpl Stuart Langridge prior to his death. They allege the CFNIS failed to properly address the issues to be investigated, and failed to properly investigate the potential criminal or service offences committed by members of the LDSH chain of command.^{Footnote 3505} They also allege the CFNIS failed to investigate their allegations concerning the LDSH’s failure to follow suicide prevention policies and the failure to conduct SIs following Cpl Langridge’s suicide attempts.^{Footnote 3506} The Fynes allege the investigation was aimed at exonerating members of the LDSH of any responsibility for Cpl Langridge’s death.^{Footnote 3507} They further allege the CFNIS members involved in the investigation lacked the skills, professionalism, experience and training necessary to conduct this investigation.^{Footnote 3508} Finally, the Fynes allege the investigation was not completed within a reasonable time.^{Footnote 3509}

The Fynes’ Complaint to the CFNIS

2. This investigation file was opened following complaints made by the Fynes to members of the CFNIS WR detachment concerning alleged CF culpability in their son’s death. The Fynes alleged members of the LDSH chain of command and the military medical community were negligent in their care of Cpl Langridge prior to his death and were negligent by failing to prevent his death.^{Footnote 3510} The allegations centered mainly on the care Cpl Langridge received on base and the conditions placed upon him in March 2008, shortly before his death, and/or the alleged suicide watch put together by LDSH.

3. On April 22, 2010, Maj Daniel Dandurand informed WO Blair Hart by email he had been contacted by the Fynes, and “they want to lodge a complaint/allegation of Criminal Negligence against those who were responsible for Cpl Langridge’s care.”^{Footnote 3511} On May 5, 2010, Maj Dandurand and MCpl David Mitchell met with the Fynes at CFB Esquimalt to take their complaint.^{Footnote 3512} The Fynes provided them with a lengthy account of their complaints and the facts they believed founded those complaints.

4. Mrs. Fynes was concerned about the medical care received by Cpl Langridge from the civilian and military medical systems. From the evidence, it is known that on the night of January 31, 2008, or early February 1, Cpl Langridge put a noose around his neck in an attempt to hang himself at home^{Footnote 3513} and on February 1, 2008, Cpl Langridge was admitted for a short stay crisis admission at the Royal Alexandra Hospital.^{Footnote 3514}

5. During the May 5 meeting, Mrs. Fynes told the investigators Cpl Langridge attempted to kill himself on February 1 and was taken to hospital.^{Footnote 3515} She referred to clinical notes and a Form 1 Admission Certificate completed by Dr. Melissa Butler, a physician at the base clinic where Cpl Langridge presented himself that morning, in which his suicidal ideation and past suicide attempts were noted.^{Footnote 3516} Mrs. Fynes stated Cpl Langridge was discharged on February 4, 2008 despite having a further suicide attempt not long before (in fact, the previous evening).^{Footnote 3517} Mrs. Fynes claimed hospital personnel discharging Cpl Langridge made him sign a discharge note indicating he was leaving against doctor’s advice when he was actually being forced out.^{Footnote 3518} The next day, Cpl Langridge drove himself to the AHE where he was committed for thirty days.^{Footnote 3519} The Fynes’ complaint focused on the involvement of the LDSH in Cpl Langridge’s care and on the investigations following his death.

6. According to the Fynes, toward the end of his stay at AHE, Cpl Langridge attempted to make plans to attend drug rehabilitation at a residential treatment facility.^{Footnote 3520} He offered to stay on at AHE as a voluntary patient until rehabilitation was available and to pay for his own travel.^{Footnote 3521} Despite this, he was ordered by his chain of command to leave AHE and return to Base. Dr. Bernard Sowa, his treating physician at AHE who had agreed to keep him on as a voluntary patient, was said to have testified at the BOI he had called the Base and confirmed Cpl Langridge was ordered to return.^{Footnote 3522} According to the Fynes, this order was made in spite of Cpl Langridge having shown signs of improvement towards the end of his admission, as evidenced by his clinical records.^{Footnote 3523}

7. The Fynes alleged, the day Cpl Langridge was ordered out of hospital, on March 5, 2008, he was transported directly to a group therapy session on base led by Dennis Strilchuk, where, given his discomfort with group therapy settings, he experienced an anxiety attack, left the session and collapsed in the parking lot.^{Footnote 3524} As they understood it, Mr. Strilchuk reportedly lost his temper with Cpl Langridge and discharged him from care.^{Footnote 3525} The Fynes also alleged the Regiment should not have been given responsibility to watch Cpl Langridge:

[…] the regiment should never have been responsible for him. He was sick. He should have been in the hospital. The regiment should never have been passed with babysitting him. They were the wrong people, doing the wrong thing.^{Footnote 3526}

8. The Fynes alleged the LDSH had made no plans for Cpl Langridge’s living arrangements despite having ordered him to return to Base, and alleged from March 5 to 7, 2008, he lived in his car.^{Footnote 3527} They maintained the failure to have a plan in place was evidenced by two affidavits provided to them by the CF when they were attempting to have Cpl Langridge’s Registration of Death amended. These affidavits reportedly provided different addresses for Cpl Langridge, only one of which was for the Duty Centre where he was required to live prior to his death. To their mind this indicated a failure on the part of the Regiment to know where he was living.^{Footnote 3528}

9. The Fynes went on to allege Cpl Langridge was forced on March 7, 2008, to accept a series of conditions restricting his movements and activities under false pretenses. They claimed the conditions were presented to Cpl Langridge by the LDSH as “structure” or accommodation, but were, in fact, a form of discipline.^{Footnote 3529} In support of this claim, Mr. Fynes cited a passage from the 2008 Sudden Death Investigation Report in which CWO Douglas Ross, the Regiment RSM, had stated the conditions were orders and Cpl Langridge could be charged for failing to follow them.^{Footnote 3530} He alleged there were further records indicating the conditions were “imposed” or “placed on” Cpl Langridge^{Footnote 3531} and that MCpl William Fitzpatrick had been ordered to start documenting him for discipline. The conditions allegedly forced Cpl Langridge to live at the Duty Centre so his discipline was public and embarrassing, amounting to an attempt to destabilize him and cause him to act out in order to give the CF grounds to discharge him.^{Footnote 3532} In Mr. Fynes’ view, Cpl Langridge was pressured into accepting the conditions on the basis that adhering to them would be the only way he could attend rehabilitation^{Footnote 3533} even though (as he alleged in pointing to Capt Mark Lubiniecki’s interview during the 2008 investigation)^{Footnote 3534} the decision had already been made he was not going to be attending rehabilitation. In Mr. Fynes’ words, “They were screwing with him.”^{Footnote 3535} Meanwhile, according to Mr. Fynes, the LDSH had decided to keep a record to document the case for discipline.^{Footnote 3536}

10. Those responsible for imposing the conditions had allegedly characterized them as having been requested by Cpl Langridge despite the fact the conditions were orders. The Fynes claimed he was forced to acquiesce to them as the AHE could not re-admit him as a voluntary patient after he left, and he had been repeatedly discharged from the Royal Alexandra Hospital after crisis admissions.^{Footnote 3537}

11. They further alleged Capt Richard Hannah was negligent in imposing the conditions without adequate awareness of Cpl Langridge’s medical conditions. They pointed to Capt Hannah’s witness statement to the CFNIS during the 2008 investigation in which he reported he was unsure whether Cpl Langridge had been diagnosed with PTSD as evidence he was not in a proper position to approve the conditions.^{Footnote 3538} They maintained Capt Hannah had never met Cpl Langridge prior to imposing the conditions and only met with him for ten minutes for that purpose.^{Footnote 3539}

12. Cpl Langridge allegedly protested he had not agreed to the conditions and wanted them changed after they were imposed. The Fynes told the investigators he attended at sick parade on March 11, 2008, and requested the conditions be relaxed because he felt embarrassed. When his request was denied, he stated he would rather kill himself than return to his Unit under the conditions.^{Footnote 3540} Cpl Langridge was said to have again expressed his disagreement with the conditions on March 14, 2008. He phoned the Fynes to say he was embarrassed by the conditions and had told this to Capt Lubiniecki. Cpl Langridge told them Capt Lubiniecki had said, if he made it through the weekend, the chain of command would look at relaxing the conditions. Cpl Langridge also reported he was told he would be going to Homewood (a residential drug rehabilitation treatment centre in Ontario) in two to three weeks.^{Footnote 3541}

13. The Fynes stated they had contacted the Regiment a few days before Cpl Langridge’s death and were told he was under a “suicide watch,”^{Footnote 3542} was living in the defaulters’ room and was safe.^{Footnote 3543} Mr. Fynes argued the LDSH was negligent in this regard as either Cpl Langridge was, at the time of his death, under a suicide watch that did not follow protocol or was otherwise defective, or he ought to have been under a suicide watch if, in fact, he was not.^{Footnote 3544} The Fynes claimed they were not aware Cpl Langridge had been provided a barracks room (the room where he committed suicide) until after his death.^{Footnote 3545} They also claimed witnesses in the course of the BOI testified there was no such thing as a suicide watch in the military.^{Footnote 3546}

14. Finally, the Fynes made allegations the LDSH leadership had not complied with CF suicide prevention requirements. They alleged the CO LDSH was required to have a suicide prevention protocol in place and “if they were following it, in this case it was defective. If they weren’t following it, there’s your negligence right there.”^{Footnote 3547} They also stated there is supposed to be a Summary Investigation (SI) following any suicide attempt, but in Cpl Langridge’s case, while there was one following his June 2007 suicide attempt, there were no others for his subsequent known attempts.^{Footnote 3548}

15. The essence of the complaint was captured in a comment made by Mrs. Fynes to Maj Dandurand and MCpl Mitchell:

I think, ultimately, he was […] their soldier, okay? At the very end of the day, he belonged to the military. You sign the dotted line, you know you belong to the military. And if the military tells you to do something, you do it. And you do it unquestioningly, right? But there's -- that contract has two people in it. And just as Stuart had an obligation to do what the military told him, they had a responsibility to look after him.

They can't ever say they didn't know that he was sick or suicidal. But we maintain what they chose to do was they saw a drunk, they saw an addict, and they were going to get him out the back door.^{Footnote 3549}

16. Shortly afterwards, Mrs. Fynes was even more direct, declaring, “They killed him.”^{Footnote 3550} Mr. Fynes, similarly, told Maj Dandurand and MCpl Mitchell, “I will go to my grave, [convinced] they killed our son […].”^{Footnote 3551}

17. Mrs. Fynes told the investigators their complaint was made against Cpl Langridge’s chain of command.^{Footnote 3552} When asked who she believed was “the most responsible and the most negligent,” she named CWO Ross and Capt Hannah.^{Footnote 3553} Mr. Fynes also blamed “[w]hoever made the decisions to pull [Cpl Langridge] out of the hospital,” whom Mrs. Fynes stated she believed to be Capt Lubiniecki.^{Footnote 3554} Mr. Fynes interjected to say he did not believe Capt Lubiniecki made that decision.

18. In the course of making their complaint, the Fynes identified several issues with the 2008 Sudden Death Investigation and with the subsequent BOI, which they believed demonstrated that investigators pursuing their present complaints should not rely on the reports of those investigations. Mrs. Fynes observed, and Maj Dandurand agreed, the BOI had a different purpose in conducting its investigation than a police investigation.^{Footnote 3555}

19. Beyond the distinction in purpose, the Fynes claimed the BOI was of no value to the CFNIS investigation because of a number of process issues. Mrs. Fynes alleged the entire inquiry was “scripted,” claiming conflicting testimony was not challenged to determine what was accurate, and the inquiry was slanted towards proving Cpl Langridge was a drug addict so as to absolve the chain of command of any liability for his death.^{Footnote 3556} Mr. Fynes supported this allegation by pointing to the fact the doctor who diagnosed Cpl Langridge with PTSD was not called to testify at the BOI.^{Footnote 3557} In addition, Mrs. Fynes alleged they were not permitted to participate in either process despite a requirement for BOIs to allow participation by the families of decedents in questioning and discussion.^{Footnote 3558} She also alleged having overheard a conversation one evening after the BOI hearings where the OC for Cpl Langridge’s squadron, Maj Jared, would have commented to the BOI President, “Well, how are you supposed to get rid of these fucking guys?”^{Footnote 3559}

20. Mrs. Fynes complained there were inconsistencies in the testimony of witnesses in the 2008 Sudden Death Investigation and these were not addressed. As well, she complained of inaccuracies in the report.^{Footnote 3560} She referred to the investigation report generally as a “hatchet job that’s being done in an attempt to absolve people’s responsibility.”^{Footnote 3561}

21. The Fynes supplemented their verbal complaint with a written one,^{Footnote 3562} dated May 5, 2010, and delivered during the interview,^{Footnote 3563} addressed to Maj Dandurand in his capacity as OC CFNIS WR, and signed by Mr. Fynes. The letter states Mr. Fynes was making a formal request to the CFNIS to conduct further investigation into the circumstances of Cpl Langridge’s sudden death. It points to “sections 215(1)(c), 217.1 and 219.1”^{Footnote 3564} of the Criminal Code of Canada as being potentially applicable to the case. These sections concern the duty to provide the necessaries of life, the duty of supervisors to take steps to prevent bodily harm to any person working under their direction, and criminal negligence (though, in fact, criminal negligence is dealt with in sections 219 and 220 of the Criminal Code, and not section “219.1”).^{Footnote 3565} The letter makes a number of allegations echoing the verbal complaint, claiming Cpl Langridge was either under a suicide watch that was deficient, or ought to have been under a watch if he was not.^{Footnote 3566} It states, “Stuart’s death was absolutely preventable had he been given the medical treatment to which any soldier is entitled. His lack of treatment and imposed discipline went far beyond cavalier to, in my opinion, Criminal Negligence.”^{Footnote 3567}

Assurances Provided by CFNIS Investigators

22. In the course of taking the Fynes’ complaint, Maj Dandurand gave a number of assurances about the investigation and how it would be conducted.^{Footnote 3568} These related mainly to: the manner in which the investigation would be conducted, including its scope, and the number of investigators; the involvement of the command team; a plan to review documents and witnesses; and the Fynes’ involvement in the case as witnesses.

23. The first assurance to the Fynes was that there was an onus on the CFNIS to investigate their allegations once they made a formal complaint.^{Footnote 3569} Mrs. Fynes asked Maj Dandurand, “So my question, then, for you is that once we formally make this allegation […] is there an onus upon you to investigate them?”^{Footnote 3570} Maj Dandurand replied, “Yes.”^{Footnote 3571} Mrs. Fynes then asked, “You have to investigate?”^{Footnote 3572} Maj Dandurand again answered, “Yes.”^{Footnote 3573}

24. Maj Dandurand told the Fynes a new GO file would be created:

[…] so that we can say that the scope of the investigation is this. Because we look at the elements of the offence of what [an] allegation entails, and then we pursue down that investigative path.

There is no doubt with this that there will be a revisitation of all documents. What we want to do is make sure that, if there’s something that snuck into a Board of Inquiry testimony here or a piece of paper or evidence there, it’s not missed.

So we revisit everything that’s available, and then we go looking for anything else that we say, “You know what, nobody ever thought to ask this question, and we’re going to go in, we’re going to pluck that and…”^{Footnote 3574}

25. Maj Dandurand told the Fynes the investigation would be conducted employing a major case management model, a form of investigation involving what he referred to as the “command triangle,” employed where the size of the file requires it.^{Footnote 3575} Maj Dandurand explained major case management involves three or more investigators and was necessary in this case due to “not only the volume of interviews that have to occur, but the manner and the order in which they have to occur.”^{Footnote 3576} Although he speculated he could assign two investigators, Maj Dandurand stated he believed the case would grow much larger and he would “need to analyze the work that has to occur with respect to this in order to investigate these three [Criminal Code offences] right here.”^{Footnote 3577} He stressed major case management is employed to maintain the speed, direction and flow of an investigation.^{Footnote 3578}

26. Maj Dandurand stated the CFNIS would be moving as fast as possible in this investigation, though he speculated the early goings might be slow due to the vast amount of research required.^{Footnote 3579} At several times in the course of the interview, he told the Fynes they would be updated on the investigation’s progress every two weeks,^{Footnote 3580} though he was cautious to warn them to temper their expectations as to what could be achieved in two weeks’ time.^{Footnote 3581} He went a step further, telling the Fynes he and MCpl Mitchell would be in contact “[…] literally. Not just for updates. We’ll probably pick your brain on something as well.”^{Footnote 3582}

27. Maj Dandurand was clear in telling the Fynes that, although the BOI would be reviewed, it would not be relied upon as fact by investigators. He stated it was the “first port of call” for the investigators,^{Footnote 3583} allowing them to see what witnesses had said in order to formulate questions and lines of inquiry before re-interviewing the witnesses.^{Footnote 3584}

28. The Fynes were given two specific assurances with respect to issues they had identified as having been left outstanding following the 2008 investigation, BOI and SI. MCpl Mitchell told the Fynes he would investigate where Cpl Langridge was living prior to his death, because they complained the information contained in the SI was wrong.^{Footnote 3585} Maj Dandurand also told the Fynes he would find out why Cpl Langridge was living at the Duty Desk, as they complained the issue was still unresolved.^{Footnote 3586}

29. Maj Dandurand stressed the CFNIS considered this case very important, as shown by him personally flying out to take the Fynes’ complaint.^{Footnote 3587} He made a general assurance with respect to the investigation, stating:

I give you this promise, if I say that a charge is merited, I have the reasonable [probable] grounds, as defined by all of police practices, I will lay that charge.

Equally, if I say that the charge is not warranted, I will have the justification for that statement.

It will be investigated without bias, right through to the truth. We will uncover the truth of what happened.

[…]

And that's all we can commit to you, is that that's what we do. We pride ourselves on excellence, truth and duty in the NIS. Those three things.^{Footnote 3588}

Translating Words into Deeds

30. Coming out of the May 2010 interview with Mr. and Mrs. Fynes, it was apparent Maj Dandurand recognized the Fynes were seeking a distinct and comprehensive investigation concerning the possibility members of the LDSH and the military medical community were criminally negligent in their son’s death.^{Footnote 3589} Mrs. Fynes went so far as to ask Maj Dandurand to take away from their meeting the message that “I really need to look closer.”^{Footnote 3590} Maj Dandurand’s statements indicated he also understood the proposed investigation of their complaints should not rely on information from the BOI report and more was required.^{Footnote 3591} The BOI had not been conducted with the same aims or to the standard required for a police investigation. The Fynes were, moreover, emphatic they did not trust the explanations offered for Cpl Langridge’s treatment.^{Footnote 3592} They stated the BOI witnesses would say “[…] whatever moves the heat from them […],” and that such witnesses were in fact afraid of being implicated in negligence.^{Footnote 3593} Maj Dandurand made it clear to the Fynes he understood the BOI report could not be taken at face value. He told them, even though the report and its annexes might serve as a starting point, the CFNIS would have to interview the relevant witnesses themselves and revisit every document.^{Footnote 3594} In the same vein, he later testified he knew the BOI report alone would not constitute an adequate factual record for the criminal negligence investigation.^{Footnote 3595}

31. Maj Dandurand was also aware the Fynes did not believe he could rely on the 2008 Sudden Death Investigation Report. The Fynes had stressed to Maj Dandurand and MCpl Mitchell they believed the 2008 Sudden Death Investigation Report was sorely lacking, being incomplete, inadequate, and often incorrect.^{Footnote 3596} Mrs. Fynes went so far as to say “[…] there’s a pile of crap in there, I gotta tell you.”^{Footnote 3597} Maj Dandurand explained to the Fynes an investigator must take all information received into account and record it in the file, even if the information was false, in order to ensure nothing is omitted.^{Footnote 3598}

32. With Maj Dandurand’s express acknowledgment of the rigorous investigative work that would be required to investigate the Fynes’ serious allegations, it remained to be seen how MCpl Mitchell and the CFNIS WR investigative team would put this understanding – indeed, this commitment – into practice.

33. Shortly after the complaint intake interview with Mr. and Mrs. Fynes, members of the CFNIS WR began to consider the investigative implications of their allegations. MCpl Mitchell recorded a rough plan in his notebook at the conclusion of the interview, indicating he planned to: (1) open a GO file; (2) research case law related to the Criminal Code sections complained of; and (3) request BOI annexes.^{Footnote 3599} On May 7, 2010, MCpl Mitchell recorded the initial complaint into SAMPIS, noting CFNIS WR assumed investigative responsibility and he had “[…] been tasked to conduct an investigation into the allegation that the LdSH(RC) CoC and Medical community were negligent when failing to provide appropriate support for Cpl LANGRIDGE.”^{Footnote 3600}

34. During the interview with the Fynes, there was no indication the investigative process Maj Dandurand described to the Fynes was contingent upon some prior step, or that the promised investigation would not ultimately be what followed.^{Footnote 3601} Nevertheless, the initial work on the file was scant. By May 10, 2010, just five days after the interview with the Fynes, the decision was made to seek legal advice before taking further action. MCpl Mitchell testified he sat down with Maj Dandurand and had a “brainstorm” session involving a discussion of what was known from the three investigations,^{Footnote 3602} and at this or at another discussion they considered the volume of work “that was entailed in the entire situation.”^{Footnote 3603} His recollection was he and Maj Dandurand agreed he would conduct an assessment of the file before proceeding to any investigation, and they decided to seek a legal opinion. MCpl Mitchell also testified his understanding was they deemed it unnecessary to actually adopt a major case management approach to the file.^{Footnote 3604} MCpl Mitchell contacted Maj Anne Litowski on May 10 to obtain a “legal assessment.”^{Footnote 3605} MCpl Mitchell was unavailable to actively work on the file between May 10 and May 21, 2010, as he was tasked with completing his PLQ course.^{Footnote 3606} A File Status Report from CFNIS WR dated May 12, 2010, stated an assessment was being conducted on the file, documents from the BOI and SI were being reviewed, and the investigative complexity of the alleged offences and the severity of the alleged offences were “Low.”^{Footnote 3607}

35. Within days of the intake interview with the Fynes, WO Hart, the initial case manager for the file, had a discussion with Maj Dandurand and MCpl Mitchell about the allegations.^{Footnote 3608} He himself did not have more than “a very basic understanding” of the circumstances of Cpl Langridge’s death, essentially being aware only that Cpl Langridge was living in Unit lines, had to check in periodically, and was under “some form of assistance and supervision to assist him during that time.”^{Footnote 3609} Knowing only this, he believed the offences alleged weren’t appropriate.^{Footnote 3610} WO Hart testified the investigators’ consensus from this first look was also that they didn’t believe the allegations were applicable in this case, stating “[…] based upon our experience as investigators, based upon our time doing the job, it just didn’t seem like appropriate charges or matters to investigate.”^{Footnote 3611} WO Hart testified that, following this initial assessment by the CFNIS WR,^{Footnote 3612} the decision was made “relatively quickly” that the Fynes’ complaint could not be substantiated.^{Footnote 3613}

36. When asked about WO Hart’s evidence, Maj Dandurand testified he recalled discussing the allegations with WO Hart and MCpl Mitchell,^{Footnote 3614} but emphasized he wished to foster in the CFNIS WR office an environment of healthy debate with respect to interpreting the Criminal Code.^{Footnote 3615} He explained these allegations were new territory for him, and he did not wish to decide one way or another whether the criminal negligence offences were applicable. He stated he wished to seek external advice first, and he denied this discussion meant they were “pre-positioning ourselves with respect to our mindset on this investigation.”^{Footnote 3616} Despite WO Hart’s early conclusion, Maj Dandurand reiterated these views had not coloured his assessment of the investigation early on, stating, “And that's the beauty of a Major Crimes unit, is you can have differing opinions, and I think that's the strength of it.”^{Footnote 3617}

37. There is reason to believe the discussion amongst the CFNIS WR members nevertheless had some impact on the direction and vigour of the ensuing action on the file. Very little was in fact done, and this stands in stark contrast with the sweeping assurances made by Maj Dandurand during the May 2010 interview with the Fynes. Acting on direction from his superiors and the discussions they held, MCpl Mitchell essentially did only two things for the file, both in May 2010. First, he compiled certain documents he identified as relevant for the assessment. Second, he sent the matter on for a legal opinion.

38. Maj Dandurand testified he relied on the interpretations and experience of his investigative team and on external advice to support the conclusion the offences could not be made out.^{Footnote 3618} This reliance would have been justifiable to the extent the interpretations were founded on an adequate factual basis.

39. MCpl Mitchell testified he did not review each and every relevant document in the course of his assessment. He explained this was because he felt sufficiently familiar with the facts of the case from his work on the 2009 investigation.^{Footnote 3619} He stated that in order to form his own initial opinion of the case, he reviewed:^{Footnote 3620} an excerpt of Cpl Rohmer’s CFNIS interview summary from the 2008 investigation;^{Footnote 3621} the interview summary from the 2008 CFNIS interview with Capt Lubiniecki;^{Footnote 3622} a document prepared by MCpl Ritco titled “MED DOC TIMINGS”;^{Footnote 3623} a draft of the BOI Report;^{Footnote 3624} and an Admission Certificate (Form 1) prepared for Cpl Langridge on February 1, 2008, by Dr. Butler at CFB Edmonton along with two pages of handwritten medical notes from the base clinic made on February 1 and February 4, 2008.^{Footnote 3625} These documents were not scanned into the 2010 investigation file, and MCpl Mitchell conceded he should have done so for the benefit of any successor to the file.^{Footnote 3626}

40. MCpl Mitchell did not include the 2008 GO file in this compilation. In fact, he testified he never read the 2008 file.^{Footnote 3627} During his review, he only referred to the 2008 Case Summary and the handful of other excerpts (including those listed above) scanned into the 2009 GO file.^{Footnote 3628} MCpl Mitchell testified he did not review any documents at the time he compiled them because his May 2010 PLQ course intervened.^{Footnote 3629} The only activity he undertook before his time was occupied by coursework was to compile these documents and send off his request for the legal opinion.^{Footnote 3630}

41. Beyond these documents, MCpl Mitchell did not, at any point, specifically review or compile any documents to satisfy himself he possessed complete information concerning the knowledge Cpl Langridge’s chain of command had concerning his past suicide attempts.^{Footnote 3631} He did not seek out documents specifically concerning whether or not Cpl Langridge may have had PTSD.^{Footnote 3632} MCpl Mitchell did not compile any specific information about the existence or non-existence of a suicide watch above and beyond the documents listed above.^{Footnote 3633} He did not conduct any investigation or seek out any information about Mrs. Fynes’ allegation she was assured Cpl Langridge was safe and was being watched constantly.^{Footnote 3634} MCpl Mitchell also did not specifically seek out and compile information about the allegation Cpl Langridge may have been denied medical treatment.^{Footnote 3635} He also did not investigate or seek out information about the reasons for the conditions placed upon Cpl Langridge or any links between the work assigned to Cpl Langridge and his suicidal ideation.^{Footnote 3636} MCpl Mitchell testified these issues would have been explored had the decision been made to conduct a subsequent investigation.

42. MCpl Mitchell did not identify any suspects,^{Footnote 3637} interview any witnesses,^{Footnote 3638} speak to the investigators from the 2008 Sudden Death Investigation, or even obtain the BOI testimony and evidence annexes^{Footnote 3639} as he had initially planned to do. MCpl Mitchell acknowledged in his testimony he did not take any investigative steps beyond compiling documents and sending off a request for advice.^{Footnote 3640}

43. MCpl Mitchell’s assessment also seems to have focused only on the Criminal Code offences listed in Mr. Fynes’ letter. MCpl Mitchell stated any service offences, such as the negligent performance of a military duty, would only have been considered if, upon assessment of the criminal offences, the decision was made to conduct an investigation.^{Footnote 3641}

44. This is somewhat difficult to understand. Code of Service Discipline offences would not have been derivative of, or dependent upon, establishing the elements of the Criminal Code offences. Part III of the National Defence Act (NDA) sets out the Code.^{Footnote 3642} Section 124 of the NDA reads: “Every person who negligently performs a military duty imposed on that person is guilty of an offence and on conviction is liable to dismissal with disgrace from Her Majesty’s service or to less punishment.”^{Footnote 3643} Section 129(1) of the NDA, which might also have been relevant, states “Any act, conduct, disorder or neglect to the prejudice of good order and discipline is an offence and every person convicted thereof is liable to dismissal with disgrace from Her Majesty’s service or to less punishment.”^{Footnote 3644} Section 129 is a section often utilized when doubt exists that a more serious charge under the NDA (such as under s. 124) is appropriate.^{Footnote 3645}

45. The Fynes had argued members of the LDSH chain of command owed a duty of care to Cpl Langridge by virtue of their positions, and they breached the standard of care in ordering him from hospital and imposing suspect conditions on him. A similar allegation was echoed against members of the military medical community. The Fynes also specifically claimed there was a CF policy requiring COs to employ a suicide prevention protocol. By failing to have such a protocol in place or failing to follow the protocol, the Fynes alleged the LDSH chain of command breached the standard of care. The allegations, if verified, could plausibly have constituted service offences, and these should have been assessed alongside the Criminal Code offences.

46. On May 10, 2010, MCpl Mitchell sought a legal opinion concerning the Fynes’ allegations.^{Footnote 3646} Because of claims of privilege asserted by the Minister of National Defence,^{Footnote 3647} we do not know and cannot know what materials were sent. We also do not know and cannot know what advice the CFNIS investigators were later provided.

47. Whatever documents were sent, the legal advisor could not have had access to more than what the investigators had themselves gathered. WO Hart agreed with the proposition that the quality of the legal advice obtained with respect to the applicability of a given charge in a given set of circumstances would only be as good as the information provided about the specific circumstances.^{Footnote 3648} WO Hart testified he was satisfied a comprehensive effort had been made to ascertain the applicable circumstances before the CFNIS WR assessment and the subsequent legal assessment.^{Footnote 3649} He also testified, however, that to the extent any documents compiled and sent on for an external assessment might have included material from the 2008 investigation, there would not have been any indication the Fynes had lodged objections to how that investigation was conducted.^{Footnote 3650} Maj Dandurand testified it was “absolutely” his view that in order to obtain a good legal analysis, it was necessary to ensure there was a complete factual record that could be consulted.^{Footnote 3651} Maj Dandurand testified the BOI would not have been an adequate factual record for the assessment, at least, “[n]ot independently.”^{Footnote 3652} When asked whether he believed the 2008 investigation was an adequate factual record, Maj Dandurand testified he believed “[t]he totality of our investigations would have been what we would have expected to be considered.”^{Footnote 3653}

48. In fact, however, the documents MCpl Mitchell assembled as being necessary for the file^{Footnote 3654} were very limited in scope and detail. Even if the entire 2008 GO file was considered and made available to an outside advisor, this Commission has found the 2008 Sudden Death Investigation was deeply flawed and extremely limited in its understanding and assessment of potential negligence.^{Footnote 3655} The investigators in that case overlooked many significant witnesses, reached questionable conclusions, and failed to identify or pursue a number of significant issues – particularly with respect to Cpl Langridge’s last weeks, the decisions about his treatment, and the arrangements made by the LDSH and the military medical community to provide supervision and care for him and to ensure his safety.

49. The allegations made by the Fynes in their interview with Maj Dandurand and MCpl Mitchell were, for the most part, not pursued or even considered during the course of the 2008 investigation. In particular, the 2008 GO file contained no information whatsoever about the following allegations:

The allegation Cpl Langridge was forced to accept a return to Base from hospital;
The allegation the conditions imposed on Cpl Langridge were intended to set him up to fail and thus to justify discharging him from the Canadian Forces;
The allegation Cpl Langridge acquiesced to the conditions imposed upon him as a condition of being sent to a substance abuse treatment facility;
The allegation Mrs. Fynes had been assured in March 2008 Cpl Langridge would be watched 24/7 and was being kept safe;^{Footnote 3656}
The allegation the LDSH CO failed to implement a suicide prevention protocol or any factual underpinnings for this alleged failure; and
The allegation the LDSH CO failed to conduct SIs as required by CF policy or any factual underpinnings for this alleged failure.

50. The BOI was also an unacceptable source of factual information for the CFNIS assessment and an unreliable source of information for any legal opinion. It consisted of the CF’s own conclusions about the matter based on their own investigation. The facts had not been gathered in accordance with police methods or with police-driven investigative aims. Having not obtained the annexes, the investigators did not even have access to the actual evidence assembled, (however imperfectly gathered), and could not see for themselves whether the manner in which it was collected left gaps. The CFNIS members could only access the BOI’s description of the evidence where said evidence was being used to support its findings.

51. The term “fruit of the poison tree” was used in the testimony of the subjects,^{Footnote 3657} and WO Hart testified he understood the term to mean inculpatory information obtained by compulsory interviews in which the witness was not given a caution, and which would accordingly be unusable in a subsequent prosecution.^{Footnote 3658} He also understood it to mean this tainted evidence could not even be used as a springboard for the CFNIS’ own subsequent investigation. In light of the weaknesses of the evidence and the dangers of using it, WO Hart testified it was unsafe to rely on a BOI to provide a factual basis for an investigation.^{Footnote 3659}

52. Relying on this material would have been completely improper from an independence perspective and from the perspective of the investigation itself.^{Footnote 3660} Maj Dandurand testified he believed some of the information contained in the BOI could be relied upon “to an extent,” however, and that the information would be weighed in making an assessment.^{Footnote 3661} WO Hart testified he was unaware of any circumstances in which the CFNIS “[…] would strictly rely upon that information without further substantiating it ourselves.”^{Footnote 3662} WO Sean Bonneteau assumed the lead investigator would only have used the BOI as “background information,” and believed every investigator knows the appropriate weight to place on the documents they review, but stated, if any of the information was to be used in a criminal investigation, it would indeed be fruit from the poison tree.^{Footnote 3663}

53. The absence of comprehensive and accurate information about the circumstances underpinning the allegations meant the legal opinion would have been of limited value as a foundation for any investigative assessment by CFNIS WR.

The “Assessment” Concludes

54. There was almost no activity on the file after May 2010. On August 17, 2010, MCpl Mitchell contacted Mr. Fynes and provided an update. He reported to Maj Dandurand, he “Spoke to Shaun. Everything went fine. He seemed to be appreciative. Explained exactly what we talked about and he was happy with the explanation.”^{Footnote 3664} Neither MCpl Mitchell^{Footnote 3665} nor Maj Dandurand^{Footnote 3666} could recall what Mr. Fynes was told, though MCpl Mitchell recalled in testimony he would have provided an update “as to where I stood,” and advised Mr. Fynes another investigator would be taking over the file.^{Footnote 3667} Mr. Fynes’ recollection of the last update was that MCpl Mitchell indicated he was seeking advice from superiors.^{Footnote 3668}

55. By this time, however, it appears CFNIS WR members had already decided to close the file. An August 14, 2010, File Status Report^{Footnote 3669} concerning the 2010 Criminal Negligence Investigation states simply, “File to be concluded.”^{Footnote 3670} MCpl Mitchell was taken off the file in mid-August because he was departing in September 2010 to undertake the residency portion of his PLQ course in preparation for an RCMP secondment that November.^{Footnote 3671} No report of any activity appears in the file throughout the fall of 2010. Indeed, WO Bonneteau, who became the CFNIS WR Operations WO in the summer of 2010, testified his understanding was there was no investigation beyond obtaining the legal opinion.^{Footnote 3672}

56. An email message sent that October by Maj Francis Bolduc, the DCO CFNIS, confirms the decision that no charges were warranted had been made some time previously. In his October 28, 2010, message to the CFPM, Col Timothy Grubb, Maj Bolduc advised that the investigative assessment was complete and had concluded there was “nothing [to] indicate that a Code of Service offence or criminal offence such as criminal negligence causing death may have occurred.”^{Footnote 3673}

57. Maj Dandurand testified it was ultimately his decision to close the file and not proceed further.^{Footnote 3674} He testified he would likely have concluded the charges were unlikely to have merit after “receiving input from external sources.”^{Footnote 3675} Because of solicitor/client privilege claims made on behalf of the Minister of National Defence, the Commission does not know and cannot know the content of the external input. The dates of the File Status Report and Maj Bolduc’s email establish that the CFNIS assessment was completed by the fall of 2010 and presumably before mid-August, 2010.

Sgt Shannon’s Briefing

58. Sgt Scott Shannon joined CFNIS WR as a team leader in August 2010.^{Footnote 3676} He was not involved in the 2010 investigation before the winter of 2010/2011. At that time, WO Bonneteau tasked Sgt Shannon with preparing a briefing for the CFNIS WR chain of command for both the 2009 and the 2010 investigations.^{Footnote 3677} Sgt Shannon testified he was assigned this task in February 2011,^{Footnote 3678} although his notebook suggests he was tasked with this on December 10, 2010.^{Footnote 3679} Whatever the case may be, his work would clearly have been informed by what was done before and the decisions made previously.

59. Sgt Shannon stated:

So upon receiving that task I read the file, the limited information that was available.

I took the letter of allegation that was presented to the NIS by Mr. Fynes. I conducted an independent and thorough review of the allegations that he presented.

I conducted an evaluation of the three Criminal Code sections that he identified in his letter.

I conducted an extensive case law review for the specific allegation of criminal negligence causing death.

And I determined through my own independent analysis of the Criminal Code and available case law that those applicable offences did not apply in this situation and, therefore, the task of offence validation which is part of a general investigation sequence was not successful and therefore there was no need to conduct any type of investigation into that matter.^{Footnote 3680}

60. Sgt Shannon’s efforts must be understood in context. The decision had already been made to conclude the file. His role was to produce a PowerPoint presentation explaining to his chain of command what had already been decided.^{Footnote 3681} MCpl Mitchell was never replaced by a new lead investigator when he was taken off the file in August 2010. It is fair to deduce this was because there was no need. Sgt Shannon’s role was not to conduct an investigation or even to advance the file, and it is evident he was not expected to do so. Sgt Shannon was not given enough time to accomplish anything of the sort. At the earliest, he would have begun work on the briefing in mid-December 2010, just before Christmas holidays began, and (in addition to his regular caseload) his time for this would be divided with the briefing for the 2009 investigation. Whatever time he did ultimately spend on the 2010 briefing, Sgt Shannon’s evidence suggests he did most of his research and preparation on his own time during the weekends leading up to the briefing.^{Footnote 3682} There was nothing left to do from an investigative perspective, and it is simply not the case Sgt Shannon conducted any further investigation. In essence, Sgt Shannon’s task was to explain the thought process underlying the decision to close the file without further investigation.

61. Sgt Shannon stated his role “[…] was limited to an academic evaluation of the complaint,” stressing he confined his analysis to Mr. Fynes’ written complaint.^{Footnote 3683} He also testified he considered his work to have been independent of any assurances or representations about the conduct of the investigation made by Maj Dandurand to the Fynes.^{Footnote 3684} In the case of Maj Dandurand’s promise to revisit all documents in detail and to re-interview witnesses, Sgt Shannon testified he did not take these steps because he never got past the analysis of the offence.^{Footnote 3685} Sgt Shannon also testified he did not believe this case met the requirements for the use of major case management.^{Footnote 3686} In fact, he never spoke to Maj Dandurand about his expectations for the investigation.^{Footnote 3687}

62. During the PIH, Sgt Shannon was asked how he prepared for the briefing. He testified he first identified the elements of each of the three Criminal Code offences cited by Mr. Fynes and then referred to jurisprudence noted in his annotated police officer’s edition of the Criminal Code in order to get a better sense of these statutes.^{Footnote 3688} Strikingly, Sgt Shannon testified “[…] it was clear that the conduct defined by those statutes does not apply in this case in any way, shape or form.”^{Footnote 3689} When asked if this meant he didn’t feel it was necessary to do a review of the facts on hand before deciding the offences weren’t applicable to the allegations, he answered that this was correct.^{Footnote 3690} He elaborated by stating “[t]he defined conduct of those three sections does not apply at all in any way, shape or form to the incidents and to the history of this case.”^{Footnote 3691}

63. On February 18, 2011, Sgt Shannon provided his briefing to the CFNIS WR command team with the aid of a PowerPoint presentation.^{Footnote 3692} In the “Allegations” section of the presentation, there is a list of the three Criminal Code sections mentioned in Mr. Fynes’ letter,^{Footnote 3693} followed by a very brief summary of Mr. Fynes’ allegations. The presentation indicates “Mr Fynes does not accuse a specific individual of this alleged negligence nor did Mr Fynes provide any “new” evidence to support allegations [sic].”^{Footnote 3694} The presentation then summarizes Sgt Shannon’s findings regarding each alleged offence, along with his ultimate conclusion none of the allegations were substantiated.

Sgt Shannon’s “Offence Validation”

64. In preparing the PowerPoint presentation, which would set out the basis for that conclusion, Sgt Shannon employed an analytical framework he referred to as an “offence validation.” According to him, this assessment involved setting out the elements of an offence and “[…] apply[ing] an examination of every piece of evidence and we conclude whether we can or cannot establish the elements of the offence.”^{Footnote 3695} With specific regard to the 2010 investigation, Sgt Shannon testified he:

[…] identified the elements of the offence for each of the three Criminal Code offences identified by Mr. Fynes and I proceeded to conduct a case law review and a law review to determine if the substance of those three statutes met the circumstances of the case as I knew them to be at that time.^{Footnote 3696}

65. Sgt Shannon did no original investigation.^{Footnote 3697} The Commission understands Sgt Shannon’s evidence as indicating he believed he undertook a sufficient review of the law and the facts to allow him to feel confident in the accuracy of his presentation. He testified he saw no need to review the documentary record before conducting this assessment because he was content to rely on knowledge he acquired during a prior review. To the extent the PowerPoint presentation was merely intended to summarize the thinking and conclusions of others, this is a reasonable way of proceeding. To the extent the PowerPoint presentation may have been based on Sgt Shannon’s own analysis of the documentary record, it would be much more difficult to justify. Sgt Shannon did review material clearly related to the criminal negligence allegations including the 2008 investigation file and the BOI draft report.^{Footnote 3698} However, he did this review of several hundred pages months before, in the context of an unrelated investigation about the appointment of a PNOK following Cpl Langridge’s death.^{Footnote 3699} This would be entirely inadequate for the purposes of analyzing a file whose subject matter is the conduct of the CF in terms of medical treatment and support leading up to Cpl Langridge’s suicide.

66. Because of the Commission’s conclusions as to the inadequacy of the factual basis for the offence validation exercise, it is not necessary to deal in detail with the legal analysis in the PowerPoint presentation. In general, however, the legal analysis in the presentation dealing with the elements of the three Criminal Code offences under consideration is open to a number of questions.

Duty to provide the necessaries of life

67. With respect to Mr. Fynes’ allegation the CF failed to provide the necessaries of life, Sgt Shannon’s presentation states section 215(1)(c) of the Criminal Code “creates a legal duty to provide necessary care to persons under their charge due to detention, age, illness, mental disorder.”^{Footnote 3700} It notes the person under charge must be unable to remove himself from that charge and unable to provide himself with the necessaries of life: food, clothing, shelter, and medical attention.^{Footnote 3701} It concludes none of the elements of the offence of failing to provide the necessaries of life were made out by the facts of this case.^{Footnote 3702}

68. In testimony, Sgt Shannon elaborated on his analysis, providing his view Cpl Langridge was not under detention because he was not under a legal arrest. Sgt Shannon maintained the conditions did not constitute detention as Cpl Langridge “was free to come and go. He had to report in every two hours. In between, he could go wherever he wished.”^{Footnote 3703} Sgt Shannon stated Cpl Langridge was able to remove himself from the Regiment by disobeying the “lawful orders” he was under and could “face the consequences” if he chose to do so.^{Footnote 3704} This is an unusual interpretation of being “free to come and go.” Sgt Shannon went on to say he did not conclude Cpl Langridge was under the charge of LDSH by reason of mental disorder because he did not believe Cpl Langridge had ever been diagnosed with a mental disorder. He testified he did not take any steps to confirm whether Cpl Langridge had been so diagnosed, relying on his memory of his file review.^{Footnote 3705} He added he could not comment on whether suicidal ideation or alcohol and drug addictions could fall within the definition of mental disorders, twice stating “I’m not a psychiatrist.”^{Footnote 3706} Sgt Shannon simply did not have sufficient facts to assess the meaning of “mental disorder” in the context of criminal negligence. To the extent they were even considered during the offence validation, the medical records in the 2008 GO file were incomplete, and Sgt Shannon did not attempt to gather further records from Cpl Langridge’s civilian hospitalizations.

69. Sgt Shannon testified he did not consider whether taking steps to ensure Cpl Langridge could not commit suicide fell under the duty to provide the necessaries of life because it is not possible to understand why Cpl Langridge took his life.^{Footnote 3707} While he accepted it is possible to foresee a person’s risk of committing suicide, he could not see this carrying into a discussion of failing to provide the necessaries of life.^{Footnote 3708} It should be noted here, at least in passing, however, the jurisprudence suggests the phrase “necessaries of life” may include “protection of the person from harm.”^{Footnote 3709} Accordingly, further assessment of this complex legal duty was very probably required.

Duty of persons directing work

70. The PowerPoint presentation also considers the duties of persons directing work in light of section 217.1 of the Criminal Code. It concludes none of the elements of the offence were made out in this case.^{Footnote 3710} It notes:

[T]his section creates a legal duty to take reasonable steps to prevent bodily harm to that person or any other person arising from that work task[.]

The senior officer who is responsible […] departs […] markedly from the standard of care that, in the circumstances could reasonably be expected to prevent a representative of the organization from being party to the offence[.]^{Footnote 3711}

71. The presentation goes on to note:

Cpl Langridge was not at “work” at the time of death as he was in his barrack room[;]

no aspect of his employment duties contributed to the circumstances of his death[; and]

[t]he “directions” given by superiors on work performance did not contribute to his death[.]^{Footnote 3712}

72. In testimony, Sgt Shannon elaborated on his thought process in analyzing this section. He stated the essence of the offence is a departure from, or failure to comply with, the legal duty to take reasonable steps to prevent bodily harm to a person in circumstances where an employer directs work.^{Footnote 3713} He agreed the officer-subordinate relationship is a form of employer-employee relationship.^{Footnote 3714} He had earlier testified he relied on Capt Lubiniecki and Capt Hannah’s statements as proof Cpl Langridge had accepted the conditions^{Footnote 3715} and was adamant Cpl Langridge’s consent had to be considered in determining whether the conditions were imposed upon him.^{Footnote 3716} Sgt Shannon reiterated Cpl Langridge was in his barrack room and not at work at the time of his death.^{Footnote 3717} He added this section of the Criminal Code did not apply if Cpl Langridge took his life due to conditions imposed upon him at work, but while he was not at work.^{Footnote 3718} Despite even the BOI’s conclusion Cpl Langridge was “on duty” at the time of his death,^{Footnote 3719} Sgt Shannon did not appear to consider the issue of whether the conditions requiring Cpl Langridge to reside on base and to report every two hours, which applied at the time of his death, meant Cpl Langridge was “at work” when he died.

73. Sgt Shannon ultimately concluded no aspect of Cpl Langridge’s employment duties contributed to his death. In his view, Cpl Langridge’s statement to medical professionals that he would rather kill himself than return to his Unit did not create a connection between his employment duties and the circumstances of his death.^{Footnote 3720}

Criminal negligence causing death

74. The presentation also concludes none of the elements of the offence of criminal negligence causing death were made out by the facts of this case.^{Footnote 3721} It notes, “Criminal negligence can arise from either acts or omission, if the accused was under a legal duty to do the omitted act. If the act or omission shows a wanton or reckless disregard for the lives or safety of other persons, this makes out criminal negligence.”^{Footnote 3722} In the discussion of the offence, it states, “no evidence to suggest that any individual member of the CF contributed to decision making process of Cpl Langridge,” and “no member of the CF had any knowledge of the intentions of Cpl Langridge on 15 Mar 08.”^{Footnote 3723} The analysis concludes by noting an organization can be held criminally responsible as a party to an offence of criminal negligence if a member of the organization acting within the scope of her or his authority contributed to or caused the negligence.^{Footnote 3724}

75. Although Sgt Shannon concluded there was no evidence to suggest any member of the CF had contributed to Cpl Langridge’s decision-making process,^{Footnote 3725} he did not seem to question whether it was, in fact, a necessary element of the offence that someone knew of Cpl Langridge’s specific intention on the day he committed suicide, as opposed to knowing only that Cpl Langridge was a danger to himself at that point.^{Footnote 3726} When asked about his view of this, he stated, “in this situation the date that’s critical and the only important date would be the 15th of March, because prior to the 15th of March, Corporal Langridge was among us.”^{Footnote 3727}

76. Sgt Shannon told the Commission it was his conclusion, based on his case law review and analysis of the elements of the offence, that the LDSH’s actions could not constitute criminal negligence causing death as there was no precedent he could find to establish such a link in a case of suicide.^{Footnote 3728} On the other hand, he did agree precedent is not a requirement when a charge is applied to a novel set of facts.^{Footnote 3729} He also agreed the actions detailed in Mr. Fynes’ complaint could constitute negligence, though he determined, in this case, they did not.^{Footnote 3730} Sgt Shannon stated he believed it was a “logical assumption” there is a “general duty in the Canadian Forces of superiors to protect subordinates from foreseeable harm.”^{Footnote 3731} However, following his offence validation, he did not believe there was any reason to conduct further investigations with respect to this issue.^{Footnote 3732}

The Factual Foundation

77. Any possible errors of law in the PowerPoint presentation are secondary to the fact the conclusions set out in the presentation rely on a questionable foundation of facts which were frequently incompletely understood or wrongly assumed. To the extent the offence validation exercise was intended to be based on, in Sgt Shannon’s words, “every piece of evidence” available to him,^{Footnote 3733} that foundation was entirely unreliable. There was no factual investigation undertaken, and whatever facts are cited in the presentation or are implicitly relied upon could only have come from an inadequate documentary record or from assumptions with no documentary foundation.

78. Sgt Shannon’s testimony that there was no need to review relevant documents before undertaking the assessment for the 2010 Criminal Negligence Investigation is concerning. Sgt Shannon’s decision to rely on his recollection of a review of several hundred pages of documents for an unrelated investigation done months previously cannot reasonably be said to be adequate. This review of documents focused on the 2008 and 2009 GO files as well as documents related to the SI.^{Footnote 3734} To the extent some of the documentary material collected for the 2009 investigation was relevant to the issues in the 2010 investigation, that material could only have been found in the BOI report. As has been discussed elsewhere,^{Footnote 3735} the BOI report would not, on its own or possibly at all, be a suitable source for a police investigation in any event. Its problematic status is only amplified by the fact it was only the report itself, containing the BOI’s conclusion, which was scanned into SAMPIS, and not the annexes that contain the actual evidence said to have led to these conclusions. As for the 2008 GO file, one of the bases of the Fynes’ request for the separate investigation, which became the 2010 investigation, was their dissatisfaction with the 2008 investigation, including its alleged factual inaccuracies and, in their view, dubious conclusions. This Commission has found the 2008 investigation was flawed in ways that include its incomplete factual investigation of the issue of negligence and its inadequate understanding of how negligence might be manifested in the circumstances of the case. Be that as it may, it would appear to be a self-defeating exercise to conduct a fresh investigation, even at the assessment stage, which begins by accepting, without further investigation, facts and conclusions disputed by the complainants.

79. Offence validations or investigative assessments constitute a very preliminary stage of an investigation. Their purpose is to determine whether, without further investigation, enough is known to justify a conclusion the offences being considered cannot be made out. They are techniques often employed to weed out frivolous or vexatious complaints.^{Footnote 3736} In this case, given the lack of reliable facts in the documentary record, a potential alternative approach would be to consider whether, even if all the facts alleged by the complainants were true, it would still nevertheless be impossible to satisfy all of the elements of the offence being considered. If there is no possibility, even if the facts alleged were found to be true, of making out the elements of an offence, there is no use proceeding any further with the investigation. Otherwise, unless there are other valid reasons for exercising discretion not to investigate, the investigation should move on and begin to actually look into the facts. What cannot be done is simply to disregard the alleged facts or assume they are untrue without further investigation.

80. It appears this is precisely what Sgt Shannon did. The Fynes’ allegations were not taken as true for purposes of the analysis. Either the facts Sgt Shannon relied on were precisely those said to be unreliable by the Fynes, or he relied only on assumptions.

81. Based on his testimony, it is clear Sgt Shannon did not even consider all of the allegations of facts made by Mr. and Mrs. Fynes during their interview with Maj Dandurand and MCpl Mitchell.^{Footnote 3737} In fact, he had not reviewed the recording for the interview.^{Footnote 3738} As such, he would only have been aware of the allegations described in summaries and notes included in the file.^{Footnote 3739} He would not have been aware of the allegations made about the suicide watch, the conditions being imposed on Cpl Langridge, the disciplinary measures being imposed on Cpl Langridge, or the negative effect the conditions had upon Cpl Langridge.^{Footnote 3740} Sgt Shannon stated he would only have examined such allegations if his investigation had gone past the offence validation stage.^{Footnote 3741} That is not the proper procedure for an offence validation.

82. The unavoidable conclusion is Sgt Shannon’s “offence validation” did not have an adequate factual basis.

Service Offences

83. Members of the CF are subject to the Criminal Code as well as a system of penal military justice as set out in Part III of the NDA, known as the Code of Service Discipline.^{Footnote 3742} The CFNIS can investigate and lay charges for both criminal offences and service offences.^{Footnote 3743}

84. Whatever the validity of the offence validation exercise described in the PowerPoint presentation with respect to the Criminal Code offences, there is no similar exercise set out in the presentation with respect to any potential Code of Service Discipline offence. Although the complainants only set out Criminal Code offences in their letter of complaint, it is unreasonable for the police to expect a complainant to be aware of the potential legal categories involved in the facts giving rise to a complaint. Complainants set out the facts they believe demonstrate a wrong has been committed. It is for the police to determine whether those facts amount to a wrong recognized by the law. In the case of the Military Police, that law includes the Code of Service Discipline. Many of the complaints made by the Fynes indicated there needed to be an investigation of potential service offences, and it seems this may never have been seriously considered at the assessment stage.

85. When asked whether it was either policy or his practice to consider service offences as alternatives to Criminal Code offences, Sgt Shannon testified he generally did consider any potentially applicable service offences.^{Footnote 3744} He testified, in this case, he considered the potential applicability of the offence of negligent performance of a military duty, but was able to rule it out when ruling out the criminal negligence offence, as he considered the elements to be very similar.^{Footnote 3745} There is nothing in the investigative record dealing with any such analysis, and it does not appear in the PowerPoint presentation. There is no mention of Code of Service Discipline offences anywhere in the file or in records related to the 2010 investigation other than in the File Status Reports to CFNIS HQ.^{Footnote 3746}

Missing Analysis in the Assessment

86. Each of the potentially applicable Criminal Code offences, as well as each of the potentially applicable service offences, such as NDA s. 124 and s. 129(1), has in common the notion of a duty to do or not to do something and conduct in contravention of that duty. For each there is also a standard against which the alleged contravention is to be measured, as well as a requisite mental element of wilfulness or recklessness.^{Footnote 3747} Whether the elements of any of the offences would actually be made out, would of course depend on the evidence. At the time of Sgt Shannon’s offence validation, there were insufficient facts in the documentary record to either establish or refute any of these elements. In the absence of a reliable factual record, the alternative would have been to ask whether, assuming the Fynes’ allegations were true, it would still be possible to conclude the elements of the offence in question could not be made out. Looking at all the elements of the Criminal Code offences being considered, as well as the elements of potentially relevant service offences, if the facts as alleged by the Fynes during the course of the May 5, 2010, interview were found to be true, it is not at all clear each and every element could not be made out.

87. If one were to assume the allegations made by the Fynes in the May 5 interview were true, then if the military had complete control over Cpl Langridge; and if it were true Cpl Langridge was compelled to agree to the conditions, and he had no choice but to abide by them; and if it were true that, to the knowledge of the military, he hated the conditions to the extent he preferred to kill himself rather than continue to abide by the conditions; then it might be concluded the military had, under the circumstances, a duty to keep Cpl Langridge safe.

88. Alternatively, if the military knew or ought to have known, absent close supervision, Cpl Langridge was in danger of attempting to kill himself; and if, despite this knowledge, the military ordered him out of the hospital in which he had been closely supervised; and if, in the past, the military had taken steps, either with respect to Cpl Langridge or others, to provide a “suicide watch” or other similar type of close supervision; then on that basis as well, it might arguably be possible to conclude the military was under a duty to provide the sort of close supervision that would keep him safe.

89. This is not to say an offence would have been made out. Each and every one of the allegations assumed to be true would still need to be proven on the facts, and it could well turn out to be the case that one or more of those allegations would not be substantiated through an investigation of the facts. There would also be further issues to resolve, including but not limited to establishing the requisite standard of care in order to assess whether the conduct in question fell below that standard. The facts might also not demonstrate the conduct complained of had any relationship to Cpl Langridge’s death. It might also be that the evidence would fail to demonstrate the requisite mental elements of wilfulness or recklessness applicable to the respective offences.

90. All an offence validation exercise based on an assumption the Fynes’ allegations were true would have demonstrated was that it was unsafe to assume, without need for further investigation, that no charges could be warranted based on the facts alleged. If a further investigation were then conducted, its purpose would be to determine whether the allegations were in fact true and, if they were, whether any charges were warranted.

91. The offence validation undertaken by Sgt Shannon was a deeply flawed, inadequate and incomplete exercise, which evidently drew upon the flawed, inadequate and incomplete processes that came before it. The legal analysis was questionable and often relied on incorrect or incomplete facts and unfounded assumptions. This can lead to a suspicion there simply may never have been an intention to conduct an investigation.

92. If the CFNIS was indeed conducting a fresh investigation and not simply recycling the conclusions of the BOI and/or the 2008 investigation, it was not appropriate in assessing the Criminal Code or Code of Service Discipline offences simply to accept, without further investigation, that the facts were not consistent with the Fynes’ allegations.

Failure to Investigate

93. On March 4, 2011, WO Bonneteau drafted the Case Summary for the 2010 Criminal Negligence Investigation:

On 5 May 10, at CFNIS WR, Mr FYNES requested an investigation be initiated into the manner in which Cpl LANGRIDGE was treated by unspecified members of the Canadian Forces which he alleges ultimately contributed to the death of Cpl LANGRIDGE on 15 Mar 08. In addition, Mr. FYNES alleges the inadequate medical treatment and/or care in which Cpl LANGRIDGE received by the Canadian Forces medical community and LdSH(RC), further contributed to his death. In the written complaint, Mr FYNES makes specific reference to s.215(1)(c) Duty to Provide Necessities of Life, s. 217.1 – Duty of Persons Directing Work and s. 219 – Criminal Negligence contrary to the Criminal Code of Canada.[sic]^{Footnote 3748}

94. WO Bonneteau also drafted the Concluding Remarks for the 2010 Criminal Negligence Investigation on March 4, 2011:

This investigation has revealed there is no evidence to suggest any member of the Canadian Forces medical community or members of LdSH(RC) committed the Criminal Code of Canada offences detailed in Mr FYNES letter. [sic]

As no further investigative actions are anticipated by the CFNIS WR, this investigation is concluded.^{Footnote 3749}

95. In testimony, WO Bonneteau conceded that when he wrote “there is no evidence,” he meant none of the evidence forwarded to the legal advisor by MCpl Mitchell was seen as sufficient to ground the allegation any member of the CF or the military medical community committed a Criminal Code offence.^{Footnote 3750} He also acknowledged, any such “evidence” had only been obtained through document review.^{Footnote 3751}

96. Sgt Shannon drafted a letter to the Fynes providing a basic summary of the conclusions for the 2009 and 2010 GO files^{Footnote 3752} on March 3, 2011,^{Footnote 3753} and it was signed by Maj Dandurand on April 27, 2011.^{Footnote 3754} With respect to the 2010 investigation, it states:

The Canadian Forces National Investigation Service Western Region (CFNIS WR) has completed two detailed and comprehensive investigations regarding the alleged conduct of members of the Canadian Forces with regard to your son, Cpl Stuart Langridge. The allegations were presented to CFNIS WR verbally and in written form by you. […]

GO 2010 – 12005 – Various Criminal Code Offence(s): […]

This investigation focused on the allegations you presented in writing on 5 May 2010. In your written correspondence, you requested that CFNIS review the actions of unspecified members of the Canadian Forces regarding issues involving medical treatment and care provided to Cpl Langridge. In your letter, you provided reference to three offences defined by the Criminal Code of Canada; […]

Conclusions of Lead Investigator:

After a complete review of all information and evidence gathered in relation to the manner in which Cpl Langridge received medical care and the manner in which he was provided with personal support by members of the Canadian Forces, the burden of proof required to establish that any of the noted offences were committed by any member of the Canadian Forces was not established by evidence.

The Lead Investigator, based on the review of all evidence, was not able to establish “reasonable and probable grounds” that any member of the Canadian Forces had committed the identified offences noted in your written submission of 5 May 2010. As such, the Lead Investigator did not recommend any charges be preferred at the conclusion of this investigation.

I have reviewed the submissions of the Lead Investigator in this matter and concur with the conclusion(s) that no charges be recommended pursuant to either the National Defence Act or the Criminal Code of Canada.^{Footnote 3755}

97. The evidence available to the Commission does not support the broad claims of thorough review and assessment of all information and evidence.^{Footnote 3756} The investigators did not assemble sufficient facts to draw conclusions about the assessment. The CFNIS members neither conducted the thought experiment of assuming the facts alleged were true in order to see whether they would then make out the elements of a Criminal Code or Code of Service Discipline offence, nor did they conduct any actual investigation to confirm or deny the facts as alleged, nor did they otherwise have an adequate independent factual basis to support the conclusions they reached. Instead, they appear simply to have assumed what needed to be proven so as to close the books on the Fynes’ complaint.

98. Maj Dandurand acknowledged in his testimony that, if one assumed all of the facts alleged by the Fynes were true, it would not be clear that neither Criminal Code nor service offences could be made out.^{Footnote 3757} He also acknowledged that it was incumbent on himself and his team to have conducted an investigation to the point where they could confirm or deny those allegations. However, he also believed this is precisely what they did.^{Footnote 3758} When asked to explain his view the CFNIS investigated the allegations and determined they were false, Maj Dandurand testified his belief was that examining the 2008 Sudden Death Investigation “identified for us facts that were relevant to this and we took those into consideration.”^{Footnote 3759}

99. In the rush to close the file, the CFNIS members never did the things they promised to do. Maj Dandurand conceded, he never did uncover “the truth of what happened.”^{Footnote 3760} Moreover, they even did the things they promised they wouldn’t do, such as taking the previous investigations at face value and relying on them for the assessment.

100. The 2008 investigation was clearly deficient and left many contradictions and discrepancies unresolved. On its own, it was simply incapable of being a sufficient source of facts the investigators could draw upon to form their conclusions. Despite this, and despite the fact the 2008 GO file only contained summaries of witness interviews and those documents gathered by the investigators in what the Fynes alleged (and what the evidence establishes) was a problematic investigation, Maj Dandurand appears to have believed he and his investigative team were able to derive from the file a reliable assessment of the allegations made by Mr. and Mrs. Fynes and to conclude the allegations were unfounded. However, Maj Dandurand could not say what allegations, specifically, were concluded to be unfounded.^{Footnote 3761}

101. Maj Dandurand was asked what happened to cause the 2010 investigation to depart from his assurances to the Fynes that, in order to get to the truth, it was necessary to interview witnesses who had been interviewed in the prior investigations, not to take anything at face value, revisit all documents in detail, and, in effect, mount a large and complex investigation in order to be sure the investigators had the facts right. Maj Dandurand acknowledged his initial view, based on the Fynes’ allegations and concerns about the prior investigations, was that it was likely the CFNIS WR would pursue a criminal investigation. He testified he did not, at that time, anticipate the offences would be viewed as not applicable.^{Footnote 3762} Once again this appears to be circular reasoning. The only way the offences could be viewed as not applicable would be on the basis of reliable facts. Where the facts as previously found were put in dispute by the Fynes and were incomplete, it would seem difficult to conclude the offences were not applicable because of the facts and then to maintain no factual investigation was necessary because the offences were inapplicable.

102. Again, none of this is to suggest a case for a charge under the Criminal Code or for a service offence would have been made out. A factual investigation may well have confirmed facts that would undermine one or more necessary elements of a possible offence and/or evidentiary gaps may have remained that would have made it impossible to make out a charge. There would also have been the issue of mens rea, the mental element of the offence. As noted in the discussion of how negligence was investigated in the 2008 investigation,^{Footnote 3763} it may well be, even if it were possible to demonstrate under the circumstances there did exist a duty for the CF to protect Cpl Langridge from foreseeable harm and that the CF did fail to discharge that duty, there would still remain the important issue of demonstrating the requisite state of mind on the part of those alleged to have failed in their duty. Absent such evidence, it would not have been possible to justify a charge, let alone to contemplate a conviction. It may therefore be the case that a thorough investigation would have led to an entirely justifiable conclusion no charges should be laid with respect to the Fynes’ allegations. The activities of the CFNIS in response to those allegations do not amount to that sort of an investigation or to any investigation at all.

103. It is understandable the investigators would have wanted to take a cautious approach with respect to the allegations made by the Fynes. They were by no means ordinary allegations, and a decision that criminal or quasi criminal negligence charges could be laid on that basis may well have been without precedent. That does not, however, justify dismissing them out of hand without further investigation.

104. In the end, not only did the CFNIS members conduct a deficient assessment, they also failed to honour the commitments made to the Fynes and did not even provide them an explanation for their conclusions.^{Footnote 3764}

Specific Issues Not Investigated

105. While many of the allegations made by the Fynes in the May 5, 2010 interview were dealt with, however imperfectly, in the 2008 Investigation, some of those allegations were never dealt with at all by the CFNIS. Whatever justification there may have been for not conducting a further investigation of matters already dealt with in some way in the 2008 Investigation, there was no justification for failing to investigate direct allegations of fact never previously investigated.

Cpl Langridge’s Discharge from the AHE

106. One issue not pursued in any meaningful way during the 2008 Investigation concerned Cpl Langridge’s hospitalization and return to Base. This meant there was insufficient information to assess the Fynes’ allegation Cpl Langridge had been forced to return to Base against his will. There is evidence Cpl Langridge wanted to remain at the AHE following his 30-day committal but was ordered to leave by his Unit or otherwise felt he had no choice but to return to the Base if he wanted to undergo substance abuse treatment. The CFNIS investigators possessed, in the 2008 investigation file, Dr. Sowa’s discharge notification from the AHE prepared on March 4, 2008.^{Footnote 3765} Along with the admission note, this made it clear Cpl Langridge had been admitted for 30 days. However, they did not possess the discharge summary subsequently prepared by Dr. Sowa. This report indicated Cpl Langridge agreed to stay at the hospital as a voluntary patient until arrangements could be made for him to attend a drug rehabilitation program:

Our plan was to keep him in the hospital until he could be discharged directly to the military.

[…]

Unfortunately the military called as to inform us and that they actually they did want him back at the Garrison and that they would make their own arrangements for him to be referred to a drug rehab program. We were rather surprised by this as Stuart had indicated his willingness to stay with us in hospital so that could be done. However based on that request he was escorted the day after his certificates expired directly to the military Garrison and handed over to his sergeant and this was done on the 5th of March 2008. [sic]^{Footnote 3766} [Emphasis added]

107. Dr. Sowa confirmed these facts in his testimony before the Commission. He was willing to keep Cpl Langridge as a voluntary patient until the arrangements he was trying to make with the rehabilitation centre were confirmed. Dr. Sowa testified it was his understanding the Regiment wanted Cpl Langridge back instead, and this surprised him:

Well, not necessarily [surprised by] the military but, in general, yes, we have difficulties sending patients out. And really with him, it wasn't like I was pushing to discharge him. I really, you know, what I was saying is 30 days are up, we don't necessarily have to renew certificates, he is willing to stay here, but he has to engage in treatment programs as I had previously arranged. And then when the final destination was arranged, he could go directly there. We had no problem with that. If during the course of his stay for the two weeks things turned negative, we always have the option of applying certificates to him again.

But notice I was being more flexible with him.^{Footnote 3767}

108. Dr. Sowa testified his understanding was the Regiment had its own substance abuse program on the base and Cpl Langridge would attend that program upon his return. In two weeks, arrangements would be made to send him on to residential substance abuse treatment. He felt the treatment goal was important, because Cpl Langridge’s addiction was a primary focus, and he was surprised by the requirement to send him back to Base before going on to treatment when Cpl Langridge was already in hospital and could be sent directly from there. Dr. Sowa testified he confirmed the LDSH decision to have Cpl Langridge return to Base with “Leo,” who he believed was a nurse or counsellor with the base medical team (likely Leo Etienne, a Base Addictions Counselor).^{Footnote 3768}

109. There was also information about Cpl Langridge’s discharge from the AHE in a statutory declaration in support of an application for survivor benefits made in July 2009 by Ms. A.^{Footnote 3769} The document indicates:

After the 30 days [as a patient], Stuart’s certification was reviewed. His doctor asked that Stuart remain at the hospital for another 30 days. Stuart wanted to stay, as he was finally making progress, and he said that he was scared to leave.

The military requested that Stuart be released into their care, where they would force him to live under close supervision on the base, for two weeks. At which time, they would commit to sending Stuart to another Drug/Alcohol rehabilitation center. Stuart’s time on the base was mandatory in order for the military to continue assisting him with his treatment.^{Footnote 3770} [Emphasis added]

110. Had investigators in either the 2008 or the 2010 investigations obtained the AHE records or spoken to Dr. Sowa, Mr. Etienne or Ms. A, they could have learned Cpl Langridge may well have been ordered out of the AHE and forced to return to the Base and comply with whatever measures the Regiment decided to put in place, or, at a minimum, may well have reasonably believed this was the case. However, the possibility Cpl Langridge was ordered to return to the Unit was never investigated by the CFNIS.

Duty to Implement Suicide Prevention Protocols and Duty to Convene Summary Investigations

111. MCpl Mitchell^{Footnote 3771} and Sgt Shannon also never investigated the essentially separate allegation the CO LDSH was under a duty to implement and follow certain suicide prevention protocols and had not done so. The Fynes alleged the LDSH failed to have a suicide prevention protocol (which was indisputably required) and failed to hold an SI after each of Cpl Langridge’s known suicide attempts (which they were indisputably required to do). MCpl Mitchell testified the allegation did not even “ring a bell.”^{Footnote 3772}

112. CFAO 19-44 states that suicide intervention – defined as the “use of measures including confrontation, therapeutic consultation and hospitalization to effectively manage incidents of suicide and attempted suicide”^{Footnote 3773} – begins when signs of potential suicidal behaviour are first observed in an individual. It requires that signs and symptoms of potential suicide be reported immediately to medical staff or certain others if medical staff are unavailable. Base commanders and COs are required “to develop appropriate intervention plans to allow a rapid, coordinated and effective response to reports that an individual displays signs of suicidal behaviour.”^{Footnote 3774} The CFNIS never investigated whether the failure to develop and implement such intervention plans could constitute negligent conduct.

113. LCol Pascal Demers testified he had not instituted any intervention policies, relying instead on the guidance of CFAO 19-44 as a “national policy.”^{Footnote 3775} One stipulation in that document was that COs are responsible for ensuring suicide prevention was given appropriate priority in the Unit.^{Footnote 3776} LCol Demers testified the extent of any educational programs in place in 2007 and 2008 geared to recognizing and responding to the signs and symptoms of suicidal behaviour came in the form of running peer counselling for a “select number of soldiers.”^{Footnote 3777} LCol Demers testified suicide prevention was also discussed at some routine safety meetings, directing members who experienced suicidal ideation to seek out medical attention.

114. The allegation of a failure to implement a suicide prevention policy is not a trivial matter. The evidence discloses that Cpl Langridge was displaying behaviour classically associated with a high risk of suicide just before he killed himself, including giving away his belongings.^{Footnote 3778} The linkage between behaviours like giving away one’s belongings and suicidal intent was specifically discussed by the CF in CFAO 19-44^{Footnote 3779} and would presumably have formed part of the sort of suicide awareness training contemplated by CFAO 19-44.

115. The CFNIS appears to have done nothing to investigate this allegation.

116. Paragraphs 12 and 13 of CFAO 24-6^{Footnote 3780} required an SI to be convened after a suicide attempt. LCol Demers testified he did not believe there was any latitude, and “there always must be an investigation.”^{Footnote 3781} He confirmed it was his expectation if any member of the chain of command or another individual with authority became aware of a suicide attempt, it should be reported and an SI convened. There is evidence the chain of command was, in fact, aware of multiple suicide attempts by Cpl Langridge,^{Footnote 3782} and yet only one SI, regarding one attempt, was ever conducted. The CFNIS never investigated whether the LDSH chain of command had knowledge of Cpl Langridge’s other suicide attempts and whether the failure to appropriately report the attempts and conduct an SI after each attempt could constitute negligent conduct.

Timeliness

117. The complaints forming the basis of the 2010 investigation were formally made on May 5, 2010. There was initial activity between May 5 and May 12, 2010. There was nominal activity in August 2010, when the assessment was complete and the file was evidently deemed to be concluded. The next activity in the file occurred when Sgt Shannon was tasked with preparing the PowerPoint presentation. Assuming Sgt Shannon was tasked with the briefing in December 2010, as indicated in his notes, rather than February 2011, as indicated in his testimony, a generous estimate suggests this constitutes perhaps 60 days of activity over the course of the nearly one year in which the file was open.

118. Although it was clear by August 2010 that little if anything would now be done in the investigation, the 2010 file remained open and continued to be listed in the File Status Reports and noted as “to be concluded” until May 2, 2011.^{Footnote 3783} Maj Bolduc testified the file was kept open in case the 2009 investigation yielded evidence to change the assessment.^{Footnote 3784} A CFNIS WR File Status Report dated November 15, 2010, again indicated the file was to be concluded, and the entry for “Date of last activity” stated only “Waiting for Conclusion of GO 09-34538.”^{Footnote 3785} It is not clear how evidence relevant to the issue of who Cpl Langridge’s next of kin were might be thought of as relevant to the issue of potential culpability for his death. Although it is true the conclusions reached in the 2010 investigation were not well supported and were premature, and in fact, much more should have been done by the investigators, it is also unacceptable that the file languished and remained open without activity or accountability.

119. As noted elsewhere in the report,^{Footnote 3786} the Fynes were not regularly updated about the progress of the file. They made it clear they did not require updates every two weeks, but they expected to be kept apprised of significant developments. Nevertheless, they found themselves having to contact the CFNIS WR to remind them of this responsibility. After a promising start to the investigation, and with the complainants having made clear their distrust and lack of faith in the CF and in prior investigations, the delays and the sporadic communication encountered appeared to be more of the same.

120. Overall, it is the responsibility of supervisors to ensure investigations are completed in a timely manner.^{Footnote 3787} In this situation, that responsibility ultimately lay with Maj Dandurand as the OC of the detachment.

4.5 CFNIS Interactions with the Fynes

1. Many of the allegations in this complaint relate to CFNIS interactions with the Fynes.^{Footnote 3788} The complaints cover a number of issues, including an alleged lack of ongoing updates or briefings; insufficient, inaccurate or offensive information or explanations provided by the CFNIS to the Fynes; and the cancelling of a verbal briefing about the investigations. In order to assess these allegations, it is important to understand the history of the interactions between the CFNIS and the Fynes, from the moment the CFNIS first became involved on the day of Cpl Langridge’s death in March 2008 to the conclusion of the last investigations in the spring of 2011.

2. Establishing proper communication with complainants matters. At times, it can allow for issues to be resolved before they become complaints. During her testimony before this Commission, Mrs. Fynes was asked what actions the CF could have taken to “make the Fynes go away” or satisfy their concerns. She answered all the Fynes ever really wanted was for someone to sit down with them, have an honest discussion about what happened and provide an acknowledgement that lessons needed to be learned from it.^{Footnote 3789} She stated:

[…] but the overriding concern for us was somebody give us some honesty and show us what lessons have been learned. That’s it.^{Footnote 3790}

3. According to Mrs. Fynes, if this had been done, “that would have been the end of it.”^{Footnote 3791}

4. It is possible that, had the contacts between the CFNIS and the Fynes been more frequent or more productive, some of the other complaints before this Commission would not have resulted. Be that as it may, these issues are important in their own right. The manner in which a police force interacts with victims and complainants is an essential part of its work. In this respect, the CFNIS’ performance in its interactions with the Fynes was less than stellar.

4.5.1 Early Contact

The 2008 Investigation

5. There was limited contact between the Fynes and the CFNIS during the 2008 investigation. Neither Mrs. Fynes nor Mr. Fynes was contacted by anyone from CFNIS asking them to provide relevant information they might have had, or advising them about the progress or results of the investigation. In fact, but for the Fynes’ own attempt to contact the investigator in charge, there would have been no contact at all during or immediately after the 2008 investigation.

6. During the first month following Cpl Langridge’s death, the CFNIS lead investigator, MCpl Matthew Ritco, made no attempt to contact Cpl Langridge’s mother or stepfather in the course of the investigation. He initially considered that the Fynes might potentially need to be interviewed.^{Footnote 3792} However, a decision was made on April 15, 2008 by the Case Manager and the Detachment MWO that it was not necessary to contact them.^{Footnote 3793}Mr. Fynes was surprised that he was not formally interviewed in the 2008 investigation. He stated:

If you’re inquiring into our son’s condition, his medical condition and his life and his recent history prior to his death to the point where you’re invading his personal medical and mental health files, it may have been relevant to speak to his immediate family as to his condition and to the conditions under which he was living.^{Footnote 3794}

7. With that, it was Mr. Fynes who contacted CFNIS and not the other way around. He initiated contact in May 2008. He testified he was distraught over the possible release of Cpl Langridge’s Jeep by the LDSH Regiment and, as a result, called CFNIS Edmonton and asked to speak to the investigator involved in investigating Cpl Langridge’s death.^{Footnote 3795} Several days later, he received a call from MCpl Ritco, whose immediate concern, according to Mr. Fynes’ testimony, was to find out how Mr. Fynes knew his name.^{Footnote 3796} In his testimony, MCpl Ritco explained he received a message on his desk asking him to contact the Fynes.^{Footnote 3797} When he did, he initially reached Mrs. Fynes and spoke with her for approximately 40 minutes.^{Footnote 3798} A few days later, he also had a conversation with Mr. Fynes that lasted a little over 30 minutes.^{Footnote 3799} These conversations were apparently unplanned. While some information relevant to the investigation was provided by the Fynes during the conversations, little attempt was made by MCpl Ritco to elicit information or ask follow-up questions, and no formal interview was conducted with either Mr. or Mrs. Fynes.^{Footnote 3800}Mr. Fynes testified, in his view, no part of his conversation with MCpl Ritco was in aid of the 2008 investigation, aside from his expectation that Cpl Langridge’s phone would be checked.^{Footnote 3801}

8. The progress of the investigation was not discussed during MCpl Ritco’s telephone conversations with the Fynes. According to MCpl Ritco’s notes, Mr. Fynes indicated he was not calling in an attempt to obtain inside information about how the investigation was going.^{Footnote 3802} No information was provided to the Fynes about the status of the investigation at any other time during the investigation. LCol Robert Delaney, who became the CO of the CFNIS after the 2008 investigation was completed, testified contact with victims or complainants could generally be initiated by the Victims Assistance Coordinator (VAC) or by the investigators.^{Footnote 3803} He explained records of calls made by VAC were maintained in an activity log kept by VAC, while records of calls made by investigators were incorporated in their notes and entries within the GO file.^{Footnote 3804} Commission counsel requested a copy of any activity log kept by VAC that would record contact with the Fynes during the three CFNIS investigations.^{Footnote 3805} No such log was produced.^{Footnote 3806} There was evidence before this Commission indicating the Fynes declined the assistance of CFNIS victims’ services when an offer was made in November 2009.^{Footnote 3807} However, there was no evidence such services were offered to them during or immediately after the 2008 investigation. Based on the evidence, the only contact between the CFNIS and the Fynes during the 2008 investigation was made through their telephone calls to MCpl Ritco, which did not involve any update to them about the status of the investigation or any information at all about the investigation.

9. When the investigation was concluded in June 2008, no attempt was made to contact the Fynes to advise them or to provide any kind of briefing to them about the findings.^{Footnote 3808} The Detachment MWO at the time, MWO Barry Watson, testified that providing closure to the family “didn’t cross [his] mind” in this case.^{Footnote 3809} He explained, looking at the CFNIS SOPs now, he believes providing closure to the family is one of the goals of a sudden death investigation. However, at the time, he did not think of it and he was unable to recall exactly why.^{Footnote 3810} He indicated it would have been part of his duties as the Acting OC for CFNIS Western Region during the relevant time period to determine whether a briefing to the family should take place and to organize it.^{Footnote 3811} He added the earlier decision that it was not necessary to speak to Cpl Langridge’s mother was unrelated to the issue of whether a briefing should be conducted, but was solely based on an assessment of whether there was information of value she could provide during the investigation.^{Footnote 3812}

10. Sgt Jon Bigelow, who was involved in assisting with the sudden death investigation, indicated he could not say contacting the family was normal practice, but noted it was “something that should have been done.”^{Footnote 3813} Asked whether this was something that came into his own mind at the time, he indicated:

I’d like to say – I’d like to believe that that would have been one of the ideals or one of the thoughts that should have been done.

[...]

Yes, at some point in time the family should have been notified that an investigation was taking place, right, and to obtain background information of the deceased.^{Footnote 3814}

11. MWO Watson explained next of kin notification and relations with a family were not part of the role of the CFNIS in 2008, but rested solely with the Military Unit.^{Footnote 3815} Up to that point, he had not done any family briefing in any of the sudden death investigations in which he was involved.^{Footnote 3816} It appears there was an expectation on the part of the CFNIS members involved – to the extent they turned their minds to the issue at all – that the briefing for the family at the conclusion of the investigation would be done by Cpl Langridge’s Unit, the LDSH Regiment. There is no evidence before this Commission of any formal protocol between the CFNIS and the Regiment providing for such a procedure. There is no indication in the GO file the CFNIS ever contacted the Regiment to discuss the need for a briefing for the family, or the potential content of such a briefing. The only contact with the Unit at the conclusion of the investigation occurred on July 1, 2008, when MWO Watson transmitted the report to the LDSH CO in accordance with the usual procedure followed for all CFNIS investigations.^{Footnote 3817} There is no indication any follow up contact was initiated with the Unit to ensure a briefing took place and, in fact, it appears the Unit never provided any briefing to the Fynes about the 2008 investigation. Neither Mrs. Fynes nor Mr. Fynes mentioned receiving such a briefing from the LDSH Regiment or the AO appointed to them by the Regiment.^{Footnote 3818}

12. Mrs. Fynes testified the only contact she had with respect to the 2008 Sudden Death investigation, aside from her telephone conversation with MCpl Ritco, was in November 2009, when the Fynes had their first meeting with Maj Daniel Dandurand and MS Eric McLaughlin.^{Footnote 3819} Mr. Fynes stated there was no briefing about the 2008 investigation and no contact with the CFNIS aside from his conversation with MCpl Ritco in relation to Cpl Langridge’s Jeep.^{Footnote 3820} The Fynes’ AO, Maj Stewart Parkinson, also testified in these proceedings. There is no mention in his testimony or in the detailed notes and records he kept throughout his duties as AO of any briefing he might have received about the progress or conclusion of the CFNIS investigation, nor of any request to provide a briefing to the Fynes about the investigation.^{Footnote 3821} It does not appear Maj Parkinson was provided any useful information about the 2008 investigation. In fact, it appears what little information he learned about the investigation was erroneous. His only reference in testimony to the 2008 investigation related to his belief that the CFNIS had tried to go into Cpl Langridge’s computer and did not find anything.^{Footnote 3822} In reality, the CFNIS never obtained or accessed Cpl Langridge’s computer.^{Footnote 3823} Without access to accurate information, Maj Parkinson was in no position to provide a briefing to the Fynes about the investigation.

13. The failure to provide information to the Fynes about the investigation into their son’s death was not conducive to establishing good relations. It likely contributed to making matters worse for both the Fynes and the CFNIS when the failure to disclose Cpl Langridge’s suicide note was discovered the following year. The Fynes should have been treated in accordance with the applicable protocols for dealing with victims and complainants. They should have been provided with notification about the existence of the investigation, updates about the status of the investigation, and a briefing when the investigation was concluded.

14. Both the MPPTP and a CFNIS-specific SOP provide for the principles to be followed by the CFNIS in dealing with victims and complainants.^{Footnote 3824} Chapter 5, Annex F of the MPPTP specifies the MP “shall ensure the fair treatment of victims of crime through the provision of immediate information, referral to support agencies and the availability of continuous contact with the victim throughout the investigation.”^{Footnote 3825} It also provides for follow up to be done every 30 days at a minimum.^{Footnote 3826} The CFNIS SOP on this issue incorporates many of the same principles, and provides for call backs every two weeks.^{Footnote 3827}

15. The family of a soldier who is the subject of a sudden death investigation should be categorized as “victims”. A restrictive or legalistic definition of the term serves no purpose. In many cases, it will not be known immediately whether a crime was committed in connection with the death, or it may be immediately apparent that the death was the result of suicide. The CFNIS SOP already specifies that a person who “appears to be the victim of a crime against the person shall be treated as such,” regardless of “any legal opinions.”^{Footnote 3828} The ultimate result of an investigation or prosecution should not impact on the level of information, courtesy and contact offered to the apparent victim by the police. When a death is being investigated by the CFNIS, the family of the deceased should be offered regular contact and information. As with any investigation, the level of information provided to the family will obviously be adjusted if there are any risks of compromising the investigation, particularly in circumstances where family members may be suspects. However, in a case like this one, where it was clear very early the death was the result of suicide and no foul play was involved, there was no reason for not providing more information to the Fynes.

16. The previous practice of having the Military Unit provide briefings to the family at the conclusion of sudden death investigations – if indeed this was the practice followed by the CFNIS – was not adequate. It should be abandoned entirely. This practice was not ideal in terms of maintaining CFNIS independence and fostering confidence in the CFNIS’ independence.^{Footnote 3829}

17. The evidence in these proceedings reveals the information provided to CF Units about CFNIS investigations is quite limited. When the investigation report is transmitted to the CO of a Unit at the end of an investigation, only three documents are sent: the Complaint Synopsis, the Case Summary and the Concluding Remarks, as edited by Case Managers.^{Footnote 3830} Leaving aside for the moment the issue of editing by the Case Managers,^{Footnote 3831} it is clear the general information contained in a Case Summary and Concluding Remarks would not be sufficient to prepare for and provide an adequate briefing to the family about the facts uncovered during the investigation, the conclusions reached, and the reasoning supporting those conclusions. Someone relying solely on the Case Summary and Concluding Remarks to provide a briefing about the 2008 investigation would have no information to provide about the suicide note left at the scene or the investigation conducted by the CFNIS into the issue of whether or not Cpl Langridge was on a suicide watch.^{Footnote 3832}

18. Further, from a purely perceptual point of view, it seems inappropriate for a Unit whose members have been under investigation in connection with events surrounding a death – as was the case for the LDSH Regiment, at least with respect to the suicide watch issue – then to be tasked with briefing the family about the results of the investigation, whether or not it was concluded there was any wrongdoing.

19. After the 2008 investigation was concluded, the CFNIS developed a specific SOP on the conduct of Sudden Death investigations, which includes references to next of kin briefings. The SOP provides for initial contact with the family of a deceased to be conducted in person by a CFNIS Region Detachment WO or higher, as appointed by the Detachment OC.^{Footnote 3833} It provides for two briefings to the family – the initial and the final briefing – to be conducted in the presence of the AO appointed by the CF.^{Footnote 3834} The section related to the final briefing makes it clear such briefings are to include a description of the conclusions reached, as well as a discussion of the timeline for the investigation and various aspects investigated.^{Footnote 3835}

20. Final briefings to the family should be more than simply a notification that the investigation is concluded. They ought to be understood as an opportunity for the family to learn about the facts uncovered during the investigation, and to understand the conclusions reached and the reasoning supporting the conclusions. For this reason, the briefing should be conducted by CFNIS members familiar with the investigation who will be in a position to answer the family’s questions.

21. The Commission considers the current SOP to be a step in the right direction when it comes to contact with families during death investigations. Conducting the briefings as set out in the SOP is a good approach. However, reconsideration should be given to the requirement in the SOP for the family’s AO to be present at family briefings.^{Footnote 3836} In many cases, involving the AO will be helpful, as it will maximize the support available to the family. On the other hand, as the AO is appointed by the CF – generally by the deceased’s Unit – care should be taken to ensure the family does not view his or her presence as an indication the CFNIS is not acting independently from the CF. As such, it would be preferable to afford the family a choice about whether they wish the AO to attend, particularly in cases where there are contentious issues between the CF and the family, or where the family believes or alleges the CF has some responsibility for the death. Further, in addition to the briefings provided for in the SOP, ongoing updates should be offered, similar to what is done for victims or complainants in other investigations.

22. It is important the conduct of the briefings – and, more generally, the provision of information to families, victims and complainants – be viewed by CFNIS members as an integral part of their duties and responsibilities. Part of the normal functions of police officers is interacting with victims and complainants and, in cases of death, families of the deceased, whether this is done through referral to VAC or directly by the investigators involved. Indeed, when representatives from other police forces testified before this Commission about their conduct of death investigations, S/Sgt William Clark of the EPS mentioned next of kin notification as one of the primary duties for the attending police officers involved in non-suspicious death investigations.^{Footnote 3837} Det. Insp. William Olinyk of the OPP also referred to the conduct of debriefings with the family to answer their questions.^{Footnote 3838}

23. Positive interactions and support for victims and complainants can serve to improve overall confidence in law enforcement authorities. The CFNIS has a role in providing assistance to CF Commanders and the CF in general in maintaining order and discipline, but also has the same role as civilian police forces in providing direct assistance to victims and complainants with respect to the investigations within its jurisdiction. CFNIS members should strive to ensure they provide adequate and timely information and maintain the appropriate level of contact. This, in fact, appears to be the spirit behind the recent CFNIS SOP on the conduct of sudden death investigations.

The Disclosure of the Suicide Note

24. After the 2008 investigation was closed, from the Fynes’ point of view, the next development in the case was their being notified 14 months after his death that Cpl Langridge had left a suicide note. At that time, the CFNIS again missed an opportunity to establish communication and provide information and support to the Fynes.

25. In April 2009, following a specific request made by the BOI, the CFNIS WR provided the BOI a copy of the suicide note.^{Footnote 3839} The CFNIS did not at the time provide a copy of the note to the Fynes and did not advise them of the note’s existence or content. It was the BOI President, Maj Bret Parlee, who on May 22, 2009, advised the Fynes of the existence of the suicide note.^{Footnote 3840} A few days later, they received a photocopy of the note.^{Footnote 3841} This was provided to them by the BOI President, and not by the CFNIS.^{Footnote 3842}

26. On May 27, 2009, the Fynes contacted their AO, Maj Parkinson, to request the original of the note.^{Footnote 3843} There then followed a flurry of correspondence between the Regiment, the Brigade, the Area, the CFNIS and the AO, in an attempt to find out what had happened and to provide the Fynes with the original of the suicide note.^{Footnote 3844} The Adjutant of the LDSH Regiment, Capt Eric Angell, contacted WO Ken Ross at the CFNIS Detachment, who initially responded the “best course of action” would be for the AO to the Fynes to make an Access to Information request for the note.^{Footnote 3845} When Capt Angell explained such a request would be of no assistance because the family wanted the original note, WO Ross advised the original was still retained as evidence and indicated he did not foresee it being turned over, but would make further inquiries.^{Footnote 3846} On May 29, 2009, Maj Dandurand, the OC for CFNIS WR, was asked by LFWA if the original of the note could be released to the family as soon as possible.^{Footnote 3847} He indicated he had just received authority to do so from CFNIS HQ and would be returning the original note the following Monday.^{Footnote 3848} He was asked by LFWA to provide the note to staff from the Brigade who would “prepare an appropriate way of getting this to the family.”^{Footnote 3849} Capt Angell was advised the CFNIS would provide him the original “to deliver to the Fynes as they have requested.”^{Footnote 3850} On June 1, 2009, the note was provided to Capt Angell by CFNIS WR.^{Footnote 3851} The original note was delivered to the Fynes on June 3, 2009 by their AO, Maj Parkinson.^{Footnote 3852}

27. Mr. Fynes testified about the chain of events surrounding the delivery of the suicide note in May-June 2009:

You know, in the first instance when we were apprised of the suicide note they forwarded the – they Purolated the note out to the NIS in Esquimalt. A Captain hand-delivered it to my wife.

I came home from work that night and the Purolator envelope was sitting on our table unopened. My wife couldn’t bring herself to open it.

And I have to tell you when we opened that envelope together and I saw that it was a photocopy with an exhibit stamp on it, I was just through the roof.

And we went back and demanded that we get our son’s suicide note, his last communication to us, and that was delivered shortly thereafter in person by our Assisting Officer who stood in our room and reached it to us and said – I believe his exact words were: “I have no words.”^{Footnote 3853}

28. Throughout the period of a few days between the time the Fynes received the copy of the suicide note and the time the original was provided to them, a great deal of email correspondence on the issue was exchanged among the various actors involved.^{Footnote 3854} In the context of these exchanges, the Fynes’ initial e-mail requesting the original note was forwarded to CFNIS members, including Maj Dandurand, the CFNIS WR OC, and LCol Gilles Sansterre, the CO of the CFNIS.^{Footnote 3855} That message left no doubt about the Fynes’ state of mind upon receiving the copy of their son’s note more than 14 months after his death. It read:

Attached is a copy (of a photocopy) of Stuart’s farewell to his family.

That his note was concealed and withheld from us for over fourteen months was cruel, callous and disrespectful.

I expect the “original” to be provided to us immediately [...]^{Footnote 3856} [Emphasis added]

29. During this time, the CFNIS still took no steps to contact the Fynes. No apology or explanation was provided when the original suicide note was finally delivered to the Fynes. In fact, no contact at all took place until a few weeks later. The CFNIS did not even deliver the suicide note personally to the Fynes. Later, when the issue began to attract significant media attention in October 2010, questions were asked about whether and when the Fynes received an apology from the CFNIS. The CFPM was then advised Mrs. Fynes had received a “face to face personal apology” from the CFNIS WR Detachment Commander, Maj Dandurand, and was told the “apology and explanation of why the delay happened and how the CFNIS would stop recurrence was given at the time that the original note from Stuart Langridge was provided to her.”^{Footnote 3857} The testimony heard in these proceedings revealed this information to be inaccurate. Maj Dandurand agreed it was “entirely incorrect,”^{Footnote 3858} and testified no apology was given to the Fynes by the CFNIS when the suicide note was delivered to them in June 2009.^{Footnote 3859} He added the face to face apology he provided was in November 2009, during a meeting with the Fynes.^{Footnote 3860}

30. It was three weeks after the Fynes received the original suicide note that the first direct contact between the CFNIS and the Fynes took place, when the then CO of CFNIS, LCol Sansterre, inadvertently called the Fynes’ home.^{Footnote 3861} Mr. Fynes described this as the first time the Fynes began direct communication with the CFNIS about the issues related to the Sudden Death investigation.^{Footnote 3862} On June 18, 2009, LCol Sansterre called the Fynes’ residence and had a conversation with Mrs. Fynes.^{Footnote 3863} He had in fact intended to call the Fynes’ AO, Maj Parkinson, but was provided the Fynes’ telephone number by mistake.^{Footnote 3864} In testimony, LCol Sansterre explained the purpose of his call was to contact the Fynes’ AO to set up an appointment with the Fynes so the CFNIS, “who obviously have not given the information to the Fynes to this date, that we could meet with them, give them the information, give them a brief on the investigation.”^{Footnote 3865} LCol Sansterre testified he apologized about the suicide note during his telephone conversation with Mrs. Fynes.^{Footnote 3866} Mrs. Fynes testified LCol Sansterre “talked about the note a bit and confirmed that we now had it.”^{Footnote 3867} She could not recall specifically what was said about the note, but was adamant neither she nor Mr. Fynes had ever received an apology “from anybody” for the failure to disclose the suicide note.^{Footnote 3868}

31. LCol Sansterre had been aware of the suicide note issue since at least May 30, 2009,^{Footnote 3869} but did not immediately take measures to have the CFNIS contact the Fynes and provide an apology and explanation. It is not clear whether the original purpose of his intended call to the Fynes’ AO included providing such an apology. LCol Sansterre emphasized in testimony the main purpose was to set up an appointment with the Fynes, so they could be briefed by someone from CFNIS Western Region.^{Footnote 3870} He did not specify what would be covered in the intended briefing, but he did indicate he was really concerned about this matter of the suicide note, and as a result, got personally involved in attempting to contact the AO, something he did not do on any other occasion during his tenure as CO of the CFNIS.^{Footnote 3871}

32. While it was appropriate for LCol Sansterre to apologize when he did speak to Mrs. Fynes on June 18, 2009 – and the Commission accepts his testimony that he did in fact say he was sorry^{Footnote 3872} – it is surprising this simple and obvious measure did not appear to be on the CFNIS’ radar prior to this fortuitous contact between LCol Sansterre and Mrs. Fynes. This is particularly disconcerting when one considers the amount of time and energy expanded by the CFNIS on creating Media Response Lines and conducting media monitoring surrounding the issue.^{Footnote 3873} It is clear the CFNIS was greatly concerned about the impact of this issue on its public image, and was taking measures to provide explanations and expressions of regret to the public. Unfortunately, no similar measures were taken to provide immediate explanations and expressions of regret to those most affected, Mr. and Mrs. Fynes.

33. The Commission is of the view that, upon learning in May 2009 the suicide note had not been disclosed or provided to the Fynes, the CFNIS should have taken immediate measures to (a) personally deliver the suicide note to the Fynes; (b) provide an immediate official apology; and (c) find out exactly what happened and provide the necessary explanations to the Fynes.^{Footnote 3874} This should have been considered a priority, and given at least as much attention as was given to the public relations aspects of the matter.

34. It is obviously to be hoped such late disclosure of a suicide note by the CFNIS will never occur again. However, if a similar situation were ever to recur in the future, or if some other unfortunate error were ever to be made by the CFNIS causing significant distress to victims, complainants or members of the public, lessons should be drawn from this incident. Immediate measures should be put in place to provide an official apology to the persons affected, along with any necessary explanations outlining how the error occurred.

4.5.2 Obtaining the 2008 Investigation Report

35. After the initial lack of communication during the 2008 investigation and the shock of discovering the suicide note, relations between the CFNIS and the Fynes improved a little when LCol Sansterre became personally involved and assured them they would be provided with a copy of the report for the CFNIS’ 2008 investigation. However, relations soon began to sour again when the Fynes were provided with heavily redacted versions of the CFNIS 2008 investigation report. This gave rise to a specific complaint alleging the CFNIS “improperly withheld information” from the Fynes by providing them with a copy of its report containing “numerous redactions having no justification in law or privacy protection.”^{Footnote 3875}

The Request and the First Version of the Report

36. On the evening of June 18, 2009, following Mrs. Fynes’ conversation with LCol Sansterre, Mr. Fynes sent an email to LCol Sansterre requesting a copy of the CFNIS file for the investigation into Cpl Langridge’s death.^{Footnote 3876} Mrs. Fynes testified LCol Sansterre was “very obliging” in responding to this request.^{Footnote 3877} The very next day, he advised the Fynes he had initiated a request with the Military Police Access to Information Section, and indicated the gathering of documents had begun. LCol Sansterre informed the Fynes the process would involve “the vetting of the report to determine if there are any Privacy Act related issues that will require severance.”^{Footnote 3878} He also suggested a debriefing could be scheduled with CFNIS investigators once the Fynes had received the report.^{Footnote 3879} On June 29, 2009, he advised the Fynes the disclosure of the file had been completed by the MP Police Policy Directorate and the file had been sent to the Director of Access to Information and Privacy (DAIP) for “final vetting.”^{Footnote 3880} He added he had requested an estimate of the time required and was awaiting an answer.^{Footnote 3881} On July 27, 2009, he advised that the file had been returned by DAIP and would be sent shortly.^{Footnote 3882} The Fynes received their first copy of the CFNIS report on July 29, 2009.^{Footnote 3883}

37. Mrs. Fynes described this copy as “very abbreviated,” with approximately 260 pages, and containing “mostly redactions.”^{Footnote 3884} Mr. Fynes indicated this version was about 40 per cent of a 500-plus-page report “and I was -- I couldn’t figure out why there was so many redactions.”^{Footnote 3885}

38. Indeed, the redactions to the file were extensive. In this hearing, a complete and unredacted copy of the GO file for the 2008 Sudden Death investigation was produced. The file has 714 pages.^{Footnote 3886} By contrast, the file provided to the Fynes totalled 270 pages.^{Footnote 3887} The basis for some of the redactions was difficult to understand. Many of Mr. Fynes’ own statements – made during his telephone conversation with MCpl Ritco – were redacted.^{Footnote 3888} All summaries and references to witness interviews, including those for the interviews with Capt Mark Lubiniecki, MCpl Erin Bowden, Cpl Jon Rohmer, Sgt Trent Hiscock, Cpl Roger Hurlburt, MCpl William Fitzpatrick, MWO Douglas Ross and Capt Richard Hannah, were redacted.^{Footnote 3889} All of the 105 pages of officer notes included in the investigation file were missing.^{Footnote 3890} Documentation about the exhibits seized and how and when they were disposed of was also redacted.^{Footnote 3891} The entry detailing the processing of the scene, along with the Evidence Collection Log recording the items seized, was redacted. Only the copy of the suicide note – which by then had already been provided to the Fynes – remained unredacted, along with copies of certain medical forms seized.^{Footnote 3892}

39. In an instance that especially angered the Fynes, an account by Sgt Hiscock of a directive he gave to cut down Cpl Langridge’s body was redacted. MCpl Ritco’s Case Summary included the following sentence referring to information learned during his interview with Sgt Hiscock: “Cpl Hurlburt returned and informed him, that he located Cpl Langridge in his room, hanging from the neck; Sgt Hiscock directed Cpl Hurlburt to return, and cut him down, and await emergency personal [sic] to attend.”^{Footnote 3893} In the copy of the file provided to the Fynes, the words “and cut him down” were redacted.^{Footnote 3894} Mr. Fynes took strong exception to this redaction.^{Footnote 3895} He testified he believed it was “an unlawful redaction,” as it was not aimed at protecting personal information, national security or investigative techniques, but at protecting the CFNIS from embarrassment.^{Footnote 3896}

40. Upon receiving this copy of the file, Mr. Fynes wrote to LCol Sansterre indicating his “first reaction was one of amazement that more than half of the file had been severed.”^{Footnote 3897} He noted his own comments were redacted, as well as information about the exhibits.^{Footnote 3898} He added he was “left to wonder what is being hidden from view and why?”^{Footnote 3899} In response, LCol Sansterre assured Mr. Fynes all of the redactions were done by “personnel who are trained and conversant with the Privacy Act and who are employed with the Director of Access to Information [DAIP].”^{Footnote 3900} He added, the CFNIS had no intent to hide any information and indicated this was the reason why a briefing by CFNIS personnel familiar with the file was being offered.^{Footnote 3901} Mr. Fynes renewed his expression of concern. He indicated Cpl Langridge had designated him on his PEN form to receive his personal information, and noted the report did not relate to sensitive, intelligence or national security information, as the ME had confirmed the death was the result of suicide.^{Footnote 3902} He indicated he remained “concerned about what was withheld, and more importantly what justifies the lack of transparency?”^{Footnote 3903}

41. Two weeks later, in mid-August 2009, Mr. Fynes again wrote to LCol Sansterre, explaining the Fynes were in no position to formulate intelligent questions on the basis of “only 40% of your report.”^{Footnote 3904} He referred to the redaction of the directive to cut down Cpl Langridge’s body and wrote: “whose privacy is being protected here? The extent of this redaction is neither acceptable nor justifiable.”^{Footnote 3905} He noted those who applied the redactions likely did not appreciate he was designated as Cpl Langridge’s personal representative. He asked LCol Sansterre for assistance in obtaining a less redacted report.^{Footnote 3906} In response, LCol Sansterre advised Mr. Fynes he had forwarded his concerns to the DND DAIP, explaining it is this office “that is responsible for the severance of our report and they are in the best position to answer your query.”^{Footnote 3907} He wrote to the DAIP, Ms. Julie Jansen, indicating he was “looking for your advice on how to respond” to Mr. Fynes’ email, which he forwarded to the DAIP.^{Footnote 3908}

42. On September 17, 2009, LCol Sansterre forwarded to Mr. Fynes a response from DAIP Acting Deputy Director, Ms. Marie Carle. The response explained DAIP is the delegated authority to administer the Access to Information and Privacy Acts. It went on to state DAIP’s position that the PEN form only authorized the release of personal information that existed at the time of signature, and “[t]herefore, a PEN form cannot be used as a release authority for the Military Police Report or any other report created after the death of an individual.”^{Footnote 3909} Consequently, Ms. Carle explained the only provision authorizing release of personal information in this case was s. 8(2)(m) of the Privacy Act^{Footnote 3910} – which provides for release of information where the head of a Government institution considers the public interest in disclosure to clearly outweigh any invasion of privacy. She indicated “DAIP exercised their authority in this case to release the personal information that would help the family to understand the circumstances surrounding the death of Corporal Stuart Langridge.”^{Footnote 3911}

43. The next day, Mr. Fynes wrote to LCol Sansterre. He indicated he was surprised by DAIP’s position that a PEN form only affords access to information in existence at the time of signing, pointing out there was no such annotation on the form, and indicating “by that logic, the entire PEN form would always be out of date and could not be actioned or relied upon in the event of injury, illness or death.”^{Footnote 3912} Mr. Fynes noted he understood LCol Sansterre was only the “messenger”. However, he stated he did not accept DAIP’s position and he mentioned the Fynes were not being provided with closure.^{Footnote 3913} In testimony, Mr. Fynes reiterated his objections to the interpretation of the PEN form being advanced, indicating it would make the PEN form consent itself invalid, since it is meant to be used in the event of a soldier’s death or injury.^{Footnote 3914}

44. LCol Sansterre forwarded Mr. Fynes’ message to DAIP and discussed the matter by telephone with them.^{Footnote 3915} Parallel discussions also occurred within LFWA, the Area in charge of Cpl Langridge’s Regiment. This led to the involvement of LCol Bruce King, who had acted as the legal advisor to the BOI into Cpl Langridge’s death and would act as the legal advisor to the eventual SI in anticipation of litigation related to the post-death administration issues.^{Footnote 3916} When Mr. Fynes wrote to LCol Sansterre to complain about the redactions and DAIP’s response, he copied his AO, Maj Parkinson.^{Footnote 3917} Maj Parkinson forwarded the message to his superiors in Vancouver, who in turn forwarded it to recipients at LFWA and 1 CMBG, asking that “the interpretation on the PEN form regarding issue of access to information when mbr is killed or injured” be confirmed.^{Footnote 3918} A request was then made to contact JAG to get a response.^{Footnote 3919} After a string of emails involving LCol King, which were redacted in the records produced before this Commission, there was an email dated September 29, 2009 from Ms. Carle to LCol King, indicating DAIP were having a management meeting the next day “on this subject” and noting LCol King should get a response soon.^{Footnote 3920}

45. On October 27, 2009, after the Fynes contacted him to arrange for a briefing in late November, LCol Sansterre forwarded a new response he had received from Ms. Carle.^{Footnote 3921} In this message, Ms. Carle indicated DAIP acknowledged the PEN form “is subject to different interpretations” and as a result, “we have to reconsider the release of the complete Military Police report.”^{Footnote 3922} Ms. Carle was unable to provide an estimate of the time required to complete this, but indicated the file was being processed as a priority.^{Footnote 3923} As of November 12, 2009, LCol Sansterre wrote he had still not been able to find out from DAIP when the report would be released.^{Footnote 3924} He pointed out he had no control over when the report would be released, but indicated CFNIS members would nevertheless be available to provide a briefing to the Fynes in late November as requested.^{Footnote 3925}

Revisiting the Redactions: The Second Version of the Report

46. The second version of the report was provided to CFNIS by DAIP on November 20, 2009 and was shipped to the Fynes the following week.^{Footnote 3926} In the cover letter, dated November 23, 2009, LCol Sansterre advised Mr. Fynes “the report received from Access to Information and Privacy” was enclosed.^{Footnote 3927} In total, five months elapsed between the Fynes’ initial request for the file in June 2009 and the receipt of this version in November 2009.

47. Mrs. Fynes testified the second report received was “much more complete,” though there were still “tons of pages redacted, lots of lines redacted,” including information about the Fynes or that the Fynes already had.^{Footnote 3928} Mr. Fynes testified this version was less redacted, estimating about 80 per cent of what was in the report was now provided, but noting the Fynes had since received another version that included officer notes.^{Footnote 3929}

48. The second version of the report contained 476 pages,^{Footnote 3930} almost double what had been provided in the first version. The file now contained information about the witness interviews,^{Footnote 3931} as well as some information about the exhibits.^{Footnote 3932} The mention of the directive to cut down Cpl Langridge’s body was no longer redacted.^{Footnote 3933} However, the officer notes continued to be missing or redacted in full,^{Footnote 3934} and some of Mr. Fynes’ own comments to MCpl Ritco continued to be redacted.^{Footnote 3935} Other information that remained redacted in the second version of the report included: information about MCpl Ritco’s contacts with EPS to obtain reports about Cpl Langridge;^{Footnote 3936} MCpl Ritco’s requests for access to Cpl Langridge’s medical and mental health records and all interactions related to them;^{Footnote 3937} MCpl Ritco’s Investigation Plan;^{Footnote 3938} information about the time of arrival of the ME at the MP Garrison and the time of arrival of the ME and the CFNIS investigators at Cpl Langridge’s room on the day of his death;^{Footnote 3939} extracts of the summary of MCpl Bowden’s interview relating to her discussions with the RSM about the use of the term “suicide watch”;^{Footnote 3940} information about CFNIS’ request for an analysis of Cpl Langridge’s BlackBerry;^{Footnote 3941} the sketch prepared by MCpl Ritco of the room where Cpl Langridge was found;^{Footnote 3942} the letter to LDSH seeking authority for disposal of the exhibits by the CFNIS, as well as information about the drafting of the letter, including the list of exhibits sent to LDSH in the authorization request;^{Footnote 3943} and the entry indicating that the then Acting CO of the CFNIS had reviewed the report and concurred with the findings of the investigation.^{Footnote 3944}

49. The Fynes could not know exactly what information was redacted and why, but continued to be concerned about the extent of the redactions to this second version of the report.^{Footnote 3945} They nevertheless agreed to meet with CFNIS members on November 28, 2009 to discuss the investigation.^{Footnote 3946}

Who Is Responsible for the Redactions?

50. Every time the Fynes complained about the redactions to the 2008 report, the CFNIS members they dealt with told them this was not their responsibility, but that of DAIP, and indicated they essentially had no say in the redactions. The evidence heard in these proceedings reveals the actual situation was somewhat more complex. As a result, these explanations were not entirely accurate.

51. Throughout his dealings with the Fynes about this issue, LCol Sansterre repeatedly reiterated he was not responsible for making decisions about the redactions to the report, stated he had “no control” over when the report would be released by DAIP, and indicated he would forward the Fynes’ concerns about the redactions to DAIP, which he did.^{Footnote 3947} During the November 2009 briefing, Maj Dandurand and MS McLaughlin provided similar explanations. Maj Dandurand assured the Fynes the version of the report they had now received had been severed “in line with the Privacy Act.”^{Footnote 3948} He told them DAIP had redacted the first copy of the report they received, and DAIP redact all the reports.^{Footnote 3949} Maj Dandurand was emphatic the Military Police was not responsible for the redactions to the two versions of the report, indicating: “so your issues are with DAIP, not with us. I completely empathize with the frustration, but I can’t.”^{Footnote 3950} He later added:

Here's the irony, or perhaps the bizarre nature of this – [...] It's not for me to say. This report disclosure to you is a Directorate of Access to Information Privacy issue. It is completely separate from the military police --

[...]

It has nothing to do with -- they do this on behalf of the whole department^{Footnote 3951} [Emphasis added]

52. He explained the process as follows:

[...] I am no expert on the Privacy Act, the DAIP Department is, which is why -- one of the areas where we have input in the severance is police tactics -- obvious reasons; right?

The methodology in which we conduct our job is protected under the Privacy -- or under the legislation.

So what we'll do, is we will highlight the portions that we believe to be tactics, and provide that to them and say -- they know the Privacy aspects, they know the National -- or even National Security aspects – [...] But DAIP holds -- that's why it's highlighted. We don't black it out, photocopy it, and send it back to them. We highlight it because they hold the final say. They will look at it and they will say, in their estimation, having severed several military police reports, no, what you guys are asking for is not severable, we're including it. Or they may say, yes, you're right, and they sever that.^{Footnote 3952}

53. This general explanation is in line with the evidence heard in this hearing about the process usually followed when access to information requests for MP information are received.^{Footnote 3953} However, it is not entirely in line with the way things happened in this case.

54. What the evidence in these proceedings has revealed is, before the file went to DAIP for review and redaction, a selection had been made – intentionally or not – by the MP analyst who printed the file. Ms. Jansen, who had been the DAIP for the past eight years when she testified before this Commission, explained her office does not have access to SAMPIS, the electronic system used by the CFNIS to store data.^{Footnote 3954} When a CFNIS report is requested, MP personnel produce a print out or PDF version of the file that is sent to DAIP for review and redaction as necessary.^{Footnote 3955} In this case, the total number of pages in the report provided by the MP to DAIP was 578,^{Footnote 3956} as opposed to the 714 pages in the report produced in these proceedings.^{Footnote 3957} Ms. Jansen could not explain the difference between the two files.^{Footnote 3958} A review of the files reveals that, aside from a small number of pages created subsequently when Maj Dandurand modified the concluding remarks,^{Footnote 3959} what accounts for the difference is mostly the fact the officer notes included in the copy of the file provided to the Commission were missing or blacked out in the copy sent to DAIP in response to the Fynes’ request.^{Footnote 3960} There is also a difference in the amount of information included in the section detailing the handling of exhibits.^{Footnote 3961}

55. Sgt Arlene Bomback-Fortin, the ATIP coordinator with the MP Group HQ, provided testimony to assist the Commission in its attempt to understand what was sent to DAIP and the underlying reasoning. Sgt Bomback-Fortin was not personally involved in preparing the file provided to DAIP in this case. Another employee, who was no longer working with the MP at the time of this hearing and who was not available to provide testimony, was in charge of this specific release.^{Footnote 3962} Sgt Bomback-Fortin explained, in her experience since joining the MP ATIP section in 2010, the entire report would be provided to DAIP following the receipt of a request from the family either made to DAIP or directly to CFNIS.^{Footnote 3963} She could not explain why the officer notes included in the 2008 report provided to this Commission were not included in the version of the file printed for DAIP following the Fynes’ request to LCol Sansterre,^{Footnote 3964} nor could she explain why the few pages of officer notes that were printed – as well as a few other documents – were redacted in full prior to the document being sent to DAIP.^{Footnote 3965} She was not aware of any policy preventing the inclusion of officer notes.^{Footnote 3966} She did not think it was likely the notes had not yet been scanned into the report at the time of printing.^{Footnote 3967} Indeed, what little information could be obtained about this indicates many of the notes were scanned previously.^{Footnote 3968} Sgt Bomback-Fortin and her colleague, Mr. Karl Beaulieu, who was the SAMPIS application manager, also did not think it was likely the notes were not included because of printing issues, since the notes were printed with the version of the file provided to the Commission.^{Footnote 3969} Some of the CFNIS members involved at the time believed police notes were not normally disclosed when MP information was requested.^{Footnote 3970} However, without the testimony of the employee responsible for the printing, the reason why the notes were not included in this case cannot be confirmed.

56. The difference in the number of pages of information relating to the exhibits was explained by the manner in which the printing was done, as well as some subsequent activity in the file. Only information about seizure and disposal of exhibits was printed in the version of the file sent to DAIP. The details related to the chain of custody and transfers for each item – including the suicide note – were not included.^{Footnote 3971} The SAMPIS system revealed another version of the file, this one including the details of the chain of custody and having 623 pages rather than 578, was printed in June 2009.^{Footnote 3972} It is not known what was done with this version, but it was not the one sent to DAIP and subsequently provided to the Fynes.^{Footnote 3973}

57. While some aspects of what was done remain unclear, it is clear that what was sent to DAIP was not the entirety of the CFNIS file. It is also clear DAIP had no involvement in making this initial selection. This was the responsibility of the Military Police.

58. With respect to the decision-making authority over the redactions added to the report after it was sent to DAIP, the Commission heard testimony from the DAIP herself, Ms. Jansen, about the process in place at the time. Ms. Jansen explained that as the DND DAIP, her role is to administer the Access to Information and Privacy acts on behalf of the Minister of National Defence.^{Footnote 3974} She explained she is the delegated authority for the DND to ensure the statutes are respected, and, as such, she is involved in making decisions about the release and redaction of information.^{Footnote 3975} Ms. Jansen described two types of requests for information that can be received: formal and informal. A formal access to information request must be directed to the DAIP’s office. When the request relates to MP information, DAIP obtains the information directly from the MP, sometimes with suggestions from the MP about redactions related to police techniques, and then proceeds to make a final determination as to what information will be released.^{Footnote 3976} By contrast, informal requests do not have to be addressed to DAIP.^{Footnote 3977} Where the MP or CFNIS receive such a request, they do have the authority to release their own records without advising or consulting DAIP.^{Footnote 3978} However, they must be careful to ensure personal information is not released contrary to the applicable legislation.^{Footnote 3979} In some cases, the MP will consult DAIP about what can be released in response to an informal request, and DAIP will provide advice to the MP.^{Footnote 3980} In such instances, it is DAIP making recommendations, and the MP making decisions about what information to release.^{Footnote 3981} However, as was learned from Ms. Jansen’s testimony about the facts of this case, in some circumstances, DAIP’s “advice” is binding.

59. Mr. Fynes’ request for the Sudden Death investigation file was viewed and treated as an informal request.^{Footnote 3982} The file was sent to DAIP by the MP who were “asking our advice to see if there is anything we can suggest, if there is personal information that we should redact.”^{Footnote 3983} However, Ms. Jansen indicated the determination as to what information could be released in the public interest pursuant to s. 8(2)(m) of the Privacy Act – the criterion used to redact the first version of the report – was still made by DAIP, without consultation with the MP.^{Footnote 3984} She added, in a case such as this one involving a Sudden Death investigation, the recommendations or advice DAIP would provide to the MP would be based on the DAIP’s views of what it is in the public interest to release.^{Footnote 3985} She indicated that, having consulted DAIP, the MP are in fact bound to follow their recommendations, at least when it comes to issues related to the release of personal information and the application of the Privacy Act.^{Footnote 3986} In other words, where an informal request is received by the CFNIS, the MP can decide to release the information without consultation. However, if they do seek advice from DAIP, they are bound to follow it. They are free to redact more than what DAIP recommends, but not less.^{Footnote 3987}

60. According to Ms. Jansen, a further distinction between the formal and informal process is that for formal requests, the MP would have an obligation to provide DAIP with the entire report, whereas for an informal request, they only have to provide the information about which they decide to seek DAIP’s advice.^{Footnote 3988}

61. Based on this evidence, it appears in this case, the Military Police and DAIP were both responsible for the redactions applied to the report provided to the Fynes. The MP made an initial selection of certain information when printing the report – essentially deciding to exclude officer notes – and then made a decision to seek advice from DAIP about the redaction of personal information contained within the selection the MP had made. Because this advice was sought, DAIP then essentially became the arbiter of the minimum necessary redactions with respect to the parts of the file sent to it. As stated in the cover letter sent by DAIP to CFNIS with the second version of the report, the final redactions done by DAIP were the same as those that would have been applied to the report if a formal request had been received and processed by DAIP.^{Footnote 3989} For the parts of the report initially sent to DAIP by the MP, this was a DAIP release, and DAIP was responsible for the redactions because the MP chose to consult with DAIP.

62. Possibly because of the complexity of the process, many of the CFNIS members involved had a different understanding about who was responsible for what redactions. MS McLaughlin testified he believed DAIP was responsible for making decisions about all redactions.^{Footnote 3990} He thought there was nothing he and Maj Dandurand could do about the Fynes’ complaints regarding the redactions because the MP section having conducted an investigation would not have the authority to make those decisions. DAIP would have the authority.^{Footnote 3991} Maj Dandurand also had a similar understanding. He testified DAIP ultimately held the “trump card,” although the MP ATIP coordinator could request certain redactions.^{Footnote 3992} However, he did agree DAIP would not be in a position to debate the MP’s views that certain documents or information revealed police techniques.^{Footnote 3993} Maj Dandurand did not think the MP could decide on its own not to produce certain parts of a report, and he was not aware the file sent to DAIP by the MP was incomplete.^{Footnote 3994} He personally had no involvement in applying or proposing redactions to the 2008 report, or in selecting parts of the file to be sent to DAIP.^{Footnote 3995} He testified no one in CFNIS WR was involved and, to the best of his recollection, “nobody within the NIS even had access to that.”^{Footnote 3996} He also stated he never found out why the direction to cut down the body had been redacted, and he did not pursue this matter.^{Footnote 3997} It appears Maj Dandurand did not take steps to address any of the Fynes’ complaints about these issues, short of providing them with an explanation of his understanding of the process, because he believed the CFNIS was not responsible for decisions about the redactions.

63. LCol Sansterre, for his part, testified he was not aware there was a formal and an informal process to request information.^{Footnote 3998} He was aware there had been a change in procedure allowing families wishing to obtain copies of CFNIS reports to present the request directly to the CFNIS through their AO, rather than having to submit an official Access to Information request.^{Footnote 3999} However, he did not understand the MP or CFNIS would then have a choice about whether or not to consult with DAIP about the redactions and what parts of the file to provide. He was not aware of which parts of the 2008 report were, in fact, sent to DAIP for redaction. He believed the MP Access to Information section played a role in redacting information related to police techniques, but was not aware of exactly how the process worked.^{Footnote 4000} His understanding was, when the Fynes’ request was received, the CFNIS sent the report to DAIP, who then sent it back to CFNIS with redactions.^{Footnote 4001} LCol Sansterre believed the CFNIS would not make their own decisions about what to release, because “the Access to Information Act and the Privacy Act are very complicated laws,” and because DAIP are “the ones that are applying the law for us. They are the department organization that applies the legalities.”^{Footnote 4002} When he realized Mr. Fynes was not happy with the redactions, LCol Sansterre agreed with some of his complaints and assisted him in trying to get a different copy from DAIP.^{Footnote 4003} Nevertheless, LCol Sansterre believed, in the end, the CFNIS could not overrule DAIP’s decisions.^{Footnote 4004}

64. The evidence revealed some of the staff working in the MP ATIP section did have a clearer understanding of the process and decision-making authority over redactions. The MP ATIP Manager who was in charge of dealing with the Fynes’ request, Mr. Austin Ambrose, wrote a message to DAIP indicating the original request from the Fynes was “treated as an informal Privacy 8(2)(m) request” and stating it would seem “CFNIS are regarded, in this instance, as the keeper of the file and the authority for its release.”^{Footnote 4005} Mr. Ambrose indicated he thought they could “extricate CFNIS” by treating Mr. Fynes’ correspondence as a formal request to DAIP. He asked DAIP to assume responsibility and to be the point of contact with the Fynes.^{Footnote 4006} LCol Sansterre, who was copied on the original message, responded he wished to remain the point of contact with the family and indicated, “the family is aware that I am not responsible for the disclosure of the report.”^{Footnote 4007} The DAIP Acting Deputy Director, for her part, responded that in this case, DAIP had “agreed to review the complete MP report in accordance with the Privacy Act and provide a copy to Mr. Fynes through LCol Sansterre.”^{Footnote 4008} She added, if the Fynes wished to request the complete MP report, “they should be informed to submit a request under the Privacy Act directly to our office.”^{Footnote 4009} This would then be considered a formal request and DAIP would deal with the family directly.^{Footnote 4010}

65. Despite having been copied on this correspondence (and perhaps potentially having access within MP HQ to a clearer understanding of the applicable process if he had made inquiries), it is clear LCol Sansterre was sincere in his understanding about the redaction of the CFNIS report being solely within DAIP’s decision-making authority. When he was contacted by Mr. Fynes about the redactions to the first version of the report, he wrote to the DAIP to ask for advice on how to respond and indicated: “it is obvious that the sender is confusing me as the CO CFNIS as having some authority or being responsible for the release of this investigation.”^{Footnote 4011} Obviously, whatever the MP ATIP staff may have been aware of, LCol Sansterre did not know there was some discretion about the release of information in the case of informal requests, and he did not know a selection was made when the file was sent to DAIP. Throughout the process for the disclosure of the 2008 report to the Fynes, LCol Sansterre attempted to be as helpful and courteous as possible to the Fynes. Mr. Fynes testified:

I think Colonel Sansterre was making a genuine effort to be helpful to us and to justify that their actions had been professional [...]^{Footnote 4012}

66. Indeed, LCol Sansterre provided timely responses and updates, and explained the process as best he could, in accordance with his own understanding.

67. The Commission now understands some of the information provided by LCol Sansterre and Maj Dandurand to the Fynes was not entirely accurate. However, this was simply the result of a lack of understanding on the part of these CFNIS members, and not of any intention to deceive the Fynes. It is unfortunate better information was not available to those in charge of interacting with the Fynes about this issue. Ms. Jansen testified DAIP has a section in charge of providing training to other DND organizations, including the MP, about matters relating to the release of information. As a result, she testified she was confident the MP have enough training to proceed with the release of information in response to informal requests without consulting DAIP, and would also know when consultation is necessary.^{Footnote 4013} The evidence in these proceedings has revealed, while the members of the MP ATIP section may possess some of the necessary knowledge as a result of this training, other CFNIS members who are dealing directly with complainants making informal requests for information do not. In this case, making this information more widely available within CFNIS may have allowed these members to provide more accurate information to the Fynes in response to their concerns, and perhaps even to address some of the redaction issues directly resulting from the selection made by the MP when sending the file to DAIP.

Were the Redactions Justified?

68. The redactions to both versions of the 2008 report provided to the Fynes were extensive. The Commission does not propose to review each in detail. However, a number of them are of particular concern and merit comment.

69. First, the redaction of all officer notes from both versions of the report provided to the Fynes was the result of a decision made by the MP, and not DAIP. The Commission sees no justification for this redaction, which covered over 100 pages of materials. When the Fynes raised this issue in their first meeting with CFNIS members, Maj Dandurand and MS McLaughlin assured them police notes are not available for disclosure through access to information requests.^{Footnote 4014} In testimony, MS McLaughlin indicated this was and remains his understanding.^{Footnote 4015} When asked where he obtained that information, he explained:

It’s not specific to any training, so we can rule that out. There’s no actual training that I’ve ever received based on DAIP or anything like that.

But police notes often speak to police tactics, interview tactics, and those things there typically are not released. So there’s serious redaction that has to be done. Notes contain all personal sensitive information.

As a general rule, my understanding based off of the amount of information that’s available in police notes, that wouldn’t typically be available in the report anyway.

No, police notes are not released based on that practice. It seems logical to me because there’s just too much stuff within police notes that is not something you would disclose.

The actual information on why those don’t get disclosed would be available from ATIP coordinators.^{Footnote 4016}

70. During his testimony, Maj Dandurand also confirmed his own belief police notes are not available through Access to Information requests.^{Footnote 4017}

71. By contrast, Ms. Jansen testified it is not DAIP’s general policy to redact all police notes. Rather, the content of the notes is reviewed and only portions relating to an accepted ground for severance – such as personal information or police techniques – are redacted.^{Footnote 4018} She could not explain why the police notes were redacted in both versions of the report provided to the Fynes.^{Footnote 4019} Maj Gord Wight of the MP Directorate in charge of the ATIP section testified about the process currently followed for the release of MP information. He stated the MP assemble everything on the file, including MP notebooks, when formal requests are received under the legislation.^{Footnote 4020} He added there is no blanket policy to recommend notebooks be redacted entirely as a matter of course.^{Footnote 4021} Instead, the MP will recommend certain redactions based on the content of the information.^{Footnote 4022} The reason for excluding the police notes from the copy of the report sent to DAIP and then to the Fynes in this case remains unclear. However, based on the evidence, it is clear this redaction was not appropriate.

72. Another particularly problematic redaction, as pointed out by Mr. Fynes on numerous occasions – was the blacking out of the direction to cut down Cpl Langridge’s body. The evidence indicates this particular redaction was applied by DAIP and was appropriately removed from the second version of the report released to the Fynes. Ms. Jansen explained it was DAIP’s view personal information about Cpl Langridge included in the report could not be released for a period of 20 years, as it belonged to the deceased.^{Footnote 4023} As a result, DAIP applied the redactions to the report pursuant to s. 8(2)(m) of the Privacy Act, which Ms. Jansen explained “left to my discretion to see if it’s in the interest of the public to release that kind of information.”^{Footnote 4024} She explained the direction to cut down Cpl Langridge’s body, even though it immediately followed an unredacted notation indicating he was found “hanging from the neck,”^{Footnote 4025} would be redacted pursuant to the DAIP’s public interest determination “out of consideration and respect for the family.”^{Footnote 4026} She added, “it’s information that can be harsh to read for the parents or the family.”^{Footnote 4027} She explained, anything “that could be difficult for the family to read, I would consider not to release.”^{Footnote 4028}

73. In making these public interest determinations about what information would help the family understand the circumstances of the death,^{Footnote 4029} what information could be difficult for the family to learn, or what information should be redacted out of consideration for the family,^{Footnote 4030} Ms. Jansen testified DAIP does not consult with the family requesting the information to find out what their preferences are and what type of information they feel they need to obtain.^{Footnote 4031} The MP members having conducted the investigation are also not consulted.^{Footnote 4032}

74. Mr. Fynes believed that the direction to cut down Cpl Langridge was redacted for the purpose of protecting the MP from embarrassment.^{Footnote 4033} The evidence has revealed this was not the case. The redaction was applied by DAIP. The CFNIS members involved in the case had no input in applying or recommending it. Further, there is no indication the CFNIS were even aware at the time of the Fynes’ complaints about the length of time Cpl Langridge’s body was left hanging, so it is difficult to imagine how the information about the direction to cut down the body could have been viewed by anyone as embarrassing. However, this does not mean this redaction was appropriate. On the contrary, it was both unfortunate and unnecessary. It gave rise to an appearance the CFNIS was trying to hide information, and it was nearly impossible to explain rationally. The process of having DAIP apply redactions on the basis of their perception of what the family would need to know, without knowing or consulting the family and without having any familiarity with the background of the case, was bound to lead to such absurd results. In this case, it resulted in an unjustified redaction that contributed to eroding the trust between the Fynes and the CFNIS.

75. The application of this discretionary determination by the DAIP as to what information the Fynes could receive was a direct result of DAIP’s interpretation of the PEN form. Because they did not view the consent to the release of personal information as extending to information created after signature or after death, they determined only the public interest analysis was available to authorize the release of the CFNIS report. The CFNIS was not involved in coming up with this interpretation, and some of the members involved appeared to disagree with it. For instance, Maj Dandurand explained to the Fynes that when he received the first version of the redacted report, he thought there had been an error in redacting it as if an Access to Information request had been made by a third party, instead of acknowledging Mr. Fynes, as Cpl Langridge’s PNOK, was entitled to obtain information about him.^{Footnote 4034} In testimony, he indicated his “immediate assumption,” upon reviewing the report provided to the Fynes, was there had been a “clerical error,” because the Fynes, as next-of-kin and executor, were entitled to receive a report redacted “as though Corporal Langridge were requesting this report himself.”^{Footnote 4035} Maj Dandurand testified he made attempts to rectify the situation when he received the report, indicating he contacted his HQ to suggest the CFNIS enter into discussions with DAIP in order to have a report with fewer redactions provided to the Fynes.^{Footnote 4036}

76. In her testimony, Ms. Jansen confirmed her view, as the DAIP, that the consent to release personal information in the PEN form cannot apply to information not in existence at the time of signing of the form or, at least, not in existence at the time of the person’s death, including post-death BOIs and MP investigations.^{Footnote 4037} However, she added the situation was not clear:

I wish it would have been that clear and we could make a decision on something so clear but we had to work with the PEN form that was not clear and left to the impression that it was giving authorization to give everything when the purpose was to only give access to limited information, so we had to work with that kind of situation at the time.^{Footnote 4038}

77. Nevertheless, she confirmed the advice provided by DAIP to the MP was that the PEN form could not authorize the release of information created after Cpl Langridge’s death.^{Footnote 4039} The subsequent change of position that led to the second version of the report being provided to the Fynes was not representative of an overall change of policy at DAIP about the interpretation of the PEN form. Rather, Ms. Jansen explained a decision was made specifically for this case to adopt a different approach, because “any act is left to interpretation or any law is left to interpretation.”^{Footnote 4040} This change in approach by DAIP was the main factor accounting for the significant difference in the number of pages released in the first and second versions of the report provided to the Fynes, and largely explains why the report nearly doubled in size between the two releases.^{Footnote 4041} As a result, many of the questionable redactions applied by DAIP to the first version were removed in the second version.

78. It should be noted, in this particular instance, the CFNIS members involved did advocate for the release of more information, and this may have contributed to DAIP’s decision to adopt a different approach in this case. However, there has been no general change of policy at DAIP.^{Footnote 4042} As a result, requests for Sudden Death investigation reports made in the future will be treated in the same manner as the Fynes’ request was initially treated, even where the PEN form includes a signed consent to the release of information.^{Footnote 4043} The newest version of the PEN form no longer provides for the option to sign this consent, so any requests involving a CF member who signed a new PEN form would be processed pursuant to the DAIP’s discretionary determination of what information should be released in the public interest.^{Footnote 4044} There is no evidence the CFNIS has taken any steps to challenge this general approach or to advocate for a different approach to the release of their death investigation reports to families.

79. One of the other redactions that appeared to strike the CFNIS members involved as inappropriate was the blacking out of Mr. Fynes’ own comments to the investigator. LCol Sansterre testified he agreed with some of Mr. Fynes’ complaints because “there was stuff redacted that was his own personal stuff.”^{Footnote 4045} Maj Dandurand thought errors were made in the redaction of the first version of the report, and specifically indicated references to the person making the request and their own statements should not be redacted.^{Footnote 4046} During his meeting with the Fynes, he speculated the desk officer in charge of severing the second version of the report likely understood it would go to Cpl Langridge’s personal representative, but did not understand Mr. Fynes was the person making the request,^{Footnote 4047} which would explain why Mr. Fynes’ own statements are redacted.

80. Ms. Jansen indicated DAIP does not generally redact the requestor’s own comments to an investigator, unless the comments are about another person.^{Footnote 4048} About the release of video recorded interviews conducted by the CFNIS, she indicated DAIP would normally release the entire recording to the individual who was interviewed “without even doing any severances whatsoever.”^{Footnote 4049} In this case, only Mr. Fynes’ comments about Ms. A were redacted in the second version of the report.^{Footnote 4050} These redactions were stated to have been made because the information was about an individual other than the person who requested the information.^{Footnote 4051} In the first version, much more information was redacted, including Mr. Fynes’ comments to MCpl Ritco about Cpl Langridge’s cell phone, his hopes the persons who sold drugs to Cpl Langridge would be investigated, his comments about the state of Cpl Langridge’s residence and the arrangements made with the Regiment for him to move out, as well as all of his comments about the funeral.^{Footnote 4052} The grounds invoked for those redactions were that the information related to police techniques or was information about another individual.^{Footnote 4053} Ms. Jansen could not indicate with certainty whether the redactions were the result of MP suggestions or DAIP decisions.^{Footnote 4054} It should be noted the relevant MPPTP Chapter applicable at the time contained a section indicating that “any individual who gives a statement has the right to a copy of that statement in whatever form it was recorded, pursuant to the provisions of the Privacy Act.”^{Footnote 4055}

81. It is difficult to understand why any of the information provided by Mr. Fynes to the CFNIS should be redacted from the report provided to Mr. Fynes. The notion any of this information could be covered by an exemption for police techniques stretches credulity. While it is not for the Commission to pass judgment on the legal aspects of the application of the Privacy Act, redacting information about another individual also appears to make little sense when applied to Mr. Fynes’ own comments to the investigator. For these reasons, the Commission considers the redactions to Mr. Fynes’ own statement in the first version of the report not to have been justified, and the redactions in the second version to be, at best, questionable. It is not clear whether DAIP, the MP, or both were responsible for these specific redactions. The CFNIS members who were subjects of this complaint certainly did not agree with them.

82. Other redactions covered information essential for any reader to gain an understanding of the investigation. The most important was the redaction of MCpl Ritco’s Investigation Plan in full, on the basis that it would reveal police techniques.^{Footnote 4056} Based on the evidence, it is likely, but not confirmed, this redaction was recommended by the MP and accepted by DAIP. It is difficult to see how disclosing the investigation plan for this concluded investigation would risk revealing police techniques. On the other hand, without this document, it would have been difficult for the Fynes to understand the investigation report and the issues being investigated.

83. The following two paragraphs from the summary of the interview with MCpl Bowden were also redacted:

d) she attended lunch and upon returning to the LDSH she was confronted by MCpl Fitzpatrick who questioned her on what she did as the LDSH RSM wants to see her in his office;

e) she attended the RSM office, where she was confronted on who gave her permission to use the word “suicide” on her email, she explained that no one had given her permission and that she was just following MCpl Fitzpatrick’s direction regarding replying to his request via email;^{Footnote 4057}

84. This was an important piece of information obtained by the CFNIS in their investigation of the suicide watch issue. Removing it from the Fynes’ copy of the file would hinder their ability to understand the circumstances described by the witness. The ground invoked for this redaction was that it was personal information pertaining to an individual other than the person requesting the information^{Footnote 4058} This justification is difficult to accept. The information related to what witnesses did in the course of their work duties, and removing it was liable to give the impression there was an intention to prevent public disclosure of the LDSH chain of command’s displeasure at the words “suicide watch” being used. Based on the evidence, it is likely this redaction was applied by DAIP, as the ground invoked relates to privacy and not police methods.

85. Also redacted was the entry indicating the Acting CO of the CFNIS had reviewed the report and concurred with the findings of the investigation.^{Footnote 4059} The ground invoked for this redaction was that the information could reveal police techniques.^{Footnote 4060} Again, this is difficult to understand, and again, it would have been relevant for the Fynes to know the CFNIS chain of command had reviewed and approved the findings they took issue with. As it relates to police techniques, this redaction was likely the result of an MP recommendation.

86. Information related to the handling of the exhibits was redacted in both versions of the report. Part of this information was not printed at all by the MP when the report was sent to DAIP. The part that was printed was redacted in full on the ground that it would reveal police techniques.^{Footnote 4061} Ms. Jansen explained this type of information is generally redacted by DAIP at the request of the MP, as relating to “evidence and technique of investigation.”^{Footnote 4062} She indicated DAIP’s usual practice is to agree to redact all information about exhibits, even after an investigation is concluded.^{Footnote 4063} While the detailed information about the chain of custody for each item seized would likely have been of little interest to the Fynes, the justification for removing this information in the case of a concluded investigation is dubious. A justification for entirely redacting even the items seized, the date of seizure and the disposal information simply does not exist in this case. At a minimum, the Fynes would have had an interest in finding out more about when their son’s suicide note was seized and exactly what was done with it during the investigation. There was no reason for redacting this information in their copy of the report.

87. In conclusion, many of the redactions in both versions of the report were either not justified at all or, at a minimum, difficult to understand. The responsibility for this rests both with the MP and DAIP. In some cases, it is not possible to determine who made the decision. Where the MP were not directly responsible for the redactions, it still remains the case it was their decision to seek advice from DAIP prior to releasing the report – whether or not they were aware or supportive of the approach DAIP used or even knew there was a choice about seeking advice.

88. More broadly, the CFNIS and the MP have not sought to challenge the existing process, which takes away much of their decision-making power with respect to the release of their own information.^{Footnote 4064} As a result, the CFNIS ended up in the embarrassing position of providing two versions of the report to the Fynes, with the second containing more than double the information and the reasons for the redactions difficult and at times impossible to explain. In the end result, it took five months for the Fynes to obtain a copy of the report about the investigation into their son’s death that still contained many unjustified redactions. This missing information, coupled with the haggling over the redactions and the resulting delay in providing the report to the Fynes, was bound to give rise to an appearance the CFNIS lacked transparency and was not forthcoming in providing information. Coming just on the heels of the late disclosure of the suicide note, these types of unfortunate incidents could only hinder any possibility of establishing a relationship of trust and open communication between the Fynes and the CFNIS.

4.5.3 The November 2009 Briefing

89. On November 28, 2009, almost 18 months after the investigation was concluded, the CFNIS provided a briefing to the Fynes about the 2008 investigation into their son’s death.^{Footnote 4065} The purpose of the briefing, from the CFNIS’ perspective, was largely to appease the Fynes in light of their mounting displeasure following the discovery of the suicide note and the redactions made to the investigation report. Indeed, this face-to-face meeting was an opportunity for the CFNIS to remedy some of its past failures, in particular as they related to the lack of contact and the lack of meaningful information provided to the Fynes. Unfortunately, the conduct of the briefing and the events that followed only provided another illustration of the pitfalls of not establishing proper communication with complainants.

90. The Fynes raised most of the complaints they subsequently brought before this Commission about the 2008 investigation during the briefing. The responses they received fuelled, rather than eased, their frustrations. Had the complaints been better handled when they were initially received, it is possible at least some of them may not have later become part of this hearing. Instead, this was a missed opportunity to establish a much needed open dialogue with the Fynes, and the briefing itself became the source of additional concerns and eventual complaints.

Purpose of the Briefing

91. The decision to provide the briefing was made at the CFNIS HQ level.^{Footnote 4066} Maj Dandurand, the Officer Commanding the Detachment who was tasked with conducting the briefing, testified he agreed a briefing was necessary.^{Footnote 4067} In his notes, he had indicated the purpose of the meeting was to provide the Fynes with a briefing on the investigation and to answer their questions.^{Footnote 4068} In testimony, he explained, from his perspective, the desired outcome was “to make sure that the famil[y] had the opportunity to ask all of their questions, to have an open and frank dialogue with us with respect to the investigation.”^{Footnote 4069}

92. In testimony, Maj Dandurand could not recall whether he was aware of the Fynes’ concerns in advance of the meeting.^{Footnote 4070} He did know they had received a copy of the investigative report and that it was “significantly redacted.”^{Footnote 4071} He was also aware there were other issues. He had contacted Maj Parlee, the President of the BOI into Cpl Langridge’s death, in advance of the meeting to ask about any concerns the Fynes may have communicated to him about the CFNIS or the investigation report.^{Footnote 4072} Maj Parlee had advised the Fynes’ main concern would likely be the suicide note, why it was not disclosed to them for so long, and why they did not receive a copy immediately. He had also indicated the Fynes would likely ask for specific details about the processing of the scene where Cpl Langridge’s body was found and may have questions about Cpl Langridge’s personal effects.^{Footnote 4073}

93. MS McLaughlin, the other CFNIS member tasked with participating in the briefing, testified he was briefed by Maj Dandurand about the reasons for the meeting with the Fynes.^{Footnote 4074} He understood the purpose was to provide the Fynes a briefing about the 2008 investigation because they had requested to discuss this.^{Footnote 4075} Based on the information he received from Maj Dandurand, he also understood, prior to the meeting, that the Fynes were “dissatisfied with certain portions of what had been done in the Ritco investigation” and that the briefing would provide an opportunity for the CFNIS members to discuss these issues with them.^{Footnote 4076} In particular, he was told there had been an issue with the length of time in the release of the suicide note, which Maj Dandurand indicated he would have to address during the meeting.^{Footnote 4077} Aside from this issue, MS McLaughlin had no knowledge of any other specific issue the Fynes would be raising or discussing about the investigation.^{Footnote 4078}

94. In testimony, LCol Sansterre indicated he had no prior discussions or awareness of what Maj Dandurand planned to speak about in the meeting, but assumed he would brief the family about the file and answer their questions.^{Footnote 4079} He noted that conducting face to face briefings with families about a concluded investigation was not the usual practice at the time.^{Footnote 4080}

95. It is clear this briefing to the Fynes was ordered by CFNIS HQ over a year after the investigation ended because of the special circumstances of this case. The CFNIS members in command at HQ and in the Detachment knew before the briefing the Fynes took issue with some of what had been done or had been left undone by the CFNIS and were hoping the briefing would contribute to alleviating the Fynes’ frustration in these respects. The briefing followed LCol Sansterre’s initial offer in the summer of 2009 to have CFNIS investigators or “CFNIS personnel familiar with the file” provide a briefing to the Fynes about the police investigation.^{Footnote 4081} This offer directly followed the discovery of the suicide note.^{Footnote 4082} It was reiterated in response to Mr. Fynes’ strong objections about the redactions to the report.^{Footnote 4083} Maj Dandurand was also aware of the issues.^{Footnote 4084} He had contacted the Fynes’ AO, Maj Parkinson, shortly after LCol Sansterre’s initial call to the Fynes and had asked him to “track” the Fynes’ satisfaction with the timeliness of the receipt of the 2008 report.^{Footnote 4085} Maj Parkinson had advised the CFNIS’ efforts would “go a long way to right the wrongs” but had indicated the Fynes were a difficult family to please.^{Footnote 4086} Maj Dandurand had reported back to LCol Sansterre that he understood the Fynes’ frustrations and hoped he and his colleagues could “end those frustrations as far as the CFNIS goes.”^{Footnote 4087}

Preparation for the Briefing

96. Neither of the two CFNIS members who conducted the briefing had been involved in conducting the 2008 investigation. Maj Dandurand became the OC for the Detachment in July 2008,^{Footnote 4088} after the investigation was concluded. He had been involved in the discussions surrounding the discovery of the suicide note in 2009,^{Footnote 4089} but had no prior involvement in the file. Maj Dandurand was tasked with conducting the briefing because of his position. In testimony, he explained providing family briefings was generally a task performed by Detachment Commanders or “as high up the chain as possible.”^{Footnote 4090} MS McLaughlin, for his part, was an investigator at the Detachment since 2007.^{Footnote 4091} He had been involved briefly in taking notes during an interview conducted in the 2008 investigation, but had no other involvement in the case.^{Footnote 4092} He testified he was asked to attend the briefing because he was still working at the Detachment and was available to attend at the requested time.^{Footnote 4093} He explained part of the reason for his presence was also “to speak on my experience and expertise as an investigator should they have any questions related to investigative process and procedures and techniques,” since Maj Dandurand was the OC for the Detachment and not a general investigator.^{Footnote 4094} When the meeting was held, MS McLaughlin had been an investigator with the CFNIS for two years.^{Footnote 4095}

97. MCpl Ritco, the lead investigator for the 2008 investigation, was still a CFNIS member when the briefing was held, but was on secondment with the RCMP at the time.^{Footnote 4096} In testimony, Maj Dandurand was asked why MCpl Ritco was not present at the briefing. He indicated it was not customary for the CFNIS to have the actual investigator in charge of the file present in such meetings.^{Footnote 4097} MS McLaughlin stated he was not aware of the reasons and never had any discussions about it.^{Footnote 4098} When Mrs. Fynes commented during the briefing that MCpl Ritco should have been present to answer their questions, Maj Dandurand answered that he could not “speak to that decision.”^{Footnote 4099} No other explanation was provided to the Fynes or to this Commission.

98. In preparation for the meeting, Maj Dandurand reviewed the 2008 investigation file.^{Footnote 4100} He explained his focus was to make sure he had a sense of the totality of the information found in the file, as some of it would be redacted in the Fynes’ copy. He stated he wanted to be able to speak to the general themes addressed in the redacted portions, in order to assure the Fynes that nothing was redacted except national security, police practices and private information.^{Footnote 4101} It does not appear Maj Dandurand had any discussions with MCpl Ritco or the other CFNIS members involved in the 2008 investigation in preparation for the meeting. He recalled one conversation with MCpl Ritco about the investigation after the meeting, and possibly one other when the failure to disclose the suicide note was discovered, but did not mention any specific discussion in preparation for the meeting.^{Footnote 4102} He did not discuss the 2008 investigation with Sgt Bigelow or WO Ross Tourout, as they had left the Detachment by the time he assumed command.^{Footnote 4103} The one issue Maj Dandurand did inquire into prior to the meeting related to the notation in the investigation report that Cpl Langridge’s room was “in disarray.”^{Footnote 4104} Maj Dandurand was told this simply indicated “bachelor-type living,” as opposed to the room being “trashed.”^{Footnote 4105} In testimony, he could not recall whom he spoke to about this issue, but though he likely discussed it with MS McLaughlin, as they were working in close collaboration to prepare for the meeting.^{Footnote 4106}

99. MS McLaughlin, for his part, did not review the file prior to the briefing.^{Footnote 4107} He also did not discuss the investigation with MCpl Ritco or other investigators involved.^{Footnote 4108} He testified his only tasking in preparation for the meeting was to verify what exhibits were still held in the Detachment’s evidence room.^{Footnote 4109} Maj Dandurand explained he asked MS McLaughlin to look into “exactly what the state of our evidentiary holdings was at that time” for the 2008 investigation file.^{Footnote 4110} MS McLaughlin indicated this was done “to ensure that everything that had to be returned or disposed” had in fact been returned or disposed, so that only police exhibits like interview recordings and witness statements were retained.^{Footnote 4111} According to him, this type of verification was common.^{Footnote 4112} In order to carry it out, MS McLaughlin went through the evidence continuity logs to identify what items were still retained.^{Footnote 4113} He then physically signed out all of the items.^{Footnote 4114} He explained the goal was to be able to confirm for the Fynes the CFNIS were only holding in their evidence room items that “were NIS property such as videos, statements, etc.”^{Footnote 4115} MS McLaughlin provided the items to Maj Dandurand for review, and discussed them with him, as Maj Dandurand wanted to know before the meeting about everything still being held.^{Footnote 4116}

Conduct of the Briefing

100. The meeting with the Fynes lasted approximately four hours,^{Footnote 4117} during which time the Fynes did most of the talking.^{Footnote 4118} The discussions were wide ranging and, at times, difficult to follow. The Fynes’ frustration was obvious. Mr. Fynes testified: “to their credit, [the CFNIS members] listened to us with a litany of complaints.”^{Footnote 4119} Many of these complaints were unrelated to the CFNIS investigation.^{Footnote 4120} For the most part, the CFNIS members listened in silence and attempted to understand the chronology of events and the Fynes’ concerns. Other concerns were directly related to the CFNIS investigation. The CFNIS members participated more actively in discussions about those concerns.

101. The Fynes had just received a less redacted version of the report for the 2008 investigation.^{Footnote 4121} During the briefing, they expressed many concerns and formulated several complaints about the conduct of that investigation. Their complaints included:

strenuous objections to Cpl Langridge’s body being left hanging for hours, along with allegations this showed a lack of respect for him as a soldier, and this was motivated by the CFNIS members’ view that Cpl Langridge was a defaulter or a “failure” and hence not deserving of proper respect;^{Footnote 4122}
equally strenuous and frequent complaints about the fact Cpl Langridge’s suicide note was withheld from the Fynes and not mentioned on any lists of property provided to them, including the fact that, as a result, the Fynes were unaware their son did not want a military funeral;^{Footnote 4123}
complaints about the finding in the 2008 investigation report’s Concluding Remarks indicating “Cpl Langridge suffered from alcohol and cocaine addiction which caused him to have mental health issues” and concluding this was a factor in the suicide,^{Footnote 4124} – which Mr. Fynes characterized as a “medically incorrect” opinion^{Footnote 4125} – as well as about the finding that Cpl Langridge’s military unit made efforts “to provide structure and support to Cpl Langridge”^{Footnote 4126} and “made several attempts to help Cpl Langridge in dealing with his problems”^{Footnote 4127} – which Mr. Fynes characterized as irrelevant editorializing, emphasizing instead, in his view, it was treatment Cpl Langridge needed and did not receive;^{Footnote 4128}
repeated complaints and questions about why “such a big investigation on the part of the police” was necessary in this case, why the investigation was so comprehensive, and why the CFNIS continued its investigation beyond the ME’s determination the death was a suicide;^{Footnote 4129}
several complaints reflecting the Fynes’ apparent belief the CFNIS members involved in the 2008 investigation exhibited bias in their approach to Cpl Langridge, including:
- the lead investigator “cherry-picked” information from an incomplete portion of Cpl Langridge’s medical files and used it to come to his conclusions, despite contrary information being present in other portions of the medical files;^{Footnote 4130}
- lack of respect for Cpl Langridge even tainted the manner in which the CFNIS investigators initially described the room where his body was found, describing it as being in “disarray”;^{Footnote 4131} and
- witnesses who provided information reflecting poorly on Cpl Langridge were interviewed, while others who could speak to his military career and accomplishments were not;^{Footnote 4132}
complaints about the fact CFNIS reported holding “approximately 13 exhibits,” but had the investigation “signed off as complete” while exhibits were still outstanding, and did not return the exhibits to the Fynes in a timely manner after the conclusion of the investigation;^{Footnote 4133}
a complaint the ME Investigator inaccurately noted in his report that Cpl Langridge had disciplinary issues and an allegation this was based on information provided to him at the scene;^{Footnote 4134} and
complaints about the redactions made to the copies of the report provided to the Fynes.^{Footnote 4135}

102. Maj Dandurand and MS McLaughlin did not take any steps during or after the briefing to refer these complaints to Professional Standards for investigation. They also did not advise the Fynes about the existence of a complaints process. Instead, they attempted to deal with the issues directly. However, not having been involved in the investigation, they were often unable to answer the Fynes’ questions or to provide factual information to address their concerns. The discussions focused on general explanations and justifications. Some of the information provided was not entirely accurate or not entirely applicable to the specific facts of this case. In other instances, the members promised to obtain additional answers but never provided them.

103. In response to the complaints and questions about why Cpl Langridge’s body was left hanging, Maj Dandurand and MS McLaughlin explained it was the ME who owned the scene and was entitled to make such decisions.^{Footnote 4136} Maj Dandurand also pointed out CFNIS members approach scenes with impartiality and do not know the individual involved, so any delay in cutting down Cpl Langridge’s body could not have been the result of any feelings of disrespect for Cpl Langridge as an individual.^{Footnote 4137} While this was correct in the abstract, neither member knew who had in fact been responsible for making the decision about when to cut down Cpl Langridge’s body in this case or why the body was not cut down sooner.^{Footnote 4138} Maj Dandurand told the Fynes he would need to speak to the lead investigator to obtain an answer to these questions.^{Footnote 4139}

104. Maj Dandurand also provided this description of the ME’s authority at the scene:

Here's the thing -- the thing is, Sheila, the medical examiner owns the scene [...] It's actually not my scene until he attends, and until he says what's to happen. And actually [...] the military police follow his directions explicitly. I mean, he's going to -- if he says "do this", then we do it. If he says "seize that bottle.", "Grab that 26-ounce bottle.", "Grab that pill case.", then that's what we do.

[...]

And then once he's satisfied -- or she -- once they are satisfied that their direction has been followed, and they determine what occurs, then we have the scene, and we can process it for all the other criminal/forensic processing that we need to do.^{Footnote 4140}

105. This does not correspond to the actual events in this case. The investigators involved in the 2008 investigation did not follow the ME’s direction in determining what exhibits to seize or how to process the scene.^{Footnote 4141}

106. With respect to the suicide note, Maj Dandurand expressed regret that it took so long after the investigation was concluded to disclose the note, but insisted on the need to keep the note for a certain period after the death.^{Footnote 4142} Maj Dandurand’s explanations – which were generally interrupted and were never completed – focused on how CFNIS policies and practices had been changed as a result of this case.^{Footnote 4143} He told the Fynes there was at the time a policy dictating not to divulge such notes until it was determined the death was in fact a suicide, indicating: “you have to appreciate that at the time, when you’re dealing with a death, it’s viewed as suspicious.”^{Footnote 4144} He began to describe what would be done under the current practices, indicating the note would still not be provided until foul play was ruled out, which he said might not happen “until well after the funeral”, but certainly hinting it would be provided much sooner than in the Fynes’ case.^{Footnote 4145} Regarding the specific mention in Cpl Langridge’s suicide note of his wishes for his funeral, Maj Dandurand said:

The thing is, though, is this: What if -- what if it was foul play, and there was this left behind, and then you act on that?^{Footnote 4146}

107. Entirely absent from Maj Dandurand’s explanations was any account of the specific reasons why Cpl Langridge’s suicide note was not disclosed to the Fynes in this case. He did not tell them whether this was the result of an oversight or of a deliberate decision made at the time, and, if there was a decision, what it was based on. He also did not discuss whether foul play was in fact ruled out in this case – or could have been – before Cpl Langridge’s funeral.

108. With respect to the Fynes’ complaints and questions about why the CFNIS investigation took so long and was so comprehensive, Maj Dandurand provided general explanations about CFNIS caseload and the need to keep an open mind.^{Footnote 4147} He also indicated the CFNIS does not “put all our eggs in that one basket” by relying 100% on the coroner’s findings without independent investigation.^{Footnote 4148} Maj Dandurand did not provide any specifics about what was actually being investigated during the three-month investigation into Cpl Langridge’s death. He made no reference to the investigation into the suicide watch issue, which was the main issue pursued after the first few days of the investigation, and which was unrelated to confirming suicide as the manner of death.^{Footnote 4149}

109. Maj Dandurand did provide an example of a step that might need to be completed by the CFNIS prior to placing reliance on an ME’s suggestion that the death was suicide, referring to a potential examination of the outside of the building, presumably for the purpose of determining whether someone else could have been present when Cpl Langridge died.^{Footnote 4150} As it happens, this was in fact a step that never was undertaken in this case. The omission had been explicitly criticized in a Quality Assurance report about the investigation, which Maj Dandurand had received in June 2009.^{Footnote 4151} When this example was used during the meeting, the Fynes were not told this step had not been completed in their son’s case, nor that it was subsequently determined it should have been.

110. When Mr. Fynes questioned a reference in previous correspondence to the CFNIS holding “approximately 13 exhibits,” Maj Dandurand told the Fynes “our [SAMPIS] system won’t lie.”^{Footnote 4152} He then indicated MS McLaughlin had signed for all the exhibits that were still held.^{Footnote 4153} Both Maj Dandurand and MS McLaughlin assured the Fynes the remaining exhibits were police-related exhibits – like officer notes and videos – and not Cpl Langridge’s personal belongings.^{Footnote 4154} Mrs. Fynes specifically asked whether they had any of Cpl Langridge’s personal effects and MS McLaughlin answered: “No, we do not. The personal effects, those are all gone, they’re all returned.”^{Footnote 4155} This did not answer the Fynes’ concerns about the initial description of the number of exhibits seized. No further information was provided about the actual number of exhibits seized or the reason for not returning them to the Fynes immediately when the investigation was concluded.

111. It is also not clear the statements made about the exhibits retained were entirely accurate. When they had conducted their review of the exhibits before the meeting, Maj Dandurand and MS McLaughlin had discovered, in addition to the officer notes and videos, that the CFNIS were still holding four other items: a pill dispenser, an empty pill bottle, a bubble pill pack, and a copy of a medical form for Cpl Langridge seized from his Jeep.^{Footnote 4156} No explanation was provided as to why, when this topic was specifically discussed with the Fynes during the briefing, they were assured only “police exhibits” were retained and were not told about these other items. In their testimony, all Maj Dandurand and MS McLaughlin stated was they did not view these items as personal property.^{Footnote 4157} They explained some of the items contained prescription medication, which was the reason for not returning them to the family, but could provide no clear or consistent explanation about why the other items were not returned.^{Footnote 4158} Maj Dandurand testified he was thinking at the time CFNIS WR were holding all remaining items “in line with our evidence policy and, therefore, that we were right to have them.”^{Footnote 4159} He did not inquire – before or after the meeting – into the reasons why these items were still being held in the evidence room almost a year and a half after the conclusion of the investigation or into the reasons why they were not listed with other evidence disposed of following the conclusion of the investigation.^{Footnote 4160}

112. As for the concerns raised by the Fynes about the mention of disciplinary issues in the ME’s certificate, Maj Dandurand told the Fynes that, while there was an initial note in the investigative file indicating Cpl Langridge was suspected of being on defaulters, this point was cleared up during the investigation, and it was clarified that he was not on defaulters.^{Footnote 4161} No information was provided about what the CFNIS investigators had in fact told the ME and whether their comments were the source of the reference in the certificate.

113. About the redactions made to the investigation report, Maj Dandurand and MS McLaughlin provided general explanations about the process – including a statement that police notes are not generally disclosed, which turned out to be inaccurate – but could provide no information about the specific reasons for the redactions made to the report.^{Footnote 4162} Their overall message was that the CFNIS was not responsible for making decisions about the redactions and there was nothing they could do about this issue.^{Footnote 4163} This explanation did not reflect the actual process followed in this case for redacting the 2008 investigation report.^{Footnote 4164}

Follow Up

114. In the first paragraph of the notes Maj Dandurand made about the briefing, he wrote: “the purpose of the interview was to provide them a briefing [...] and to ensure their questions were either answered or taken down for providing them answers at a later date.”^{Footnote 4165} During the briefing, Maj Dandurand repeatedly assured the Fynes he would be providing them with answers to all of their questions and concerns.^{Footnote 4166} He specifically stated they should have full satisfaction that all queries related to CFNIS responsibilities were either answered or noted down to be answered later.^{Footnote 4167} He also made specific commitments to obtain answers to particular questions. For example, he indicated he would be speaking to his CO “on Monday morning” to discuss the Fynes’ concerns about the Concluding Remarks.^{Footnote 4168} He also promised he would speak to MCpl Ritco to get an answer to the Fynes about why the body was left hanging for so long.^{Footnote 4169}

115. Two days after the briefing, Maj Dandurand wrote to the CFNIS PAO.^{Footnote 4170} He provided an update about the meeting and indicated:

We have many questions to answer and have created a list of them from the interview tape itself (I taped it so nothing was missed or omitted from our end). I plan to now answer [these] questions; however, I wish to send my responses to the CO and yourself for input. I’ll be in touch tomorrow.^{Footnote 4171}

116. On the same day, MS McLaughlin prepared an e-mail containing a list of questions the Fynes posed during the briefing.^{Footnote 4172} In testimony, Maj Dandurand explained he had asked MS McLaughlin to prepare this list in order to ensure they would have “quick references” to the Fynes’ concerns.^{Footnote 4173} MS McLaughlin explained the e-mail was an attempt to list and separate the issues, and was prepared on the basis of his recollection of the meeting and his review of the audio recording for the portion of the meeting that was recorded.^{Footnote 4174}

117. In his e-mail, MS McLaughlin noted the questions listed were those concerning the CFNIS and its investigation.^{Footnote 4175} He added, the Fynes also made comments about the BOI process, but these were not listed as the BOI report had not yet been released.^{Footnote 4176} The following fifteen items were listed:

Why was the suicide note not disclosed until 14 months after the suicide
Why was Stewart [sic] left hanging for 4 hours before he was cut down
Someone was surfing the internet from Stewart’s [sic] BB account just after his death. How is that possible
What is the role of the CFNIS vice the BOI
Why did an investigation into an “obvious suicide” take so long
Why was the investigation so comprehensive
MCpl Ritco stated in his concluding remarks that Stewart [sic] was addicted to drugs and alcohol. This should not be since MCpl Ritco is not qualified to make this assessment (either change the concluding remark or provide an apology)
MCpl Ritco concluded that the Unit tried to provide structure and support for Stewart [sic]. Further, the report indicates Stewart [sic] was residing in defaulters barrack. This indicates that Stewart had disciplinary issues. Why does the investigation reflect Stewart [sic] as having been a disciplinary problem [versus] having suicidal tendencies and being on suicide watch
MCpl Ritco took details and photographs of the condition of the jeep. It appears the person(s) responsible for the jeep allowed for it to incur damages during the time they were in possession of it. Why are the photos not disclosed to the family.
several people were interviewed and provided information that reflects poorly on Stewart [sic]. Why was no one interviewed that would provide information speaking to Stewart [sic] bright Military Career and accomplishments.
Why did MCpl Ritco comment in his report that Stewart’s [sic] room was in disarray, with pornographic posters. Further, why have the parents not received his pornographic posters
Why did it take so long for the family to be provided with Stewart’s [sic] belongings. They incurred a cost to maintain a storage container to place all the items in, however the items were not released for three months after
What was the location of a chair and stool held by the unit. The unit was itemized and was to be sent to the family. The items were not provided to the family until they threatened a lawsuit and police involvement.
Why has the Fynes family not been given the memorial cross in memory of Stewart’s [sic] death
A member of the BOI had requested a meeting with the Fynes’ lawyer [versus] speaking with the Fynes’ directly. This cost was incurred on the Fynes’. Why are they responsible for paying for this meeting if the member requested to speak with their lawyer [versus] speaking with the Fynes’ personally.^{Footnote 4177} [Emphasis in original]

118. Despite Maj Dandurand’s expressed intentions and his early plans to provide answers to all of the Fynes’ questions, follow up activity was limited.

119. Maj Dandurand did follow up on the issues raised about the Concluding Remarks. He spoke to the CFNIS CO and suggested the Remarks should reflect the cause of death, “be kept short and be factually representative of what had happened and not editorialize.”^{Footnote 4178} On March 2, 2010, the day before a second meeting was scheduled with the Fynes,^{Footnote 4179} Maj Dandurand entered a note in the 2008 investigative file indicating LCol Sansterre had provided authorization to amend the Concluding Remarks for the investigation.^{Footnote 4180} In testimony, he explained this was likely done at that time because he was catching up on his administrative tasks and ensuring everything was done prior to the second meeting, but did not necessarily reflect the time when he had the discussion with LCol Sansterre about this issue.^{Footnote 4181} Indeed, MS McLaughlin testified Maj Dandurand had told him prior to the December 2009 break that the Concluding Remarks would be rewritten to address Mr. Fynes’ concerns.^{Footnote 4182}

120. The new Concluding Remarks, also dated March 2, 2010 and authored by Maj Dandurand, simply stated it was determined, following examination of the scene and subsequent interviews, and further supported by the ME’s findings, there were no signs of foul play in the death of Cpl Langridge and the death was deemed to be a suicide.^{Footnote 4183} The accompanying GO file entry described the two issues identified as problematic by the Fynes, stated the Remarks would be rewritten and indicated the new version would form the official Concluding Remarks for the report.^{Footnote 4184} During his March 3 meeting with the Fynes, Maj Dandurand presented the new Remarks to them.^{Footnote 4185} He explained the original Remarks would remain on the file, but this new version would now be the official Concluding Remarks.^{Footnote 4186} The Fynes indicated they did not take issue with this manner of proceeding,^{Footnote 4187} and thanked Maj Dandurand several times for changing the Remarks.^{Footnote 4188}

121. Follow up was also done with respect to the CFNIS pictures of Cpl Langridge’s Jeep. During his second meeting with the Fynes, Maj Dandurand provided them with the pictures taken shortly after the death, which could be used to demonstrate the Jeep was not in the same condition when the Regiment subsequently returned it.^{Footnote 4189} The CFNIS members also made inquiries in an attempt to follow up on the issues raised about the BlackBerry usage.^{Footnote 4190}

122. Further, Maj Dandurand brought some of the Fynes’ concerns to the attention of the LFWA during a meeting held to address issues viewed as peripheral to the CFNIS investigation.^{Footnote 4191} After the meeting with the Fynes, Maj Dandurand had written in his notebook that the concerns they raised would be forwarded to those responsible for the BOI, as they fell outside the CFNIS mandate.^{Footnote 4192} During his subsequent meeting with LFWA, he communicated several of the Fynes’ concerns, including: issues about the condition of the Jeep and the return of Cpl Langridge’s property by the Regiment; the cost they incurred to have Cpl Langridge’s death certificate corrected; the cost they incurred for legal fees in connection with the meeting held with the BOI’s legal advisor; issues surrounding the awarding of the Memorial Cross to the Fynes and the recognition of Cpl Langridge at the Western Area Memorial; as well as the issues raised by the Fynes about certain comments they overheard during the BOI process.^{Footnote 4193} In testimony, Maj Dandurand explained he brought the matters he “deemed not criminally relevant” to the attention of the LFWA because he believed they would be in a position to rectify them.^{Footnote 4194} All of these issues were unrelated to the CFNIS’ own prior investigation.

123. The concerns directly related to the 2008 investigation did not receive the same (or any) follow up. Aside from the changes made to the Concluding Remarks, there is no evidence any action was taken to address them.

124. When asked about how follow up was conducted to address the issues raised by the Fynes, MS McLaughlin explained his own focus was on investigating the PNOK allegations.^{Footnote 4195} He described the other issues raised about the 2008 investigation as “administrative” and indicated Maj Dandurand was in charge of following up on all such issues.^{Footnote 4196} He explained:

[T]hose issues would be dealt with because they're not investigative issues, they're administrative issues. They want action and answers taken on some of these because they're relative to the investigation conducted by Master Corporal Ritco.

[...]

So, those are put to the OC so that he can liaise with those higher authorities either whether it's within our own chain of command or outside of that chain of command to identify how we're going to address these issues. So, that's with him.^{Footnote 4197}

125. MS McLaughlin was not aware of how Maj Dandurand planned to address these issues.^{Footnote 4198} He was not involved in any follow up on these matters beyond forwarding the list of questions.^{Footnote 4199} He was not aware whether the Fynes ultimately received any answers, either before he left for deployment in January 2010 or at any time after.^{Footnote 4200}

126. In testimony, Maj Dandurand confirmed no written response was prepared to the questions listed in MS McLaughlin’s email.^{Footnote 4201} LCol Sansterre did not recall receiving a list of the Fynes’ questions or of the proposed answers^{Footnote 4202}

127. Of the 15 questions listed in MS McLaughlin’s e-mail, eight received some form of follow up, or at least were discussed by Maj Dandurand with LFWA. The remaining seven questions, as well as additional questions not noted in MS McLaughlin’s list but raised by the Fynes during the meeting – all of which were directly related to the 2008 CFNIS investigation – were not addressed. As a result, aside from the limited discussions that occurred during the briefing itself, questions about the following issues remained unanswered:

the suicide note;
the treatment of the body;
the length of the investigation;
the comprehensiveness of the investigation;
the distinction between the role of the CFNIS and the BOI;
the notation in the report indicating that Cpl Langridge may have been on defaulters and not indicating he was on suicide watch;
the reasons for interviewing persons who provided information reflecting poorly on Cpl Langridge while not interviewing persons who could provide positive information;
the reasons why the entirety of the property described as being in Cpl Langridge’s room was never returned to the Fynes;
the mention of disciplinary issues in the ME’s certificate; and
the redactions to the 2008 investigation report.

128. The Fynes were still asking many of those same questions over a year later when Col Gerard Blais was appointed as their contact for all CF-related matters.^{Footnote 4203}

129. In particular, Maj Dandurand did not get back to the Fynes after the briefing as promised with an answer about the reasons for leaving Cpl Langridge’s body hanging during the processing of the scene or with an explanation as to why this length of time was required prior to removing it, nor did he ask MCpl Ritco those questions. In testimony, Maj Dandurand indicated he could not recall whether he provided the Fynes with an answer about this issue.^{Footnote 4204} He did have a discussion with MCpl Ritco after the meeting, but he did not recall asking him a specific question or obtaining a specific explanation about the time it took to cut down Cpl Langridge’s body.^{Footnote 4205} Instead, he indicated he asked MCpl Ritco to provide a description of the sequence of events that unfolded.^{Footnote 4206} During his next meeting with the Fynes in March 2010, the issue was discussed again and Maj Dandurand indicated he could not provide insight about the reasoning of the MP first responders for not cutting down the body sooner, as he had not asked the question.^{Footnote 4207} He did not then provide an explanation about the reasons why the body was not cut down sooner after the CFNIS investigators arrived. The Fynes were still asking the question in January 2011.^{Footnote 4208}

130. In testimony, Maj Dandurand admitted “the follow-up was sparse and was not up to the standard of follow-up that we would come to expect from an NIS detachment.”^{Footnote 4209} He provided no additional information to explain the failure to follow through with his initial plan to prepare answers to the Fynes’ questions. He was asked whether the questions listed in MS McLaughlin’s e-mail were addressed during subsequent meetings with the Fynes. He indicated he believed some of them were discussed, but noted he would have to go through the list in more detail to confirm whether he answered each of the questions specifically.^{Footnote 4210} On the whole, he testified his general impression was that the issues listed had “for the most part” been addressed during the subsequent meetings with the Fynes.^{Footnote 4211} Having reviewed the transcripts for those two meetings, it is apparent to the Commission, while many of the topics were brought up again by the Fynes – both to seek answers and express their dissatisfaction – the discussions continued to focus on general explanations or justifications.^{Footnote 4212} No additional specific, factual answers were provided to the questions listed.

Complaints about the Conduct of the 2008 Investigation

131. The National Defence Act establishes the process that must be followed when complaints about the conduct of Military Police members are made. The Act provides that such complaints may be made orally or in writing to a number of designated persons, as well as to “any member of the military police.”^{Footnote 4213} The member of the MP who receives the complaint has a number of obligations, including, if the complaint is not in writing, to put it in writing, and to “ensure that notice of complaint is sent as soon as practicable” to the CFPM and the MPCC Chair.^{Footnote 4214} Under the Act, the CFPM is then responsible for dealing with the complaint (in practice these duties are delegated to the Deputy Commander of the CF MP Gp).^{Footnote 4215} The CFPM has authority to determine whether the complaint can be resolved informally and to attempt such resolution if considered appropriate.^{Footnote 4216} The CFPM also has authority to determine whether an investigation of the complaint is required.^{Footnote 4217} Where an investigation does take place, the CFPM Professional Standards personnel will conduct it, and the CFPM will then determine what actions to take to dispose of the complaint.^{Footnote 4218} If a complainant is dissatisfied with the results of the CFPM investigation – or with the CFPM’s decision not to investigate – the complainant can refer the complaint to the MPCC for review.^{Footnote 4219} In certain cases – in particular, where the MPCC Chair considers it advisable in the public interest – the MPCC, rather than the CFPM, will be in charge of conducting the initial investigation into the complaint.^{Footnote 4220}

132. The policy guidance available to MP members at the time of the briefing to the Fynes emphasized the importance of advising complainants about the complaints process. Chapter 13 of the MPPTP stated that members of the public often contact the MP to seek explanations about specific incidents or policies, seeking to obtain information rather than to lodge a complaint.^{Footnote 4221} In such cases, the policy encouraged MP members to answer the queries and provide assistance in preparing a complaint form if the person still wished to submit a complaint after receiving the information. The policy stipulated:

The complainant shall be made aware that if his/her queries are not satisfactorily answered, the complaint shall be documented by either the complainant or the Military Police member on the Military Police Public Complaint form and forwarded to the Deputy Provost Marshal Professional Standards for action.^{Footnote 4222} [Emphasis added]

133. The policy also reiterated the statutory requirement to transmit complaints to the CFPM, indicating “if a member of the Military Police receives the complaint, he/she shall forward the complaint to the CFPM.”^{Footnote 4223}

134. The complaints made by the Fynes about the conduct of the 2008 investigation were not forwarded to the CFPM or the MPCC. The Fynes were not notified, during or after the briefing, about the existence of a complaints process overseen by a civilian agency.^{Footnote 4224} Mr. Fynes testified he learned of the existence of such an agency over a year later through Internet research.^{Footnote 4225} It was as a result of acquiring this knowledge that the Fynes filed their initial complaint with this Commission, which includes many of the allegations they had already made during the briefing.^{Footnote 4226}

135. In testimony, Maj Dandurand recognized many of the concerns expressed by the Fynes during the briefing were complaints about an investigation conducted by the CFNIS.^{Footnote 4227} However, he testified he did not believe the complaints needed to be referred to the relevant authorities or processed as complaints.^{Footnote 4228} He stated he was dealing with a family who were “full of questions” and may have had a “lack of understanding of contemporary investigations” and of the manner in which the CFNIS conducted investigations.^{Footnote 4229} As a result, he testified he did not believe their comments constituted formal complaints, but rather thought they “required discussion.”^{Footnote 4230} He indicated he was “making an assessment of the situation and trying to conduct a briefing with the family.”^{Footnote 4231} He explained:

I can say that my goal in that first meeting was to be able to have a good relationship with them, to be able to have them walk away with questions answered and to feel as though their interaction was what they would come to expect from a major crimes unit, not at first sign of their dissatisfaction with something to turn around and say, well, it's all well and good that you've come to me but here's another phone number to call to raise your concerns with, because it was very evident at that time that they were not satisfied with their interactions with the Canadian Forces, at the same time they were frustrated and my goal wasn't to do that, it was -- as well, one of the trains of thought that I had was it became evident very early on through our first interaction that they were very cognizant of -- my interpretation was, they were very cognizant of various bodies that were out there and avenues were open to them and although I did not ask them if they were cognizant of the Military Police Complaints Commission, I had no doubt that they would have been.

That was an assumption on my part.^{Footnote 4232}

136. Maj Dandurand also testified that in order for complaints to be reported, it was his experience CFNIS members would normally verify whether the individual intended to complain formally: “We pose the question: Is this what you’re complaining about?”^{Footnote 4233} In this case, he did not pose the question because, as he explained it, he did not think he was dealing with possible complaints.^{Footnote 4234}

137. LCol Sansterre, for his part, was not aware of the details of all of the issues raised during the meeting with the Fynes. He did receive a verbal briefing from Maj Dandurand after the meeting, and he was advised of some of the Fynes’ questions, particularly about the Concluding Remarks, the suicide note, the treatment of Cpl Langridge’s body, as well as the intrusiveness and length of the 2008 investigation.^{Footnote 4235} He could not recall whether any consideration was given to treating these matters as complaints against the CFNIS and referring them to the appropriate authorities.^{Footnote 4236} He believed Maj Dandurand would be providing answers to the questions raised by the Fynes.^{Footnote 4237} LCol Sansterre had a clear understanding of the MP policies and obligations where potential complaints were received, but explained he did not perceive the issues Maj Dandurand reported were being raised by the Fynes as complaints by the family, but rather as requests for information.^{Footnote 4238} He stated: “they were issues that [Maj] Dandurand was going to address with them -- get answers to and address them with them.”^{Footnote 4239} He could not confirm whether Maj Dandurand in fact addressed the issues to the satisfaction of the Fynes.^{Footnote 4240}

138. From its review of the briefing and limited subsequent follow up, it is clear to this Commission the Fynes’ concerns were not addressed by the CFNIS members. In many cases, no information addressing the concerns was provided. In other cases, explanations were provided, but the Fynes indicated in no uncertain terms during the briefing itself and in subsequent meetings that they did not accept them.

139. The Fynes openly disputed the explanations provided about the ME being responsible for deciding when to cut down Cpl Langridge’s body.^{Footnote 4241} In their March 3, 2010 meeting with Maj Dandurand, they indicated Mr. Fynes had made inquiries with the Alberta Solicitor General’s Office and believed, as a result, that it was the CFNIS who had jurisdiction.^{Footnote 4242} They reiterated their strong view it was disrespectful to leave Cpl Langridge’s body hanging for so long.^{Footnote 4243} During the initial briefing, Mr. Fynes had also openly disputed Maj Dandurand’s claim that the CFNIS approach scenes with impartiality, indicating instead that the CFNIS’ approach to the scene in this case was tainted from the beginning by a belief that Cpl Langridge was a defaulter.^{Footnote 4244} Not surprisingly, Maj Dandurand testified he did not form the impression the Fynes were satisfied with the answers to their questions about the timing for cutting down Cpl Langridge’s body.^{Footnote 4245}

140. Mrs. Fynes also made it quite clear during the briefing she did not accept the explanations provided about why the CFNIS investigation took so long and was so comprehensive. She indicated:

So you're telling me that [you see] it from a premise of Stuart may have been murdered, or Stuart may have committed suicide, and that's what you were investigating for months?

I find that a real stretch. I'm sorry, I do.^{Footnote 4246} [Emphasis added]

141. Throughout the meeting, she reiterated forcefully she did not believe anyone in the CFNIS thought Cpl Langridge had been murdered, indicating “I just don’t buy it.”^{Footnote 4247} She made it clear she did not see why such a big investigation was necessary.^{Footnote 4248} It was eventually suggested to move on to another topic, with Mr. Fynes stating: “we’ll just agree to disagree.”^{Footnote 4249} Later, during the interview, Mrs. Fynes added the following, which could leave little doubt about her views:

But, you know what? When somebody says to me, "Well, you know, we had to do a huge investigation to make sure that he did commit suicide.", that I find offensive. Like I said, everybody on the base new [sic] Stuart committed suicide. Everybody. You didn't need to do this--^{Footnote 4250} [Emphasis added]

142. In testimony, Maj Dandurand acknowledged he did not believe this issue was or could be resolved through discussions. He explained:

And we would go around and around and around discussing this only to agree to disagree.

[...]

But at the end of the day it wasn't something that I saw was going to be easily resolved.^{Footnote 4251}

143. With respect to the suicide note, the Fynes testified they did not view Maj Dandurand’s expressions of regret as an apology for what happened, let alone a sufficient or adequate apology.^{Footnote 4252} During the briefing itself, Mrs. Fynes interrupted Maj Dandurand’s explanation about the policy changes, stating: “But what does it do for us? How does it impact how we feel?”^{Footnote 4253} She then stated plainly she did not accept the explanations provided about why the note was not disclosed immediately:

Okay, I'm only going to say this once, and then I'm pretty much done with this bit about the note, because I'm not going to be talked into thinking anything other than what I already think: Okay, my son had a last communication with me. I do not believe for one second, nor will I ever, that anybody on that base thought that there was anything other than a suicide in that room that day. And I don't believe that anybody, even for a heartbeat, thought that. And I think that to expect us to believe that is -- I think it's almost insulting our intelligence.

[...]

I think that -- I think it was cruel, I think it was really cruel. I think that at the very most, all you needed was a copy of that note [...]^{Footnote 4254} [Emphasis added]

144. Maj Dandurand was aware his explanations did not satisfy the Fynes’ concerns. In testimony, he confirmed “there was a definite air of displeasure throughout the duration of that discussion.”^{Footnote 4255} He also discussed this with the Fynes’ AO, Maj Parkinson, during a March 2010 interview. He then indicated the Fynes had been told many times the note could have had no bearing on funeral dealings because the determination of foul play had not yet been made at that time, but that they still continued to bring up this issue and “[…] insinuat[e], that they should have been told right away –”.^{Footnote 4256}

145. Mr. Fynes also remained steadfast in his complaint about the CFNIS’ initial approach to the case and the impact he believed it had on the ME’s certificate, despite Maj Dandurand’s explanations.^{Footnote 4257}

146. With respect to the Concluding Remarks, Mr. Fynes had expressed his concerns in strong terms during the meeting. He had alleged the remarks were “part and parcel of the demeaning of [Cpl Langridge]” and aimed at blaming him for his condition and his death while simultaneously exonerating the Army.^{Footnote 4258} He had complained not only about the findings’ continued presence in the report, but about the fact they were made in the first place. He had directly asked for an apology: “[...] I would like to see that corrected, and I would like an apology for that. To err is human, to cover up is inexcusable.”^{Footnote 4259} The action taken by the CFNIS in response to these complaints was to remove the mentions of addiction, mental health issues and assistance provided by the Unit from the Concluding Remarks.^{Footnote 4260} However, there was no acknowledgement that the initial comments found in the Remarks were substantively wrong, and no apology was provided for having initially included them in the report. Not surprisingly, this issue continued to form part of the Fynes’ complaints.^{Footnote 4261} In his testimony before this Commission, Mr. Fynes stated that, although the findings were “officially removed” from the report, “they spoke to a mind-set that was exculpatory for the military and passing blame to the victim.”^{Footnote 4262} Considering the manner in which the Fynes had presented their concerns during the briefing, it was to be expected that simply changing the Remarks without admitting any error would not be sufficient to address this complaint.

147. In light of this, it is surprising the CFNIS members continued to view the Fynes’ complaints as requests for information or points that could be addressed or resolved through discussion. It is difficult to understand why they did not report the complaints once it became clear that the Fynes did not accept the explanations provided, that no further action would be taken to provide additional information, and that the Fynes continued to reiterate the concerns. That being said, on the basis of the testimony heard, the Commission concludes there was no deliberate attempt to frustrate the complaints process in this case. It rather appears this aspect was overlooked in the midst of an attempt to address the multitude issues raised in the briefing – some related to new complaints for investigation by the CFNIS, others relating to the conduct of CF members unconnected to the CFNIS, and yet others directly related to the previous CFNIS investigation. It also appears both Maj Dandurand and LCol Sansterre held an honest (though misguided) belief that discussion of the issues would be sufficient to resolve them. LCol Sansterre’s knowledge of all matters raised was also not as complete or detailed.

148. Nevertheless, having Maj Dandurand attempt to address the Fynes’ concerns directly was problematic. MS McLaughlin, when he was asked why he did not investigate the Fynes’ concerns about the 2008 investigation, indicated:

Let's look at this from the transparency portion first. I've worked with Sergeant Ritco now, Sergeant Ritco at the time I spoke with Ritco for the entire time that I have been at the NIS he has been there as well. So, (a), there is a conflict of interest with me investigating one of the investigators I work with, that just makes no sense, I can't do it.

[...]

So, I focused on the actual allegations as brought forward with regards to the new negative performance military duty allegations. So, those wouldn't take me into looking into whether sergeant Ritco did a good job, bad job, a half-way job, anything like that, it wouldn't take me there, so -- and that makes sense.^{Footnote 4263} [Emphasis added]

149. While MS McLaughlin believed Maj Dandurand, as the OC for the Detachment, could investigate and address those issues,^{Footnote 4264} the fact is the Fynes’ complaints related to the conduct of CFNIS members Maj Dandurand also knew personally. Some of the allegations were quite serious, putting in question the integrity and motives of the investigators.

150. Maj Dandurand had already expressed strong views about the integrity of the members involved in the investigation. In an email to the CFNIS PAO dated June 18, 2009, he had written:

In a nutshell, the investigator and the case management team did everything in good faith and at no point was the family’s well being pushed aside. [...] Mr. Pugliese’s persistence in asking about disciplinary measures needs to be curbed because it would be completely inappropriate for any actions to be taken against anyone in this case. Believe me, if there was an appropriate disciplinary action to be recommended and taken, I would be the first to say so.^{Footnote 4265}

151. In testimony, Maj Dandurand discussed the basis for the beliefs expressed in this correspondence and reiterated his views:

The basis would be that the investigators that I had the pleasure of working with always conducted themselves in good faith and had no ulterior motives in anything that they would ever do.^{Footnote 4266}

152. He also shared some of these views with the Fynes during a subsequent meeting with them in March 2010, indicating:

For [MCpl Ritco], he tackled everything with vigour, and I can tell you that, of all my investigators, he is one of the most un-- well, he is one of the most proficient that I have.^{Footnote 4267}

153. There is a reason for having a separate complaints process. The investigation of complaints by a separate Professional Standards section supervised by an independent agency provides a level of confidence for complainants that their complaints will be examined and resolved objectively and independently. Given his own working relationship with the individuals complained about, Maj Dandurand’s involvement could not provide these same assurances, regardless of the sincerity or good faith of his efforts.

154. Some of the events about which the Fynes were complaining took place after Maj Dandurand assumed command of the Detachment and involved matters that may have been under his responsibility. Complaints about the failure to return exhibits in a timely manner after the investigation and the failure to disclose the suicide note for 14 months related to events which occurred or continued after July 2008, when Maj Dandurand took command of the Detachment.^{Footnote 4268} As the OC, his responsibilities included conducting semi-annual inspections of evidentiary holdings,^{Footnote 4269} which may have affected the return of both the suicide note and other exhibits.^{Footnote 4270} As a result, addressing the Fynes’ complaints in these respects may have put in question – directly or indirectly – Maj Dandurand’s own conduct since assuming command of the Detachment.

155. For all these reasons, it is of concern that when the Fynes presented their complaints, Maj Dandurand took it upon himself to make his own attempt to resolve the issues. It is also of significant concern that during his testimony before this Commission, Maj Dandurand referred to his own assessment of the merits of the Fynes’ complaints to explain why he did not report them. He indicated:

I think that if I had at the time believed that there was a marked departure from normal practices, then I would have referred that to another body in order to investigate or I would have recommend[sic] we investigate it ourselves.^{Footnote 4271}

156. By contrast, LCol Sansterre testified that a perception by an MP member that a complaint is not well founded would not constitute a legitimate basis for failing to refer the complaint to the appropriate authorities.^{Footnote 4272} Indeed, both the National Defence Act and the MP policy applicable at the time clearly stipulated the decision to classify a complaint as frivolous, vexatious and/or made in bad faith – and therefore not requiring further investigation or resolution – belongs to the CFPM and not the MP member receiving the complaint.^{Footnote 4273} Further, Maj Dandurand’s factual knowledge about the issues raised by the Fynes was not sufficient to allow him to assess whether there was a “marked departure from normal practices” in this case.

157. The Fynes’ complaints should have been referred for investigation. At the very least, the Fynes should have been advised of the avenues available to them through the complaints process.

Public Relations and Family Briefings

158. In a case like this one, it was inevitable there would be concern at the CFNIS about the potential for negative publicity. Throughout all of the events in this case, media attention always resulted in a flurry of activity at the CFNIS to provide responses and put new measures in place, both in terms of internal procedures and contact with the Fynes.^{Footnote 4274} Those concerns may not have been entirely absent from LCol Sansterre’s mind when he directed Maj Dandurand to provide the briefing to the Fynes, or from Maj Dandurand’s mind when he provided it.

159. The late disclosure of the suicide note had led to media attention in June 2009. Both Maj Dandurand and LCol Sansterre had been involved in preparing Media Response Lines about that issue.^{Footnote 4275} The initial contact with the Fynes and the initial offer to provide the briefing were part of the efforts to mend relations in light of what had happened. On the Monday morning immediately following the briefing, Maj Dandurand wrote to the CFNIS Public Affairs Officer, asking her to “please tell me I’m NOT in the papers this morning, after the family brief I gave Saturday.”^{Footnote 4276} He then described the briefing, indicating the discussion lasted approximately four and a half hours, the family presented their points very well and did not yell at him. He concluded: “from that perspective I believe it met the purpose of the meeting.”^{Footnote 4277} He also indicated he was planning to provide his draft responses to the Fynes’ questions to both the CFNIS CO and the PAO for input.^{Footnote 4278} LCol Sansterre had also sought input from the PAO about his earlier communications with the Fynes.^{Footnote 4279} In both cases, the PAO testified it was not usual for her to be asked for advice about communications with families.^{Footnote 4280} She believed her input was sought about wording or “the way that things are said” because of the earlier media interest about the case.^{Footnote 4281}

160. The CFNIS members involved cannot be faulted in any way for recognizing the obvious public relations reality. It was certainly not inappropriate for them to have a desire to preserve the CFNIS’ image and to attempt to rehabilitate it in the Fynes’ eyes, both because of their pride in the institution they served and because of their awareness of the potential for public attention or negative publicity. However, at times, because this matter was seen as having the potential to attract media attention and cause embarrassment, the concern to preserve the CFNIS’ image appears to have become exaggerated. Throughout the events that occurred before, during and after the briefing, it may be observed too much emphasis was sometimes placed on this aspect, at the expense of other important requirements. The focus was often on defending the CFNIS’ actions instead of providing substantive answers.

161. In the preparation for the briefing, Maj Dandurand reviewed the redacted portions of the file carefully for the purpose of assuring the Fynes nothing was redacted that should not be. MS McLaughlin was asked to conduct a detailed review of the remaining exhibits for the purpose of assuring the Fynes no exhibits that should have been returned to them were still being held. Meanwhile, no attempt was made to find out the reasons why their son’s suicide note was not disclosed to the Fynes for 14 months, and no answer was provided to them about this.

162. In the follow up done after the briefing, the only step taken to address the Fynes’ concerns about the 2008 CFNIS investigation was carried out in a manner that specifically avoided recognizing any substantive error. In the note added to the GO file to explain the change to the Concluding Remarks, the passages to be removed were described and it was stated: “while these may have been uncovered during the process of the investigation, these facts do not speak to the primary focus of the investigation as identified in the investigation plan.”^{Footnote 4282} Both in conversation with the Fynes and in testimony before this Commission, Maj Dandurand explained the removal of the comments by reference to their relevance, rather than their substantive correctness.^{Footnote 4283}

163. This reasoning for changing the Remarks did not entail any examination of the underlying complaints made by the Fynes that the comments themselves were inaccurate and possibly biased. Further, the notion that the comments were not relevant to the investigation or did not speak to its primary focus is perplexing. The comments were about addiction, mental health and assistance provided by the Unit. All of these aspects were directly related to what was, in fact, the focus of the investigation, both as conducted and as represented in the Investigation Plan.^{Footnote 4284} In their final submissions, counsel for the subjects of the complaint defended the original Concluding Remarks and explained the reasons for changing them as follows:

[MCpl] Ritco wrote in his concluding remarks that Cpl Langridge “suffered from alcohol and cocaine addiction which caused him to have mental health issues”. These statements were based on the evidence he had before him from the medical records and the explanation of the records he received from [Capt] Hannah...

[MCpl] Ritco put these details in his report to provide those reading the report an understanding of the information he had uncovered related to what happened to Cpl Langridge. It was not to discredit Cpl Langridge in any way. Out of compassion for the Fynes, the concluding remarks were later changed. [...]^{Footnote 4285} [Emphasis added]

164. This attempt to satisfy or appease the Fynes without admitting any error was in line with the overall approach to the briefing.

165. During the briefing itself, references to general practices and procedures rather than specific facts about this case were used to defend past CFNIS conduct. This was not surprising, since the two members who provided the briefing were not involved in the investigation and had not received a detailed briefing from those who were. In many cases, they would not have been aware some of their general statements did not accurately represent the way things actually unfolded during the investigation. Involving members with more knowledge about the case may have made the discussions more substantive and meaningful, but a decision was made not to involve them.

166. At the time of the briefing to the Fynes, the CFNIS had no specific policies about family briefings for sudden death investigations. As explained by Maj Dandurand, the practice was to have senior ranking members, rather than the investigators involved, provide such briefings. The CFNIS SOP created subsequently specifically stipulates the contact with and briefings to the family must be done in person by a member of the rank of Detachment WO or above, as appointed by the Detachment OC.^{Footnote 4286} It is not known what the reasons are for this policy and the similar practice followed previously.

167. Sgt Scott Shannon, who participated in drafting the SOP, testified his understanding of the reasons for not involving the investigators in the initial briefing to the family is to ensure they are not distracted from the task at hand.^{Footnote 4287} He provided no explanation about the reasons for not involving them in the final briefing, other than to indicate this briefing should be done by the same members who conducted the initial briefing because “a bond has been established.”^{Footnote 4288}

168. During a CFNIS Detachment Commanders’ conference held in May 2011, the OC for the Atlantic Region Detachment, who had been put in charge of elaborating the new SOP on Sudden Death investigations, provided a presentation about the family briefings.^{Footnote 4289} He noted shifting responsibility for dealing with the family to the chain of command relieved the investigators from distractions in their investigation.^{Footnote 4290} With respect to the final briefing, he stated it was for the Chain of Command to decide who would provide the briefing.^{Footnote 4291} He indicated the lead investigator could give the briefing, but cautioned they should “stick to [the] script” very closely.^{Footnote 4292} He also noted “if family starts interacting, Chain of Command intervenes and deals with family.”^{Footnote 4293}

169. Whatever the reasons might be for having higher ranking members provide the family briefings, those members are unlikely to have detailed factual knowledge about the case or to be able to provide complete and accurate answers to the family’s questions. The Commission sees no reason for not involving the lead investigator in final family briefings in all cases where it is possible. Even where the investigator has moved on to a different posting or secondment, efforts should be made to involve him or her in the briefing.

170. To the extent the CFNIS’ approach to the Fynes briefing was motivated in part by a concern to preserve the CFNIS’ image, it can only be observed that it was entirely counterproductive. The Fynes have complained to this Commission that the CFNIS failed to provide adequate and timely information to them and participated in broader CF efforts to withhold information from them.^{Footnote 4294} They have also alleged CFNIS members provided inaccurate rationales to explain or justify the actions taken by CFNIS, referring specifically to explanations provided about the suicide note, the treatment of Cpl Langridge’s body, the information contained in the ME’s certificate and the return of the exhibits.^{Footnote 4295} While some of the specific allegations related to these complaints did not relate solely – or in some cases at all – to discussions that occurred during the November 2009 briefing, many of the discussions that did occur contributed to setting the stage for the Fynes’ perception – in some cases justified – that they were not being provided complete or accurate information, that their questions were not being answered, and that rationales they did not accept were being offered to justify or explain CFNIS behavior.

171. The Commission recognizes the Fynes’ own exasperation had crystallized significantly by the time this briefing was held, in part because of the CFNIS’ failure to communicate with them earlier, and in part because of their other issues with the CF. As such, satisfying their concerns entirely or changing their views would have been difficult, perhaps even impossible. Nevertheless, it was not inevitable the briefing would completely fail to address their concerns. At a minimum, it could have been approached in a way that would have avoided creating new concerns.

172. Even bearing in mind all the difficulties for the CFNIS, the approach adopted to deal with the Fynes’ concerns is difficult to understand. In this case, putting the Fynes in a room with two CFNIS members who had no detailed knowledge about their son’s case, who provided broad justifications instead of answering their questions, and who promised answers that never came, was just about the worst possible course of action. It could only exacerbate an already tense situation. Regrettably, the responses provided to the Fynes’ complaints about past CFNIS conduct often only served to illustrate the importance of having a separate process to investigate complaints.

4.5.4 2009/2010 Investigations – Interviews, Updates and Briefing

173. During the November 2009 briefing, in addition to the issues raised about the 2008 investigation, the Fynes had also discussed their concerns about the designation of Ms. A as Cpl Langridge’s PNOK, with authority to plan his funeral.^{Footnote 4296} An investigator from the DND/CF Ombudsman’s office had also brought this issue to the attention of the CFNIS.^{Footnote 4297}

174. A few weeks after the November briefing, on February 12, 2010, Maj Dandurand contacted Mr. Fynes to advise the CFNIS had decided to open an investigation into allegations of negligence in the determination of Cpl Langridge’s PNOK.^{Footnote 4298} He also indicated MCpl David Mitchell would be replacing MS McLaughlin, who had been deployed since the last meeting.^{Footnote 4299} Shortly after, on March 3, 2010, an interview was held with the Fynes to discuss this new investigation (the 2009 PNOK investigation).^{Footnote 4300} On May 5, 2010, another interview was held to discuss another new investigation, the 2010 Criminal Negligence investigation.^{Footnote 4301} These investigations remained open until the spring of 2011, when the Fynes were provided a letter outlining the CFNIS’ decision not to proceed with charges in either file.

175. In these proceedings, the Fynes have made specific allegations about the CFNIS’ failure to provide them with adequate and timely information during the 2009 and 2010 investigations.^{Footnote 4302} In particular, they have complained about the lack of regular updates or communication, the cancelling of a verbal briefing about the investigations, the delay in providing the written briefing offered in replacement and the contents of that briefing.^{Footnote 4303}

176. The evidence before this Commission has revealed there was a clear failure on the part of the CFNIS members to make regular contact and to provide information to the Fynes during these investigations. To make matters worse, the CFNIS members made direct commitments to the Fynes about the updates they would be providing and the manner in which they would be conducting the investigations. None of those commitments were fulfilled, and yet the Fynes were provided no explanations.

The Interviews and the Promises

177. During the March 3, 2010, interview, the Fynes’ concerns and allegations about the PNOK issue were discussed at length.^{Footnote 4304} Maj Dandurand made several statements about the investigation to be conducted. He indicated:

[…] we have documents and, quite frankly, documents only bring us so far, in my opinion.

And as an investigator, I want to uncover as much as I can with respect to what transpired regarding that [PNOK] decision.

We have reviewed so much that we have assumptions, but those assumptions need to be put to rest, so that we deal exactly with what happened, because that's the whole point of the investigation, is to get to the truth of what occurred.^{Footnote 4305} [Emphasis added]

178. Maj Dandurand told the Fynes the CFNIS would conduct interviews in order to find out how the PNOK decision was made. He stated he was “going to be poking around, and asking everyone and their dog what happened and why, with regard to this next of kin decision.”^{Footnote 4306} He explained the CFNIS would be questioning those involved in the decision to find out how and why it was made.^{Footnote 4307} When Mrs. Fynes suggested LCol Bruce King, the JAG Officer who had written to their counsel, should be on the list of persons to be interviewed, Maj Dandurand indicated he was “already there, don’t worry.”^{Footnote 4308} He also stated the CFNIS would be interviewing Cpl Rohmer and Ms. A’s Assisting Officer.^{Footnote 4309} When the Fynes expressed concern witnesses might not provide complete or accurate information to the CFNIS, Maj Dandurand assured them the appropriate interview techniques would be used:

But Sheila, I want to make this also clear, to hopefully appease some of your -- maybe your trepidation, is there I'm pretty loose in how we speak here, but some of our witnesses are not going to have that luxury, to be as loose.

There will be a very structured interview. We'll be pulling out -- we'll be pulling out all the investigative tools. […] So, you know, what I like to think of -- my charms and good looks will not be at the forefront, it will definitely be our more savvy investigative tactics.^{Footnote 4310} [Emphasis added]

179. Maj Dandurand also discussed the individuals the CFNIS intended to investigate. He noted the Regiment Adjutant was not the only person of interest, emphasizing, “there is a chain of command.”^{Footnote 4311} He explained he did not believe a single person would be the sole decision-maker in a case like this, and noted the CFNIS would be looking into the role played by the Chief Clerk, the RSM, the OC for Cpl Langridge’s squadron, and the Regiment CO.^{Footnote 4312}

180. In addition, Maj Dandurand explained administrative changes could result from the CFNIS investigation, even if charges were not laid:

One of the -- one of the interesting things – […] that stems out of a military police criminal investigation, or investigation into a code of service discipline offence is that, for instance, if charges are not laid, that doesn't mean – […] that's the end of it. […]

[W]hat comes with my report is not just, "Yeah, we couldn't do anything." I put a covering letter on it, it goes to every commanding officer, it goes to every department in NDHQ, and -- needless to say, all the other things that come of it is accounted in the report. That's the wonderful thing about the report. Even though a charge doesn't get laid, all the data is there, all the evidence is there to say, "You know what? The reason why -- I can't prove you stole that weapon, but I can prove this: A unit was negligent in their administrative procedures for losing that weapon." […]

So while they're not criminally negligent, they are administratively negligent, and all of a sudden, hands start getting slapped, and procedures start getting changed, and that unit has audits every six months for the next two years.

My point being is that, even in this particular case, hypothetically, if I cannot meet the elements of the offence for negligence, one of my determining factors in that is should somebody ought to have known that the primary next of kin, were Mr. and Mrs. Fynes.^{Footnote 4313} [Emphasis added]

181. Mrs. Fynes testified what she took away from this meeting was the CFNIS were still investigating the matter.^{Footnote 4314} She stated both she and Mr. Fynes told the CFNIS members they still had many questions, and the CFNIS members assured them they were still investigating and would get back to them with answers.^{Footnote 4315}

182. During the next meeting, held on May 5, 2010, the PNOK investigation was discussed again. MCpl Mitchell told the Fynes he was trying to determine when the PNOK decision was made and by whom.^{Footnote 4316} He indicated he was completing his review of the SI relating to Cpl Langridge’s post-death administration and noted the list of persons he planned to interview was “growing by the day” as a result.^{Footnote 4317} He explained the information he reviewed had allowed him to identify additional individuals who may have been involved in the PNOK decision, and he indicated he was using the SI to prepare for his own interviews and find information he could use to confront the witnesses if necessary.^{Footnote 4318} Maj Dandurand also told the Fynes:

Now, the information may be in a Summary Investigation, however, if somebody has provided information to the investigating officer, that investigating officer is not a military policeman. We need to go and speak to that person. And we have, as you know, a manner in which we ask questions – […] and deal with things and investigation, and that is also, in large part, to support our independence, because we may not come to the same conclusion or formulate the same theories that a Summary Investigation has.^{Footnote 4319} [Emphasis added]

183. Maj Dandurand also indicated the Regiment Adjutant, Capt Mark Lubiniecki, had not yet been interviewed because the CFNIS had not “gotten to that stage in the investigation yet.”^{Footnote 4320} Overall, he assured the Fynes the investigation was being conducted in a thorough manner:

And all I beg of you is the patience that we are moving through this extremely methodically to make sure that at the end of the investigation, when we finalize our report, it is final, there is no question mark.

And as you've seen from our investigative work, we don't leave stones unturned.^{Footnote 4321} [Emphasis added]

184. The remainder of the May 5 interview was devoted to discussing the Fynes’ new allegations of criminal negligence related to Cpl Langridge’s death, which led to conducting the 2010 investigation.^{Footnote 4322} During the interview, Maj Dandurand commented on his intentions regarding the conduct of this investigation, stating:

There is no doubt with this that there will be a revisitation of all documents. What we want to do is make sure that, if there's something that snuck into a Board of Inquiry testimony here or a piece of paper or evidence there, it's not missed.

So we revisit everything that's available, and then we go looking for anything else that we say, "You know what, nobody ever thought to ask this question, and we're going to go in, we're going to pluck that and [...]".^{Footnote 4323} [Emphasis added]

185. Maj Dandurand told the Fynes the investigation would be conducted in accordance with the Major Case Management (MCM) model.^{Footnote 4324} He explained:

I'm looking at this and I'm saying -- my gut right now is saying that this is not a run-of-the-mill major investigation that we deal with, in the sense that I can assign two investigators. I suspect this will become bigger – […] and I need to analyze the work that has to occur with respect to this in order to investigate these three things right here.

And just based on my experience and my gut, I think it's going to be more than just a two-man team dealing with this. […]

But the one thing that is certain is that the decision to go down that path is not bureaucratic, it is in the interest of expediency because of the recognition that it is so big.

The three things that have to be maintained by the case manager is the speed, the direction and the flow […]

So it will be moving as fast as possible. What I do suspect early on is that the degree of research will be vast in order to have the investigators and the investigative team wrapped around the issues.^{Footnote 4325} [Emphasis added]

186. In addition to the volume of information to review, Maj Dandurand spoke of the number of interviews to conduct, and of the preparation necessary for these interviews:

In this case, we have so much information that has to be analyzed systematically and accounted for that we don't go over it six times, we actually -- "Okay, that's been analyze[d]. All right. This hasn't. Okay".

If you have more than two guys on an investigation, right away, you can imagine – […] the flow of communications issues that are going to arise. We need to make sure that the speed of the investigation remains at it's top notch, the direction of the investigation stays focused on what needs to be done, and the flow, in other words the communication among the team is there.

The minute that you employ three or more investigators, you're into what is considered a major case management model of an investigation and in policing circles there's the academics of that, which in this case is not only the volume of interviews that have to occur, but the manner and the order in which they have to occur.

And as Dave says, you have to have your homework done so that when you go and ask that question, you already know what three possible answers – […] are going to be given when you go into that room. And that's why we do as much thorough background, so that when we get in that interview -- nothing worse, when you're asking a question, there's a surprise answer, right? Nothing worse.

You want to know every possible theory or iteration of answer that could come of that question, and then see where that answer leaved [sic] you. And based on your assumption of what some of those answers may be, you anticipate your next move.

This is what we're trained in doing, and this is why I say it's huge. It's huge in volume of activity that has to occur, and it's also huge in terms of importance. I mean, that's why it comes to the NIS[…]^{Footnote 4326} [Emphasis added]

187. Maj Dandurand also assured the Fynes the CFNIS would not be relying on the BOI’s conclusions.^{Footnote 4327} He indicated because “we can’t take anything at face value,” the CFNIS would “have to go point by point, minute by minute, through that BOI.”^{Footnote 4328} He explained the BOI testimony would be examined critically and would be used by the CFNIS members to formulate their own questions.^{Footnote 4329} He specifically stated the CFNIS would be revisiting the BOI witnesses.^{Footnote 4330}

188. On the whole, Maj Dandurand committed to conducting a vigorous and thorough investigation:

I give you this promise, if I say that a charge is merited, I have the reasonable probabl[e] grounds, as defined by all of police practices, I will lay that charge.

Equally, if I say that the charge is not warranted, I will have the justification for that statement.

It will be investigated without bias, right through to the truth. We will uncover the truth of what happened.^{Footnote 4331} [Emphasis added]

189. During the May 5 interview, the issue of the updates to be provided to the Fynes by the CFNIS was also discussed. The Fynes had not received any update about the 2009 investigation since the March 3, 2010 meeting.^{Footnote 4332} Mrs. Fynes noted they had “no idea what’s going on” because they had not been contacted.^{Footnote 4333} She added they experienced significant frustration because they “keep getting ignored and ignored and ignored” by the military.^{Footnote 4334} Mr. Fynes stated he was not complaining about the lack of updates from the CFNIS specifically, as this was not something about which they had previously agreed upon with the CFNIS, but did note he felt the general lack of information from the CF contributed to increasing their frustration.^{Footnote 4335} Maj Dandurand assured the Fynes the CFNIS would “increase the frequency of our updates.”^{Footnote 4336} He indicated MCpl Mitchell could call the Fynes every two weeks to provide updates.^{Footnote 4337} The Fynes both agreed this “would be great.”^{Footnote 4338}

190. Later in the interview, Mr. Fynes clarified he did not insist on receiving calls every two weeks.^{Footnote 4339} Instead, he insisted on the importance of receiving substantive information about the case, rather than mere courtesy calls. Mr. Fynes wanted contact to be regular so they would not be ignored, but he mostly wanted the updates to be meaningful.^{Footnote 4340} In testimony, he explained, “[…] to be fair, I never asked that they observe the two-weekly updates, I asked only for regular, because I had been warned by other people that you get the phone call every two weeks, but there is nothing to report.”^{Footnote 4341}

191. During the interview, he told the CFNIS members the updates could be provided “when they’re due or when appropriate.”^{Footnote 4342} He also explained his expectations regarding the substance of the updates:

I've talked to another dad […] this one particular father, a couple of weeks ago we had a long discussion, and he was updated on a regular basis, but after many months he got frustrated because he said he was getting his phone calls on a regular basis, but there was no information being passed. […] So when you use the word "information", I like to hear that.

Sorry, and if there's no information or nothing new, I understand that, but I just don't want somebody ticking off a box, "Well we called the Fyneses today and we told them there's nothing new for them". Now, if that goes on for six months, that's not – […] that's not enough, right?^{Footnote 4343} [Emphasis added]

192. In response, Maj Dandurand indicated “Absolutely not, no” and assured Mr. Fynes one thing the CFNIS was “really good at” was to get “movement on the files.”^{Footnote 4344}

193. Maj Dandurand reiterated his commitment to provide regular updates on several occasions during the interview, stating “All I can control is the sphere in which I operate, and we've touched on the fact that we were remiss in our commitment to update you. That is done. That's changed.”^{Footnote 4345}

194. He also promised there would be an “open flow of communication.”^{Footnote 4346} He explained, “We will be giving you an update. And it may not be as voluminous as perhaps you may assume it should be for that period of two weeks o[f] time, but it will be […] it will be an update nonetheless. And […] it'll be transparent, that's the bottom line.”^{Footnote 4347}

195. When Mrs. Fynes noted she felt they were “always the back burner,” both Maj Dandurand and MCpl Mitchell assured her the file was not on the back burner for the CFNIS.^{Footnote 4348} MCpl Mitchell apologized for not calling the Fynes previously, and assured them he was doing as much work as possible on the file.^{Footnote 4349}

196. During the interview, the Fynes explained clearly to the CFNIS members how important it was for them not to be ignored during the investigations. When Maj Dandurand expressed concern the CFNIS’ regular updates may become a stressor for the Fynes by constantly reminding them of the issues, Mrs. Fynes indicated they would not be.^{Footnote 4350} She insisted, “What's really important for you to know is that the stressors for us aren't getting the information, it's being ignored. Because we've had it up to here with that.”^{Footnote 4351}

197. In response, Maj Dandurand assured Mrs. Fynes “that won’t happen with us. And that’s why I’m here.”^{Footnote 4352}

198. Having received those assurances, the Fynes were entitled to expect, at a minimum, that the CFNIS would stay in contact with them and keep them informed of the progress of the investigations. They could also expect the case would be taken seriously and large-scale investigations would be conducted, as described by Maj Dandurand. While it would not have been reasonable for them to expect the CFNIS’ conclusions would necessarily be in accordance with their wishes, the Fynes could certainly expect to receive a complete explanation of those conclusions, based on all the investigative work completed and all the evidence gathered. Regrettably, events did not unfold as could have been expected on the basis of the promises made during the interviews.

Failure to Provide Regular Updates

199. In the period immediately following the May 5, 2010, interview, there was an effort to contact the Fynes regularly. However, the frequency of the updates quickly diminished, and the Fynes ended up receiving very little information about the investigations.

200. On May 25, 2010, MCpl Mitchell contacted Mr. Fynes to provide an update.^{Footnote 4353} He advised he had completed his review of the SI materials for the 2009 investigation, and would be scheduling witness interviews shortly.^{Footnote 4354} With respect to the 2010 investigation, he advised he had “submitted the file for legal review.”^{Footnote 4355}

201. On June 23, 2010, MCpl Mitchell spoke to Mr. Fynes again, providing an “update on the progress of the file” for each of the investigations.^{Footnote 4356} The nature of the information provided was not recorded in the GO files.^{Footnote 4357} The next day, Mr. Fynes contacted MCpl Mitchell by email to inquire about the SI conducted by the CF, and also to express concern about any reliance to be placed on the BOI draft report in support of the 2010 investigation.^{Footnote 4358} MCpl Mitchell responded on July 5, 2010. He indicated he was aware of only one SI having been conducted and, in response to the concerns about the BOI report, he noted the CFNIS legal advisor was “aware that the BOI is the still unapproved draft.”^{Footnote 4359}

202. No further contact was initiated by the CFNIS during the ensuing weeks. On August 16, 2010, Mr. Fynes contacted MCpl Mitchell by email, copying Maj Dandurand.^{Footnote 4360} He noted they had not spoken since June and indicated he would appreciate receiving an update.^{Footnote 4361} The following day, MCpl Mitchell contacted Mr. Fynes.^{Footnote 4362} There is no record in the file of the content of the conversation. In an email he sent to Maj Dandurand at the time, MCpl Mitchell reported, “Spoke to Shaun. Everything went fine. He seemed to be appreciative. Explained exactly what we talked about and he was happy with the explanation.”^{Footnote 4363}

203. In testimony, Maj Dandurand could not recall the discussion he had with MCpl Mitchell, and was not able to provide further information about the update MCpl Mitchell would have provided.^{Footnote 4364} MCpl Mitchell recalled only that he provided “an update as to where I stood,” and advised Mr. Fynes another investigator would be taking over the file, as MCpl Mitchell was going on training and would then be transferred from the Unit.^{Footnote 4365}

204. Mr. Fynes, for his part, could not recall the exact timing, but did remember receiving two updates from MCpl Mitchell. In the first one, MCpl Mitchell advised the CFNIS had referred the matter to their legal advisors.^{Footnote 4366} In the second update, MCpl Mitchell advised, “not that the legal advisors were holding up their investigation, but now he was seeking advice from superiors.”^{Footnote 4367}

205. After the August 17 update, MCpl Mitchell had no further contact with the Fynes. The file was turned over to Sgt Scott Shannon in September.^{Footnote 4368} On September 17, 2010, Sgt Shannon contacted Mrs. Fynes to advise he was now the lead investigator.^{Footnote 4369} In testimony, he recalled providing Mrs. Fynes with his contact information and giving her a general understanding of his credentials.^{Footnote 4370} He also recalled telling her he would make this his “priority file.”^{Footnote 4371} In her testimony, Mrs. Fynes indicated Sgt Shannon was “very nice” during the conversation, and told her he had taken over the file from MCpl Mitchell and would be spending his weekend reading up on it.^{Footnote 4372} She recalled he also said they would hear from him again “the very next business day.” ^{Footnote 4373}

206. The Fynes did not hear again from Sgt Shannon, or from any other CFNIS member, until February 2011, when the investigations were concluded and the Fynes were contacted to schedule a briefing.^{Footnote 4374}

207. In testimony, Sgt Shannon explained he was aware of the previous commitment to provide regular updates to the Fynes.^{Footnote 4375} However, Maj Dandurand advised him he would be providing the updates himself.^{Footnote 4376} As a result, Sgt Shannon did not think there was any need for him to contact the Fynes until he was tasked to do so at the end of the investigations.^{Footnote 4377} He testified he felt he had fulfilled his own commitment to Mrs. Fynes by making this file his priority.^{Footnote 4378}

208. The two case managers involved in supervising the investigations recalled Maj Dandurand had directed there be no further communication with the Fynes.^{Footnote 4379} WO Sean Bonneteau believed the direction had been issued after Mrs. Fynes held her press conference in late October 2010.^{Footnote 4380} He testified Maj Dandurand had then “directed that we […] not make any telephone contact with her until we heard back.”^{Footnote 4381}

209. In testimony, Maj Dandurand confirmed he instructed Sgt Shannon not to contact the Fynes, as he would be contacting them personally.^{Footnote 4382} He also confirmed this direction was issued as a result of Mrs. Fynes’ press conference.^{Footnote 4383} However, he testified the ultimate failure to make contact had “nothing to do” with the press conference.^{Footnote 4384}He explained, “at that point I did not feel that it was something that I wanted my investigators to be preoccupied with. I, as the detachment commander, would take on that responsibility, and I had full intention of communicating; however, things got away from me and I never did.”^{Footnote 4385}

210. Maj Dandurand recognized he did not live up to his commitment to provide regular updates.^{Footnote 4386} He explained this was “a complete oversight on my part,”^{Footnote 4387} and testified:

At the time I had those discussions with Mr. and Mrs. Fynes, I had proposed every two weeks, and it very quickly shifted to: No, no, just when there is a -- We don't need that every two weeks, just when there is a development. And we agreed to that.

I had lost track of time throughout, and not only that, but had drawn assumptions, as well, that others would be making contact, up to a certain point, where I believed that it would be my place to make contact with them.^{Footnote 4388} [Emphasis added]

211. Of all the CFNIS members involved in these investigations, MCpl Mitchell was the only one who at least attempted to make contact with the Fynes regularly. Still, he only provided two updates, and then only contacted Mr. Fynes again after receiving a specific request. In testimony, MCpl Mitchell recognized he was not able to fulfill the commitment to contact the Fynes every two weeks.^{Footnote 4389} He explained this was due to his caseload and travel schedule.^{Footnote 4390} The actual commitment agreed upon with Mr. Fynes was not to make contact every two weeks, but rather to provide regular updates. With three updates in four months, MCpl Mitchell may not have quite achieved the regular contact expected by the Fynes, but at least he took action and came closer to fulfilling the commitment than did any of the other members.

212. Overall, the CFNIS’ track record of keeping the Fynes informed about the progress of the investigations was extremely poor. During the nine-month period between the May 2010 meeting and the conclusion of the investigations in February 2011, the Fynes were only contacted four times. Of these, only three involved actual updates, as Sgt Shannon made only an introductory call. One of the remaining three contacts had to be specifically requested by Mr. Fynes. Between Sgt Shannon’s introductory call and the contact made at the end of the investigations, five full months went by without any contact whatsoever.

213. Not surprisingly, both Mrs. and Mr. Fynes testified they felt the CFNIS did not fulfill their promise to provide regular updates.^{Footnote 4391} As a result, they felt they were being ignored by the CFNIS.^{Footnote 4392} Mrs. Fynes testified, “It was like everything else to do with everything administrative after Stuart died it was just more of the same, being ignored and Major Dandurand did it with a smile on his face, but the fact was we got no answers and we were ignored as much as possible.”^{Footnote 4393}

214. It is difficult to understand how there could be a reasonable justification for this failure to make contact and provide information. The explanations heard during this hearing did not reveal any acceptable justification. Maj Dandurand did mention he was dealing with family emergencies in early 2011.^{Footnote 4394} This could explain, to some extent, his own lack of contact, at least during the final portion of the investigations. However, it still does not explain why other members were not tasked with providing the updates.

215. There were policies in place at the time of the investigations requiring regular updates be provided to complainants by CFNIS investigators or Victims Assistance Officers. The general MP policy provided for contact every 30 days, while the CFNIS SOP provided for call backs by the Victims Assistance Coordinator every two weeks.^{Footnote 4395} In this case, the Fynes apparently declined an offer for victims’ assistance services.^{Footnote 4396} As a result, the CFNIS SOP requirement for contact every two weeks may not have applied. However, at a minimum, the general policy requiring contact every 30 days should have been followed. More importantly, the CFNIS members had made a specific commitment to provide regular updates. The failure to honour this commitment was a serious oversight on the part of the Detachment and its OC, Maj Dandurand.

216. The failure was especially serious in this case because the Fynes had specifically explained the hardships they suffered when they did not receive updates. They had told the CFNIS there was nothing worse for them than to be ignored. Yet, the CFNIS proceeded to let weeks and months go by without making any contact, leaving the Fynes feeling ignored and side-stepped, which was exactly the result they had told the CFNIS they wanted to avoid.

Failure to Provide Substantive Information about the Investigations

217. During the May 5, 2010 interview, Mr. Fynes had insisted on the importance to him of being provided substantive information about the investigations, rather than simply receiving regular telephone calls. In the end, he testified he felt the few updates he did receive from the CFNIS had no content.^{Footnote 4397} Mr. Fynes explained, “We never really had any information as to an investigation that was being done or what the reasons were, we were just largely ignored.”^{Footnote 4398}

218. The updates provided by MCpl Mitchell did contain some information about the immediate steps being taken in each of the investigations. However, throughout the months following the May 5 interview, the Fynes were never provided with information which could have allowed them to understand what was really happening with the investigations, what decisions had been made about how they were being approached, or what the reasoning was for coming to certain preliminary conclusions or deciding not to pursue certain avenues. Largely due to the CFNIS’ silence during most of the investigations, as well as because of the limited information included in the updates provided, the Fynes never did receive substantive information about the progress of the investigations.

219. This was particularly unfortunate in light of the statements made by the CFNIS members about how the investigations would be conducted. These commitments, as contrasted with how things were actually unfolding, made it all the more necessary for the CFNIS to keep the Fynes informed. Having received specific assurances about the manner in which the investigations would be conducted, and in the absence of contrary information, the Fynes could reasonably expect things were proceeding as planned and as promised. At a minimum, they were certainly entitled to expect they would be told if there was a significant change in approach. The failure to provide information in this case was likely to create the impression the investigations were proceeding as outlined during the interviews with the Fynes. In reality, that was not at all the case.

220. In the 2009 investigation, the plan to conduct numerous “structured” interviews was abandoned after only three fact witnesses were interviewed.^{Footnote 4399} The members of the Regiment chain of command, and those involved in the PNOK decision, were not interviewed.^{Footnote 4400} Other witnesses Maj Dandurand had specifically mentioned as being on the list to be interviewed, like LCol King, Cpl Rohmer and Capt Lubiniecki, were also not interviewed.^{Footnote 4401} Despite assurances the CFNIS would not be relying solely on documents and would be interviewing the SI witnesses again, the investigation became entirely focused on document review once Sgt Shannon took over the file.^{Footnote 4402} No more fact witnesses were interviewed, and the majority of the SI witnesses who had information about the PNOK issue were never interviewed.^{Footnote 4403} Contrary to what the Fynes had been told would be done, the CFNIS never determined who made the PNOK decision and how it was made.^{Footnote 4404} The final report provided no information about this issue.^{Footnote 4405} It also contained no information that could have been used in making administrative changes.^{Footnote 4406} The CFNIS concluded, on the basis of Sgt Shannon’s document review and policy analysis, that the correct decision had been made with respect to the PNOK, and, as a result, did not pursue the lines of investigation discussed with the Fynes.^{Footnote 4407}

221. In testimony, MCpl Mitchell indicated his own plans for the investigation were generally consistent with many of the representations made to the Fynes, although he only planned to use “structured interviews” for suspects or subjects under investigation.^{Footnote 4408} Still, he did intend to conduct numerous interviews and find out how and why the PNOK decision was made.^{Footnote 4409} In the end, he only conducted three interviews before his involvement with the file ended.^{Footnote 4410} As a result, he was not able to make a determination about how the PNOK decision was made and by whom.^{Footnote 4411}

222. When he took over the file, Sgt Shannon did not investigate the facts surrounding the PNOK decision made by the Regiment.^{Footnote 4412} His own approach to the investigation did not include conducting any interviews, “structured” or otherwise, with fact witnesses, as he preferred to rely on the documentary record.^{Footnote 4413} In testimony, he explained he did not share the views expressed by Maj Dandurand during the meetings with the Fynes about the importance of conducting witness interviews and of not relying solely on documents.^{Footnote 4414} Nor did he feel bound to conduct the investigation in accordance with the representations made to the Fynes by Maj Dandurand.^{Footnote 4415} He did not take those representations into account when making his own plans for the investigation.^{Footnote 4416} He did not receive any instruction from Maj Dandurand, nor did he have any discussion with Maj Dandurand about his initial assumptions or plans for the investigation.^{Footnote 4417}

223. Sgt Shannon believed any commitments made by Maj Dandurand were “between him and Mr. and Mrs. Fynes,” and were not made on behalf of the Detachment, but rather in Maj Dandurand’s personal capacity as an investigator involved in the file.^{Footnote 4418} He testified:

MR. FREIMAN: Major Dandurand seems to be under the impression that it's necessary to interview these people as part of the investigation.

SGT SHANNON: Yes, if he made those statements, but this is at the very early onset of the investigation. Those are his initial thoughts on how he's going to proceed. By the time months later that this file was transferred to me there was so much more additional information available[…]^{Footnote 4419} [Emphasis added]

224. The 2010 investigation also did not unfold as outlined by Maj Dandurand. In fact, the reality could hardly have been more different from the plans outlined. Rather than, as Maj Dandurand had described, a major investigation involving numerous interviews and re-visitation of all documents, there was only an investigative assessment.^{Footnote 4420} No investigation at all was conducted in support of the assessment. There were no witness interviews, nor were the documents revisited.^{Footnote 4421} In testimony, MCpl Mitchell explained it was not necessary to investigate the facts or revisit documents and witnesses at the assessment stage.^{Footnote 4422} With respect to the earlier representations Maj Dandurand made to the Fynes about the conduct of the investigation, MCpl Mitchell explained, “Essentially what he is describing here in looking at it, again, I don't want to speak for him, but this is the steps that we would have done in the investigation phase, not in an assessment phase.”^{Footnote 4423}

225. Sgt Shannon, who was tasked to conduct an “offence validation” analysis before the file was concluded, also agreed there was no need to revisit documents or interview witnesses, since the file “never got past the analysis of the offence.”^{Footnote 4424}

226. Further, contrary to the representations Maj Dandurand made to the Fynes, the MCM model was never used.^{Footnote 4425} MCpl Mitchell did not recall being advised of a specific determination not to use MCM in this case, although he did recall general discussions about the option of using MCM to address the volume of work required to investigate the totality of the Fynes’ allegations in the two cases.^{Footnote 4426} Sgt Shannon testified he never contemplated using MCM for this investigation.^{Footnote 4427} He did not think the model would have been helpful or even applicable in this case.^{Footnote 4428} In fact, he felt using it would have been a “hindrance.”^{Footnote 4429}

227. The specific assurances provided to the Fynes about how the BOI report would be used in support of the investigation were also not honoured. During the May 5, 2010 meeting, Maj Dandurand had insisted the BOI report would not be taken at face value, and had indicated the evidence before the BOI would be examined in detail and the witnesses interviewed again.^{Footnote 4430} In testimony, he explained the message he intended to convey to the Fynes:

It was very clear to us at the time that the Fynes had had an experience with the Canadian Forces through the process of the BOI and through their interactions with the Canadian Forces as a whole, that they had become very skeptical and perhaps distrusting.

And what I wanted to specifically address in there is that if we're going to be pursuing something, we're going to be pursuing it according to our methods, not according to anybody else's song, we're going to be doing it ourselves and we have our own methods of getting to the bottom of things.^{Footnote 4431} [Emphasis added]

228. Nevertheless, the BOI report was included in the documents reviewed in support of the assessment.^{Footnote 4432} Yet, there was no review of the evidence presented at the BOI, and no interviews with any of the BOI witnesses.^{Footnote 4433}

229. In the end, Maj Dandurand recognized he did not “uncover the truth of what happened” as he had promised the Fynes he would do.^{Footnote 4434} He explained:

At the time, with the presentation of the allegations and my understanding in that meeting […] I was of the thought that we would be pursuing a criminal investigation in this and that I had perhaps situated the -- situated the investigation such that I had no expectation going external that it would be viewed as not applicable.^{Footnote 4435} [Emphasis added]

230. The investigations were open for more than a year, but at no time were the Fynes ever advised of the change in approach in the two investigations.

231. The few updates the Fynes received from MCpl Mitchell about the 2009 file were generally consistent with the initial plans described to them, as MCpl Mitchell still intended to proceed with numerous interviews.^{Footnote 4436} When the focus moved to documentary review after Sgt Shannon took over the file, the Fynes were not advised.

232. The Fynes were provided limited information about the steps being taken in the 2010 investigation. Maj Dandurand testified he had no reason to believe the Fynes did not understand what the steps were.^{Footnote 4437} He thought he might even have advised them during the May 5 interview of his intention to conduct an assessment and seek legal advice before proceeding with the investigative steps he outlined.^{Footnote 4438} However, he could not recall with certainty whether this was discussed with the Fynes or when the conversation would have taken place.^{Footnote 4439} MCpl Mitchell also could not recall whether this plan was discussed with the Fynes during the interview, although he did recall a discussion with Maj Dandurand.^{Footnote 4440} The transcript for the May 5 interview shows the Fynes were not advised during the meeting of any plan to conduct a preliminary assessment or to seek legal advice.^{Footnote 4441} When the initial representations were made to them by Maj Dandurand about the extensive investigation to be conducted, the Fynes were not provided with any indication those plans were conditional upon a preliminary assessment being conducted.

233. In the subsequent updates received by the Fynes, they were provided with some information about legal advice being sought and consultation taking place with supervisors.^{Footnote 4442} On the basis of this information, they did understand the CFNIS were “still assessing” the case, and they knew there was “no actual investigation at that point.”^{Footnote 4443} They were also aware the BOI report was included in the materials being reviewed as part of the assessment.^{Footnote 4444} However, as recognized by Maj Dandurand during his testimony, the Fynes were never formally advised a decision had been made not to proceed with any of the extensive investigative steps he had described during the initial interview.^{Footnote 4445}

234. The documentary record suggests the decision to conclude the file without conducting an investigation may have been made as early as August 14, 2010.^{Footnote 4446} By October 28, 2010, the CFNIS DCO advised the CFPM the investigative assessment was “completed” and a determination had been made there was “nothing indicat[ing] that a Code of Service offence or criminal offence such as criminal negligence may have occurred.”^{Footnote 4447} In testimony, Maj Francis Bolduc explained the file was kept open in case evidence uncovered in the 2009 investigation changed this assessment.^{Footnote 4448} The last update the Fynes received about this investigation was on August 17, 2010.^{Footnote 4449} There is no record of its content, and the witnesses had no specific recollection.^{Footnote 4450} While Maj Dandurand testified he had no reason to believe the Fynes did not understand the current status of the investigation at the time, as he was confident MCpl Mitchell “would have had an open and candid conversation with them,” he also recognized MCpl Mitchell would not have told the Fynes about the contents of any legal opinion received.^{Footnote 4451} As of January 2011, the Fynes were under the impression the investigation had “fallen inactive,” as they had received “no further update or response” about it.^{Footnote 4452} They were not told about any preliminary decision not to pursue an investigation, either when the decision was made, or at any time afterward.^{Footnote 4453} Even at the very end, the Fynes were advised of the ultimate result of the assessment – the determination that no charges were warranted – but they were still not told no investigation had been conducted or that the final determination was based solely on an investigative assessment.^{Footnote 4454}

235. WO Blair Hart, one of the supervisors for the investigations, testified he was not aware of any policy requirement to notify complainants of a change in approach during the course of an investigation in cases where initial representations were made about how the investigation would proceed.^{Footnote 4455}

236. WO Bonneteau, the other supervisor, testified he did not know about the representations made to the Fynes, and, as a result, had no discussions with Maj Dandurand about the difference in approach.^{Footnote 4456} However, he stated he believed Maj Dandurand was aware the “new plan” for the investigations did not involve the type of extensive interviews or MCM he had discussed with the Fynes.^{Footnote 4457}

237. In testimony, Maj Dandurand recognized the Fynes were never told the investigations did not end up unfolding as he had indicated during their meetings.^{Footnote 4458} He explained it was his intent to advise them of the change in approach during the final briefing at the end of the investigation.^{Footnote 4459} He did not provide any explanation or reason why the Fynes could not have been advised earlier through the regular updates promised to them.^{Footnote 4460}

238. In all cases, updates provided to complainants should involve more than mere courtesy calls without substantive content. In light of the need to protect the integrity of ongoing investigations, there will be limits regarding the amount of detail that can be shared. However, if they are to serve their intended purpose of keeping complainants informed, updates must be meaningful. Substantive information must be provided to allow complainants to understand the investigative approach and the direction of the investigation. At least a general outline of the investigative steps required should be provided. Each update should then allow complainants to gain an understanding of the progress made and the work remaining to be done.

239. Where specific representations are made to complainants about the conduct of the investigation, additional obligations will arise to provide information. There will not be an obligation to carry out the investigation in accordance with the plans outlined to the complainants since, for obvious reasons, decisions about how to conduct a police investigation should be dictated solely by the needs of the investigation and by the investigators’ assessment of the steps necessary to carry out their policing duties. However, there will be an obligation to advise the complainants when a different approach is adopted. Otherwise, they could be misled about the extent of the investigative work being conducted.

240. In this case, the CFNIS’ failure to provide substantive information about the investigations not only left the Fynes feeling they were being ignored, but was also likely to leave them with the impression the promised investigative steps were being taken. When they eventually found out this was not the case, it could only make their already strained relationship with the CFNIS more difficult, and erode what little trust the CFNIS had managed to establish in previous encounters.

Final Briefing

241. In February 2011, after months without any contact, the CFNIS finally contacted the Fynes to schedule a briefing about the conclusion of the two investigations. Shortly after, the CFNIS decided not to provide this briefing after all, because the Fynes had requested it be conducted in the presence of their counsel. The Fynes were told they would be receiving a written briefing instead. Many more weeks went by without further contact. Then, in early May 2011, the Fynes were provided with a three-page letter outlining the CFNIS’ conclusions in the two investigations. The letter contained practically no substantive information about the investigations, and it became a source of further concern and complaints for the Fynes.

The cancelled verbal briefing

242. On February 20, 2011, Sgt Shannon contacted the Fynes to advise the two investigations were completed and to schedule a formal briefing about their outcome.^{Footnote 4461} In testimony, Mrs. Fynes explained her understanding at the time was the CFNIS intended “to give us a PowerPoint presentation at a hotel room.”^{Footnote 4462} She noted they did not want to receive such a presentation, but wanted a “back-and-forth conversation” about the investigations’ findings.^{Footnote 4463} In the end, the briefing did not take place.

243. The Fynes requested the briefing be held at their lawyer’s office with their lawyer present.^{Footnote 4464} In testimony, they explained they wanted the briefing to be held in a neutral location to avoid having to receive CFNIS members into their home or having to attend the military base.^{Footnote 4465} They also explained they wanted their lawyer present as an observer or “as a witness on our behalf.”^{Footnote 4466} Mr. Fynes testified it had been “clearly delineated” the lawyer would not be asking questions “and wasn’t going to interfere” with the briefing in any way.^{Footnote 4467}

244. Sgt Shannon forwarded the Fynes’ request to Maj Dandurand.^{Footnote 4468} After consultation with CFNIS HQ, a decision was made to cancel the briefing and to advise the Fynes of the outcome of the investigations in writing instead.^{Footnote 4469} On February 24, 2010, Sgt Shannon told the Fynes of this decision and advised they would be receiving written correspondence from the CFNIS “in the near future.”^{Footnote 4470}

245. As part of their allegations about the CFNIS’ failure to provide them with adequate and timely information, the Fynes have specifically complained about the CFNIS’ decision to cancel the verbal briefing because of the Fynes’ request for their lawyer to be present.^{Footnote 4471}

246. The briefing was cancelled because of concerns about the presence of a lawyer having an impact on the briefing and on the interests of the investigators involved in the briefing.^{Footnote 4472} Based on the testimony of the CFNIS members, it appears the CFNIS was reluctant to become involved in eventual civil litigation they were aware the Fynes intended to pursue.^{Footnote 4473} They did not want the briefing to turn into a contest between lawyers, and they did not want the investigation to be “picked apart” or scrutinized for civil litigation purposes.^{Footnote 4474}

247. This reluctance to become involved in an external process was understandable. It is not the role of the police to conduct investigations in support of civil litigation claims. CFNIS participation in this process could create additional demands on its resources and could lead to scrutiny or questioning of its investigative process from a perspective unrelated to the needs of its criminal investigations or eventual prosecutions. The CFNIS could also risk being viewed as demonstrating a lack of neutrality as a police force. As a result, it is not surprising the CFNIS did not wish to provide a briefing in the presence of the complainants’ civil litigation lawyer.

248. Nevertheless, the CFNIS’ understandable aversion for litigation also had to be balanced with its responsibility to provide meaningful information to the complainants. In light of the commitments made to the Fynes about how the investigations would be conducted and about the updates to be provided, and in light of the woefully inadequate information provided during the investigations, the Fynes’ interest in finally receiving information about the investigations should have been given more consideration. The CFNIS had a responsibility to provide this information, both to honour its own direct commitments and to fulfill its duties as a police force to provide information and support to complainants.

249. The Commission considers giving precedence to the CFNIS’ desire to stay out of the civil litigation process over the interests of the complainants to receive information was not the appropriate decision. This decision would only have been acceptable if the CFNIS could find an alternative meaningful way to provide timely, substantive, accurate and complete information to the Fynes. As it happened, the failure to provide the verbal briefing simply led to a further period without any communication, leaving the Fynes, once more, without any information about the steps taken to investigate their complaints or the conclusions reached. The written briefing eventually provided by the CFNIS could not possibly convey the information that would have been available in a verbal briefing, and in fact, did not contain adequate or sufficient information.

250. Under the circumstances, the decision to cancel the briefing could only further aggravate the Fynes’ frustrations and the perception they were being ignored by the CFNIS. Since the CFNIS’ own conduct had contributed to creating this perception, the CFNIS should not have allowed its own interests and desire to avoid becoming involved in the civil litigation to prevail over the need to finally fulfill its basic responsibilities towards the Fynes.

Delay in providing the written briefing

251. It was February 24, 2011, when the Fynes were advised the verbal briefing would not take place and were told they would be receiving a written briefing soon.^{Footnote 4475} After this, they did not hear from the CFNIS again until over two months later. The written briefing was signed on April 27, 2011.^{Footnote 4476} Because of an address error, it was returned to the CFNIS and finally mailed to the Fynes on May 6, 2011.^{Footnote 4477} In their allegations before this Commission, the Fynes made a specific complaint about the failure to provide the written briefing within a reasonable time after the verbal briefing was cancelled.^{Footnote 4478}

252. The delay in providing the written briefing to the Fynes remains largely unexplained. After the verbal briefing was cancelled, Sgt Shannon promptly prepared a draft for the written briefing. It was sent to Maj Dandurand for approval on March 3, 2011.^{Footnote 4479} By March 8, 2011, the text of the letter had been approved by CFNIS HQ and the decision had been made it should go out under Maj Dandurand’s signature.^{Footnote 4480} There was no further activity on the file, nor were there any changes to the letter. Yet, it took almost two months for Maj Dandurand to sign the letter. In testimony, Maj Dandurand could not recall any reason or provide an explanation for this delay.^{Footnote 4481} He did mention he was dealing with family emergencies in early 2011, and explained, as a result, he could not give the file his full attention and was forced to rely on his second-in-command (2iC).^{Footnote 4482}

253. On April 11, 2011, the new CFNIS CO, LCol Robert Delaney, wrote to Maj Dandurand to ask whether the written briefing had been sent.^{Footnote 4483} Maj Dandurand responded he intended to sign and send the letter “when I get back.”^{Footnote 4484} He explained the letter was ready to go, but indicated: “I just need to finalize the file so that when I send it the file [is] ready for ATIP.”^{Footnote 4485} In testimony, he explained he was referring to the need “to close out the file in order for it to formally be concluded in SAMPIS.”^{Footnote 4486} He testified that, until the file was officially concluded, it would not be accessible following Access to Information requests, because it would be considered ongoing.^{Footnote 4487} He indicated while this was not necessary, he wished to have the file concluded and accessible at the same time as the letter was sent to the Fynes.^{Footnote 4488} The Concluding Remarks for the investigations were dated March 3 and 4, 2011.^{Footnote 4489} The files were marked as concluded in the SAMPIS system by Maj Dandurand on May 2, 2011.^{Footnote 4490}

254. Maj Dandurand provided no explanation to this Commission as to why the Detachment 2iC or other supervisors or investigators could not have provided assistance in moving forward the process of concluding the files and providing the written briefing to the Fynes. After such a long period without contact or information, and following on the heels of the decision to cancel the verbal briefing, the additional delay of two months for the Fynes to receive information about the investigations created unnecessary anxiety and frustration for them. The Fynes should have received timely updates and information during the investigations, and they should have been advised promptly of the results once the investigations were concluded.

Lack of substantive information contained in the written briefing

255. The Fynes’ chief complaint about the written briefing is that it did not contain sufficient information to answer their questions.^{Footnote 4491} Mr. Fynes testified, “We got a letter that was kind of a gunny sack of things. Didn’t really tell us anything, except that they were all finished and closed and done. […] And no one was being charged or found responsible for anything.”^{Footnote 4492}

256. Mrs. Fynes, for her part, stated, “We felt, to sum this letter: We did nothing wrong then and we are doing nothing wrong now and will do nothing wrong in the future.”^{Footnote 4493}

257. There is no question, and all of the CFNIS witnesses agreed, the written briefing contained less information than would have been provided in the verbal briefing initially planned.^{Footnote 4494} Comparing the written briefing to the PowerPoint presentation Sgt Shannon had prepared in anticipation of the verbal briefing, he testified, “the two are night and day.”^{Footnote 4495} The PowerPoint slides contained a discussion of at least some of the CFNIS’ individual conclusions about the issues they identified as relevant, and some of the reasoning supporting those conclusions.^{Footnote 4496} They would have allowed the Fynes to understand, at a minimum, some of the reasons why the CFNIS members came to their conclusions. In addition, Maj Dandurand testified he expected the verbal briefing to involve “free and frank dialogue, not just on the topics covered on the slide but, rather, the entire -- the totality of the investigations.”^{Footnote 4497} LCol Sansterre also thought an oral briefing would have led to discussions and much more information being exchanged.^{Footnote 4498} By comparison, the information contained in the written briefing was very limited.

258. In testimony, Sgt Shannon recognized the letter was limited to presenting conclusions and did not really set out any of the reasoning supporting those conclusions, although he indicated he still believed the written briefing answered “the substantive questions based on the allegations that were referred to.”^{Footnote 4499} LCol Sansterre felt the written briefing “strictly spoke to what the investigation was and what the outcome of that investigation was.”^{Footnote 4500} He maintained the letter to the Fynes “did give them the fullness of the results of the CFNIS investigation.”^{Footnote 4501} However, he recognized the letter had “less detail” about the analysis supporting the conclusions.^{Footnote 4502}

259. In total, the letter was three pages long.^{Footnote 4503} It contained very little information about the basis for the CFNIS’ conclusions and no information about the steps taken during the investigations.

260. The first page of the letter provided an overview of the two files. It included a general description of the allegations investigated in each case, and advised no charges would be brought. The only information about the investigations was a statement indicating they required “extensive review” of “all matters relating to Cpl Langridge,” as well as statutes and policies, and a statement only federal legislation, policies and regulations valid and in force on March 15, 2008, were considered.^{Footnote 4504}

261. The second page of the letter was devoted to the 2009 PNOK investigation. It set out the two allegations investigated by the CFNIS and listed the potential offences considered during the investigation. It then went on to provide some information about the conclusions drawn. It stated the investigator had concluded Cpl Langridge was in a common-law relationship at the time of his death, and had found the Regiment Adjutant did not “appoint” his next-of-kin, but rather confirmed the existence of valid documentation indicating Cpl Langridge was in a common-law relationship. It advised no repealed policy had been quoted to support the determination of Cpl Langridge’s common-law status, as the relevant policy was in effect until 2009. As a result, the letter indicated no evidence had been identified to suggest any CF member had failed to fulfill his or her duty, and concluded the “elements of the offence” were not established.^{Footnote 4505}

262. This limited information was capable of informing the Fynes about at least some of the conclusions reached in the investigation. In particular, it made it clear the CFNIS concluded Cpl Langridge was in a common-law relationship at the time of his death. However, it provided no explanation at all about why this was viewed as determinative of the issue under investigation, namely, who Cpl Langridge’s PNOK should have been and who should have had authority to plan his funeral.^{Footnote 4506}

263. During this hearing, it was learned the lead investigator believed the common-law spouse was always the correct PNOK.^{Footnote 4507} This was based on the investigator’s understanding of the applicable laws and policies and of the “customs of society.”^{Footnote 4508} However, nothing in the letter provided to the Fynes could have alerted them to this or allowed them to discern how or why the CFNIS arrived at its ultimate conclusion in the investigation. It is not surprising they complained the written briefing did not answer their questions.^{Footnote 4509} They complained about the wrong PNOK being appointed to plan the funeral, and were told in response, the person in question was correctly recognized as Cpl. Langridge’s common-law spouse. In testimony, Mr. Fynes explained:

But [we] asked the question about why was Stuart's ex-girlfriend inserted as the primary next of kin to arrange the funeral, I guess more appropriately is, the person arranging the funeral at least technically should have been the executor.

And we -- answered back that she was still considered by the military or recognized in status as being common-law.

So, the answer isn't an answer to the question that [we] asked. Who inserted that person and why was she inserted in, because she was common-law. Oh, okay. That's not the criteria for arranging the funeral.^{Footnote 4510}

264. Indeed, without more information, it was not possible for the Fynes to understand what link the CFNIS investigator made between the PNOK, the common-law spouse, and the responsibility for planning the funeral. As such, they could not understand and assess the basis for the conclusions reached by the CFNIS.

265. Further, the briefing contained no information at all about the investigative steps or the overall approach adopted during the 2009 investigation. On the basis of this letter, the Fynes could not have known the plan to interview all those involved in the PNOK decision was ultimately not carried out.^{Footnote 4511} They could not have known Sgt Shannon’s conclusions were based solely on his own analysis of the “documentary record” and of the policies he considered applicable, supported only by interviews with policy witnesses and the three previous interviews conducted by MCpl Mitchell.^{Footnote 4512} They could not have understood, based on the written briefing they received, what kind of investigative activity was carried out to support the conclusion arrived at.

266. The third and last page of the letter was devoted to the 2010 Criminal Negligence Investigation.^{Footnote 4513} It contained even less information than had been provided about the 2009 investigation. After setting out the Criminal Code sections invoked by Mr. Fynes in his initial complaint letter, the briefing simply indicated that after “a complete review of all information and evidence gathered,” it was concluded “reasonable and probable grounds” to believe CF members committed the listed offences were not established, and the “burden of proof” for the offences was not established “by evidence.”^{Footnote 4514} There was no information about what materials were reviewed, about whether any investigative steps were taken to gather the “evidence” referred to, or about what the reasoning was for concluding no charges were warranted. On the basis of the information contained in the briefing, it would have been impossible for the Fynes to gain any understanding of how the 2010 investigation was approached by the CFNIS.

267. All of this was particularly problematic in light of Maj Dandurand’s earlier commitments. During the May 5 interview, he had specifically told the Fynes he gave them his “promise” if he concluded a charge was not warranted, he would “have the justification for that statement.”^{Footnote 4515} Yet, the briefing simply stated the conclusion without providing any explanation or justification.^{Footnote 4516} In testimony, Maj Dandurand recognized he never provided the Fynes with the justification he had promised.^{Footnote 4517} He explained:

I did not give them that justification. One of the intents of the family briefing that would have occurred at the conclusion of this investigation and the other would have been to discuss that exact issue, and I had full anticipation that this would be a point of contention and would require me to explain it at length.^{Footnote 4518} [Emphasis added]

268. Maj Dandurand testified he did not “get a chance” to provide the justification in the end, because the CFNIS “backed out of the family briefing” when the Fynes requested it take place at their lawyer’s office.^{Footnote 4519} He did not explain why the justification could not have been provided in the letter sent in lieu of the verbal briefing.^{Footnote 4520} He only commented, “the letter was not a briefing, per se.”^{Footnote 4521} At the time, he had not considered the question of whether the Fynes’ insistence to conduct the verbal briefing in the presence of their lawyer relieved him of his own commitment to provide a justification for determining charges were not warranted.^{Footnote 4522} He made no other effort to provide the Fynes with an explanation regarding the basis for the CFNIS’ conclusions in the 2010 file.

269. The written briefing also provided no information about the investigative steps in the 2010 file. From the letter they received, the Fynes could not have known only an investigative assessment had been done. On the contrary, some of the language in the letter could have created the inaccurate perception an investigation was conducted. The first page of the letter referred to “two detailed and comprehensive investigations” having been conducted.^{Footnote 4523} In addition, the portion of the letter devoted to the 2010 investigation referred to a “complete review of all information and evidence gathered in relation to the manner in which Cpl Langridge received medical care and the manner in which he was provided with personal support by members of the Canadian Forces.”^{Footnote 4524} The words “all information” appeared to imply, at a minimum, that all existing materials were reviewed, which was not the case.^{Footnote 4525} More importantly, the reference to a review of “all evidence gathered” created the impression evidence had actually been gathered by the CFNIS and an investigation had been conducted, especially in light of Maj Dandurand’s initial representations about the plans for this investigation. In the letter, there was nothing indicating the “information and evidence” reviewed was limited to a selection of previously held information, with no new evidence being gathered and no investigation being conducted. In testimony, Maj Dandurand recognized the letter, as drafted, would not have allowed the Fynes to know the CFNIS did not do the things he had said they would do during the May 5 interview.^{Footnote 4526} He testified:

MR. FREIMAN: Is it your belief that this letter would have given the Fynes the ability to understand that there was no investigation at all conducted or no direct investigation conducted with respect to 2010 investigation … ?

Would the Fynes have known that you didn't do the things that you said on May the 5th that you were planning to do?

MAJ DANDURAND: No, they would not.

MR. FREIMAN: Should they have known that?

MAJ DANDURAND: It was my intent to discuss that at the family briefing.^{Footnote 4527}

270. The CFNIS members did not provide a satisfactory explanation for the failure to include substantive information in the written briefing. Sgt Shannon, who drafted the text of the letter, testified the lack of detailed explanations was the result of his understanding of “typical rules of writing” when drafting correspondence.^{Footnote 4528} He explained the reason he did not break down the elements of the offences or provide individual explanations of the conclusions was “just for simplicity.”^{Footnote 4529} He also indicated preparing this type of briefing in a case like this was unusual, as normally the complainants would be advised of the results of the investigation through a phone call only.^{Footnote 4530} Maj Dandurand, for his part, explained the intent of preparing the letter was to ensure the Fynes were at least provided with information about “what it was that we were investigating and what it was that we had concluded.”^{Footnote 4531} He could not recall why it was decided to include significantly less detail in the written briefing than would have been provided in the verbal briefing.^{Footnote 4532} He only noted: “We do not normally encounter this and that was the decision that we made at the time.”^{Footnote 4533}

271. Final briefings provided to complainants at the conclusion of an investigation must be more than mere courtesy exercises. They must provide meaningful information. Once an investigation is concluded, concerns about the need to protect its integrity are less important. Hence, final briefings should include more information than updates during the investigation. At a minimum, they must provide complainants with an outline of the investigative steps taken and an explanation of the basis for the conclusions. If substantive information is not included, the mere fact of providing a final briefing to complainants, whether by phone call, in a meeting, or through a letter, will not be sufficient to fulfill the CFNIS’ duties or commitments to keep complainants informed about its investigations.

272. In this case, the decision to use written communication instead of a verbal briefing was, by its very nature, bound to result in the Fynes receiving less information. However, had the CFNIS provided adequate information in the letter about the steps taken in each of the investigations and the reasoning supporting the conclusions reached, the written briefing could have provided the Fynes with at least some of the information they were entitled to receive. As it was, the letter did neither. It ended up answering none of the Fynes’ questions beyond the final outcome of the investigations and providing no substantive information about the investigations. Most concerning, the written briefing left the Fynes entirely in the dark about what was done in the investigations and how it differed from what they had been told would be done. In particular, the Fynes should have been advised clearly of the decision to conduct only an investigative assessment in the 2010 file. The decision to cancel the verbal briefing did not relieve the CFNIS members of their obligation to provide this information. Even after receiving their final “briefing” about the investigations, the Fynes still had no way of knowing the extensive investigation Maj Dandurand had promised was never carried out. Had there not been proceedings before this Commission, and had the Fynes not made an Access to Information request for the investigative file, they would still not know there had been no investigation.

Accuracy of written briefing

273. In addition to their more fundamental complaints about the lack of substantive information in the written briefing, the Fynes have also made specific allegations about inaccurate information they believe was included in the briefing.^{Footnote 4534}

274. The Fynes have alleged the briefing improperly characterized the 2009 investigation as having been opened at their request.^{Footnote 4535} Instead, they believe this investigation was “the result of the Military Ombudsman’s Office contacting the NIS to start that investigation.”^{Footnote 4536} In testimony, Mr. Fynes explained he wanted to “set the record straight” by making this allegation, because he believed they did not initiate the 2009 investigation, although he noted they were “sort of parties to it.”^{Footnote 4537}

275. The evidence before this Commission has revealed there was a lack of clarity as to the identity of the complainant within the 2009 investigative file. As both the Ombudsman’s office and the Fynes had communicated similar concerns to the CFNIS, some notations in the file appear to indicate the Fynes were the complainants, while others appear to indicate the investigation was opened as a result of the allegations communicated by the Ombudsman’s investigator.^{Footnote 4538}

276. However, the evidence has also revealed the CFNIS members involved in the investigation generally viewed the Fynes as the true complainants, while they viewed the Ombudsman’s investigator as a “third party complainant” or a conduit for the Fynes’ complaint.^{Footnote 4539} Since the information communicated by the Ombudsman’s investigator originated from the Fynes, and the concerns he communicated to the CFNIS were the result of the Fynes’ complaint to the Ombudsman’s office, this view was not unreasonable.^{Footnote 4540} In fact, when he was first advised by Maj Dandurand of the allegations brought forward by the Ombudsman’s investigator, Mr. Fynes himself stated, “I made that allegation a long time ago, so I won’t hide behind anybody else.”^{Footnote 4541} In her testimony, Mrs. Fynes also recognized they had complained about the NOK issue “all along,” and indicated she expected the Ombudsman’s investigator contacted the CFNIS on the basis of the information she and Mr. Fynes had provided.^{Footnote 4542} As to her views about the identity of the “complainant” in the 2009 file, she testified:

Q. Moving on to the 2009 investigation. You had stated, and I know that this is one of the allegations in your complaint, you object to any reference that you and Mr. Fynes were the complainants in the 2009 investigation.

A. I'm not saying I object to it. What I'm saying is that we voiced our complaints to the military ombudsman and eventually he told me that he had spoken to the NIS and there would be an investigation done and then when we met with Major Dandurand, we did voice our complaints with him.^{Footnote 4543}

277. On the basis of the evidence, the Commission cannot conclude the information contained in the written briefing provided to the Fynes was inaccurate. While the lack of clarity in the file about the identification of the complainant was unfortunate for other reasons,^{Footnote 4544} the statements made in the final briefing did not misrepresent the situation. In fact, strictly speaking, the statements were accurate. The letter did not purport to identify the Fynes as the sole complainants. It simply stated they had made verbal allegations regarding the NOK issue and noted the investigation focused on those allegations.^{Footnote 4545} This represented the investigators’ genuine and reasonable understanding about whose allegations were being investigated.

278. The Fynes have also alleged the statement in the written briefing, “the NDA hold[s] precedence over provincial legislation,” was inaccurate.^{Footnote 4546} In testimony, Mr. Fynes explained his understanding was the NDA “does not override or supersede provincial legislation in matters of provincial jurisdiction.”^{Footnote 4547} He added, “So, I don't know if the investigator doesn't understand that or if he's deliberately misrepresenting it.”^{Footnote 4548}

279. The Commission has noted elsewhere in this report, Sgt Shannon’s categorical rejection of the relevance of provincial law on the basis of his understanding the NDA held legal precedence was based on a great over-simplification and was not the correct approach to address the issues raised in this investigation.^{Footnote 4549} Whether federal law will prevail over provincial law in specific circumstances depends on a number of factors, which were not considered by Sgt Shannon.^{Footnote 4550} In this case, provincial law should not have been dismissed out of hand, and may well have been relevant to answer some of the questions under investigation.^{Footnote 4551} As such, the unqualified statement included in the final briefing was indeed not accurate in the context of this investigation.

280. However, the statement was not a deliberate misrepresentation, and it was not intended to mislead the Fynes. It represented the investigator’s honest belief about the applicable law. While the Commission is of the opinion this belief was misguided, and a legal opinion should have been sought before coming to such conclusions,^{Footnote 4552} it was appropriate to advise the Fynes in the final briefing of the approach actually taken by the investigator. This would have allowed them to make their own assessment of the investigation, and to pursue any available recourse to challenge the investigator’s approach. The statement included in the briefing did accurately report the legal theory adopted during the investigation. It was inaccurate because of a failure in the legal analysis, not because of a failure to provide information to the complainants.

281. Aside from the specific points complained about by the Fynes, there were other concerns with the content of the written briefing. Not only was very little substantive information provided, but also the manner in which the allegations were described did not present a complete picture of the issues the Fynes had asked the CFNIS to investigate. While the descriptions included in the briefing were not intended to mislead the Fynes, since they did represent the investigator’s understanding, they were nevertheless overly narrow and, certainly for the 2009 allegations, they contributed to creating the impression the answers provided in the briefing were more responsive than they in fact were.

282. The main allegation investigated in the 2009 file was described as an allegation CF members “misinterpreted documents and policies regarding the common-law status of your son,” as well as an allegation Ms. A “had been appointed as the next-of-kin (common-law spouse) […] in the absence of any documentation to support that [Ms. A] had ever been formally appointed as such by Cpl Langridge.”^{Footnote 4553} In the GO file, this allegation had consistently been described as an allegation CF members had been negligent in appointing Ms. A as the NOK, and not in recognizing her as the common-law spouse.^{Footnote 4554} During interviews with the CFNIS, the Fynes had made it clear their complaint related to the appointment of Ms. A as the NOK for purposes of making decisions about Cpl Langridge’s funeral.^{Footnote 4555} Sgt Shannon was of the view the common-law spouse was the appropriate NOK and, as a result, believed if Ms. A had been appropriately recognized as the common-law spouse, it would necessarily follow she had also been appropriately recognized as the NOK.^{Footnote 4556} In the written briefing, this conclusion was incorporated into the description of the allegation being investigated. While this represented an accurate description of the investigator’s ultimate view of the file and of his own understanding of the issue to investigate, it did not represent an accurate description of the allegations as presented by the Fynes.

283. The issue brought to the CFNIS for investigation was whether Ms. A had appropriately been recognized as the NOK, specifically for purposes of funeral planning. The conclusions set out in the letter indicating she was appropriately recognized as the common-law spouse,^{Footnote 4557} did not, without more explanations, answer the question. However, because the letter inaccurately stated the question to be investigated as only relating to common-law status, the conclusions appeared to answer the question.

284. The description of the 2010 criminal negligence allegations also did not capture all of the Fynes’ complaints. The allegations were described as relating to “unspecified members” of the CF.^{Footnote 4558} In fact, during their interview with the CFNIS, the Fynes had identified at least some specific individuals they believed were responsible.^{Footnote 4559} Strictly speaking, the information in the briefing was not inaccurate, as it referred only to the Fynes’ written complaint, and this complaint did not specify the individuals allegedly involved.^{Footnote 4560} However, by using this narrow description of the allegations, the briefing did not present a full picture of the issues at stake. While Sgt Shannon’s focus in completing the offence validation in this case was on the written complaint, in testimony he recognized the Fynes’ verbal allegations were also relevant.^{Footnote 4561}

285. Maj Dandurand, who signed the briefing letter, testified the description of the allegations included in the letter was not meant to indicate the investigation would be limited to the allegations made in the Fynes’ written complaint.^{Footnote 4562} He stated the omission to record the identity of the persons complained about in the investigative file and in the letter was not deliberate.^{Footnote 4563} If, indeed, the overall approach the CFNIS meant to adopt was to take into account the Fynes’ verbal allegations, and not just their written complaint, this was not reflected in the written briefing.

Conclusion

286. On the whole, the series of failures and mishandling of communications observed in the CFNIS’ interaction with the Fynes during the 2009 and 2010 investigations provided an unfortunate example of how not to act when interacting with complainants. The Fynes were not treated with the respect and consideration they were entitled to receive. They were not provided with meaningful information either during the investigations or after the investigations were concluded. Their questions were not answered, and they had numerous promises made to them, which were never fulfilled. Regrettably, these missteps and communication failures represented a continuation of similar problems observed since the beginning of the 2008 investigation.^{Footnote 4564}

4.5.5. The ‘Stockholm Syndrome’ Comment

287. The Fynes have alleged to this Commission CFNIS members commented during an interview that a statement made by their AO indicating the Fynes had been “deceived, misled, and intentionally marginalized in their dealings with DND and the CF”^{Footnote 4565} was likely the result of ‘Stockholm syndrome.’ They claim this comment demonstrated a bias against criticism of the CF and such views acted to prevent CFNIS members from conducting independent investigations.^{Footnote 4566} In her testimony, Mrs. Fynes suggested the recordings for this interview had been altered.^{Footnote 4567}

288. The Commission finds these allegations are unsubstantiated. The evidence available indicates no CFNIS member made such a comment to the Fynes during the interview in question. A forensic analysis of the interview tapes conclusively determined no alterations were made to the audio or video recordings.

Context of the Allegations

289. The circumstances giving rise to these allegations begin with an email from Maj Parkinson to Maj Glen Hamilton-Brown on January 21, 2009.^{Footnote 4568} The email was reportedly sent after the Fynes met with Maj Parkinson at his Reserve Unit one evening. Mrs. Fynes stated they were “angry” at that point, feeling they were being ignored by the CF in the lead up to the BOI and went to speak with Maj Parkinson to see if he could help.^{Footnote 4569} Maj Parkinson testified he sent the email to Maj Hamilton-Brown in an effort “to ensure that the Fynes were participants in the board of inquiry.”^{Footnote 4570} The email states, in part:

I personally have no issues but I feel it my duty to inform you that the Fynes definitely have a multitude of issues not the least of which is their participation in the BOI in a meaningful way. You’ll understand if after 10 months of being deceived, misled, and intentionally marginalized a [sic] various points that they have no faith left in the system.^{Footnote 4571}

290. Mr. and Mrs. Fynes complained to this Commission and maintained in their testimonies that Maj Dandurand commented Maj Parkinson’s statements were likely the result of ‘Stockholm syndrome’. They believed the comment was made during the third interview between the Fynes and CFNIS investigators at CFB Esquimalt on May 5, 2010.^{Footnote 4572} Mr. Fynes stated he believed the comment was made near the middle of the interview.^{Footnote 4573}

291. None of the audio recording, video recording,^{Footnote 4574} or transcript^{Footnote 4575} of the interview shows Maj Dandurand making such a comment. When confronted with this information during her testimony, Mrs. Fynes acknowledged there was no such comment in the recordings, but alleged there are portions of the interview “missing” from the recordings.^{Footnote 4576} Mr. Fynes did not make any such allegation, but did state he could think of no reason he would accept for the comment not being captured in the recordings.^{Footnote 4577}

292. The Fynes’ allegations are very serious in nature and are concerning for a number of reasons. If investigators had made such a comment, it would suggest a bias against criticism of the CF and would call into question their impartiality in conducting their investigations. It would also be unprofessional for investigators to liken a family’s AO to a hostage victim, and by implication, the family to hostage-takers. The allegation that portions of the interview are “missing” amounts to an allegation the interview recordings were altered to remove the impugned statement. Editing a witness interview recording would be highly unprofessional as the contents of the recording would no longer be a complete and accurate representation of events. It would risk jeopardizing an investigation and the professional reputations and integrity of the investigators involved.

The Investigators’ Responses and the Evidence

293. For their part, neither investigator involved in the interview recalled any such comment being made. Maj Dandurand testified he did not recall making any comment regarding ‘Stockholm syndrome’ as alleged by the Fynes, and he was unaware of any basis for their belief the interview tapes were altered.^{Footnote 4578} MCpl Mitchell testified he could not recall any discussion of ‘Stockholm syndrome’ or of Maj Parkinson being stigmatized for the comments he made.^{Footnote 4579}

294. The interview recordings and transcript indicate neither Maj Dandurand nor MCpl Mitchell made any comment about Maj Parkinson suffering from ‘Stockholm syndrome’. There is no record of Maj Parkinson’s email, or of any fallout that may have occurred as a result of it, being discussed. Maj Parkinson’s name does come up during the interview, as MCpl Mitchell had interviewed him as part of the 2009 investigation. MCpl Mitchell told the Fynes he thought Maj Parkinson was a “very nice man.”^{Footnote 4580} The only other mention of Maj Parkinson was made by the Fynes when they told investigators he had informed them, in the days following Cpl Langridge’s death, they were not PNOK.^{Footnote 4581} This is the extent of the discussions relating to Maj Parkinson.

295. This Commission ordered a forensic analysis of the May 5, 2010, audio and video interview recordings from the RCMP Audio and Video Analysis Section to determine whether they had been altered in any way. The analyses conducted included frame-by-frame video analysis, audio comparison of the separate audio and video recordings, and digital file property analyses.^{Footnote 4582} A comprehensive report on the analyses concluded there was no “evidence of deletions or modifications done to any of the recordings. On the contrary, there is strong evidence they are exactly what they are purported to be.”^{Footnote 4583} Thus, there is no evidence to support Mrs. Fynes’ allegation the recordings were altered.

4.5.6 CFNIS Answers to the Col Blais Questions

296. During the five-month period when the Fynes had no contact from the CFNIS, while the 2009 and 2010 investigations were still ongoing, the Fynes transmitted questions about the CFNIS’ past and present investigations to Col Gerard Blais. The Fynes had raised many of these previously but had not received satisfactory answers or, in some cases, any answers.^{Footnote 4584}

297. The CFNIS prepared responses to the Fynes’ questions and transmitted them via Col Blais. The Fynes were not satisfied with the answers.^{Footnote 4585} In many cases, the responses only increased their general concerns and complaints about the failure of the CFNIS to provide them with information.^{Footnote 4586} The responses also led to further complaints alleging inaccurate information or rationales were provided to explain or justify the CFNIS’ actions.^{Footnote 4587}

Compiling the CFNIS Information

298. Col Blais was the Director of the CF’s Casualty Support Management Unit.^{Footnote 4588} Shortly after Mrs. Fynes’ October 2010 press conference, he was appointed as the point of contact to answer the Fynes’ questions on behalf of the CF.^{Footnote 4589} Col Blais asked the Fynes to provide a list of their questions or concerns and undertook to obtain answers from the relevant CF organizations.^{Footnote 4590}

299. On January 4, 2011, the Fynes sent Col Blais a document listing a number of questions they wanted answered by the CF, including six questions specifically related to the CFNIS investigations.^{Footnote 4591} Col Blais forwarded the questions to “subject matter experts” within the CF in order to obtain the necessary information.^{Footnote 4592} On January 11, 2011, the CO of the CFNIS, LCol Sansterre, received the questions, along with Col Blais’ request to provide answers as soon as possible.^{Footnote 4593} On the same day, the questions were forwarded to Maj Dandurand, the OC of the WR Detachment, and he was asked to provide answers.^{Footnote 4594}

300. MWO Terry Eisenmenger, the Detachment chief investigator, was tasked with compiling information to answer the Fynes’ questions.^{Footnote 4595} On January 14, 2011, he sent Maj Dandurand draft responses for five of the six CFNIS questions.^{Footnote 4596} On January 18, Maj Francis Bolduc, the CFNIS DCO, transmitted the CFNIS responses for all six questions to Col Blais.^{Footnote 4597}

301. It is not clear who prepared the final version of the answers sent by Maj Bolduc. The content was the same as in the draft responses prepared by MWO Eisenmenger.^{Footnote 4598} The only difference was MWO Eisenmenger had reproduced entire sections of MP policies he considered relevant, whereas the final version contained only references to the sections and a more general description of their content.^{Footnote 4599} Text was also added to MWO Eisenmenger’s response to the sixth question, dealing with the failure to disclose the suicide note. As well, a response was added for the fifth question, dealing with the “next of kin” investigation, which MWO Eisenmenger had left unanswered.^{Footnote 4600}

302. In testimony, Maj Bolduc indicated he received the answers directly from Maj Dandurand and passed them on to Col Blais without making any changes.^{Footnote 4601} Maj Dandurand, for his part, explained he was dealing with family emergencies during this period.^{Footnote 4602} As a result, he could not give the file his full attention and was forced to rely on his 2iC.^{Footnote 4603} He could not recall whether he made changes to the draft answers provided by MWO Eisenmenger, or whether he drafted the additional answers included in the final version.^{Footnote 4604} Maj Dandurand did note the new responses corresponded to his own belief at the time.^{Footnote 4605} He also testified it would have been common practice for MWO Eisenmenger to forward the draft answers to him for review and input.^{Footnote 4606} On the basis of this evidence, it is likely Maj Dandurand contributed to creating the final version of the CFNIS answers ultimately forwarded to Col Blais.

Answers Provided to the Fynes

303. After Maj Bolduc sent the CFNIS answers to Col Blais on January 18, the answers were incorporated into a larger document containing responses from other CF organizations.^{Footnote 4607} The document was reviewed and edited by the CF before it was sent to the Fynes.^{Footnote 4608} There were a few minor edits to the CFNIS answers, but their substance remained unchanged.^{Footnote 4609} The answers were sent to the Fynes by Col Blais on January 31, 2011.^{Footnote 4610}

Question 1: “Why was Stuart not shown any respect and his body left to hang for several hours?”

304. This was a question the Fynes had asked CFNIS members in their first two meetings on November 28, 2009, and March 3, 2010.^{Footnote 4611} Maj Dandurand had specifically undertaken to find the answer, but did not get back to the Fynes with the information.^{Footnote 4612} During the meetings, general information had been provided about the legal authority to make decisions to move or remove the body, but there was no specific answer addressing what happened in this case.^{Footnote 4613} The answer provided through Col Blais was no different.

305. The Col Blais answer begins by explaining all sudden death investigations are treated as homicide investigations where the cause of death is unknown.^{Footnote 4614} It notes the intent is to prevent the loss of evidence and ensure the scene is not contaminated.^{Footnote 4615} It then states, “The decedent can not be removed until authorization has been provided by the Lead Investigator who receives direction from the coroner.”^{Footnote 4616} The response goes on to describe the events of March 15, 2008. It indicates Cpl Langridge was discovered in the “defaulter Barrack room.”^{Footnote 4617} It states both MP and emergency services attempted to save his life upon arriving at the scene, but quickly determined he could not be revived.^{Footnote 4618} It notes the room was formally declared a crime scene and indicates, “At 1725 hrs, 15 Mar 08, the CFNIS Lead Investigator and the Coroner arrived and commenced processing the crime scene which consisted of video recording and photographing the crime scene.”^{Footnote 4619} The response notes Cpl Langridge’s body was removed at 1916 hrs, and concludes with a statement indicating the methodology for processing a potential homicide scene is “extremely lengthy and labour intensive.”^{Footnote 4620} It states investigators must be cautious to collect all possible evidence as any uncollected evidence may be lost to an investigation or inadmissible in court. It indicates if Cpl Langridge’s body had been removed while the scene was being processed, “it would have further contaminated the crime scene […] which could potentially have had a significant impact on the criminal investigation.”^{Footnote 4621}

306. This response does not answer the Fynes’ question. It contains many general statements about policies and requirements, but there is limited information about the actual events in this case. It provides little clarity about who made the decision not to remove Cpl Langridge’s body earlier and the basis for such a decision. Some of the factual information included is also inaccurate.

307. While the point is not expressed as clearly as it could have been, the response does indicate it was the ME who had authority to provide direction to move or remove the body.^{Footnote 4622} This is consistent with the statements CFNIS members had made during earlier meetings with the Fynes.^{Footnote 4623} Mr. Fynes disagreed with this interpretation of the law and believed it was the CFNIS, rather than the ME, who had authority to determine when the body could be removed.^{Footnote 4624} In their allegations to this Commission, the Fynes specifically complained CFNIS members “inaccurately stated that the responsibility for failing to promptly cut down Cpl Langridge’s body rested with the Alberta Medical Examiner.”^{Footnote 4625} To the extent it was based on the Fynes’ understanding regarding legal responsibility for making decisions about the removal of the body, this allegation is not well founded. The ME did have the legal authority to make the decision and, as such, the description of the applicable legal framework included in the response is factually accurate.^{Footnote 4626}

308. However, the response, as drafted, provides no clarity about the respective roles played by the ME and the CFNIS investigators in determining when Cpl Langridge’s body could be removed in this specific case. By focusing on information about the legal responsibility for making the determination and providing no detail about the facts, the response appears to imply the decision was made by the ME. In reality, while the CFNIS investigators did not have the authority to determine when Cpl Langridge’s body could be removed, they did influence the time it took to remove the body by asking the ME Investigator to wait while they exhaustively catalogued the room and its contents through photographs and video.^{Footnote 4627}

309. The Commission has found the time taken by the investigators to process the scene in this case was within the range of what can be considered reasonable under the circumstances.^{Footnote 4628} As such, the CFNIS investigators cannot be faulted for the length of time Cpl Langridge’s body was left hanging. However, the fact remains the main reason Cpl Langridge’s body was not removed earlier was their request to the ME Investigator to wait while they completed the various steps they wished to undertake. The response provided to the Fynes entirely omits this information. To the extent the response implies the ME was, in fact, responsible for the decision regarding the timing of the removal of Cpl Langridge’s body, it is not accurate.

310. The response also makes reference to a potential contamination of the scene if the body had been removed earlier. It is not clear the statements to this effect are supported by the facts. The description of the general procedures and methodology followed at the time by the CFNIS in such cases is accurate. It is also accurate, in the abstract, to state one of the reasons for having these procedures is to avoid contaminating the scene or losing evidence. However, on the facts of this case, it is not clear these statements have any special application.

311. While the Commission has found the time taken to conduct detailed surveys of the room prior to removing the body was not unreasonable and was in accordance with the usual CFNIS methodology and procedures,^{Footnote 4629} there is no basis for an implication the length of time taken was necessary. The response provided to the Fynes affirms it was and categorically states the scene would have been contaminated if this had not been done. The evidence before this Commission does not support that claim. There is no evidence to support a conclusion to the effect that once the ME Investigator had examined Cpl Langridge’s body and photographs and/or video had been taken to show its position in the room, removing the body prior to conducting the more exhaustive catalogue of the room would have interfered with or affected the remainder of the investigators’ work or would have “contaminated” the scene.^{Footnote 4630} The blending in this response of a description of the general procedures with a description of the facts of this case resulted in potentially misleading information being provided to the Fynes.

312. The response also contains a number of factual inaccuracies in the description of the events of March 15, 2008. It states MP and emergency services personnel attempted to save Cpl Langridge’s life when they attended at the scene, but there is no evidence indicating this. Instead, emergency personnel simply confirmed there were no vital signs.^{Footnote 4631} Under the circumstances, this was the appropriate course of action, as it was clear Cpl Langridge was already deceased.^{Footnote 4632} There were no failures or inappropriate behaviour by the MP or CF members involved in this respect. However, the response does not accurately describe the events. The confusion again appears to have resulted from an attempt to blend a description of applicable protocols with a description of actual events. Because the normal protocols generally involve attempting resuscitating measures,^{Footnote 4633} it was apparently assumed this was done in this case.

313. The notation indicating Cpl Langridge was discovered in the “defaulter Barrack room” is also not accurate.^{Footnote 4634} In testimony, Maj Dandurand admitted this was a “false statement.”^{Footnote 4635} In fact, while he was required to reside in the defaulter’s room, Cpl Langridge was discovered in his room in the barracks.^{Footnote 4636} There is no indication the error was intentional or intended to mislead the Fynes. It was likely the result of confusion or a misunderstanding in reviewing the investigative file. However, the error was significant for the Fynes, as they were involved in a disagreement with Cpl Langridge’s Regiment about the appropriate address for Cpl Langridge at the time of his death.^{Footnote 4637} When they received this response from the CFNIS, the Fynes specifically noted the inaccuracy of the information about where Cpl Langridge was found.^{Footnote 4638}

314. These types of errors and inaccuracies in the description of the basic facts surrounding the discovery of their son’s body were not likely to inspire confidence by the Fynes in the responses being provided from the CFNIS. Not surprisingly, Mr. Fynes testified he did not accept the explanations provided by the CFNIS, and believed the response was “inconsistent with what actually happened at the scene.”^{Footnote 4639} While this perception was partly based on the Fynes’ own misunderstanding about the legal responsibility for making decisions about removing the body, it was also true the response did not contain an accurate description of the events or an account of the actual reasons why Cpl Langridge’s body was not removed earlier.

Question 2: “Why did the NIS need to access Stuart’s ‘Personal Information’ contained in his medical and health records?”

315. The brief CFNIS response provided to the Fynes identifies two reasons why Cpl Langridge’s medical records were obtained. First, it states the CFNIS investigators had received information indicating Cpl Langridge may have suffered from drug dependency and had attended a medical institution to receive treatment for mental health issues, including “suicidal tendencies.”^{Footnote 4640} Second, the response indicates medication was found at Cpl Langridge’s residence and “confirmation was necessary to establish/corroborate that he was issued the medication by the Canadian Forces, and to determine if the medication may have contributed in any way to his death.”^{Footnote 4641}

316. Although it does not provide elaborate explanations about how the medical information being sought could be used to confirm suicide was the most likely cause of death, this response is generally factually accurate. The investigators had received information indicating Cpl Langridge had mental health and substance abuse issues, and they had been told about past suicide attempts.^{Footnote 4642} They had also found medication in Cpl Langridge’s storage locker and Jeep, and investigators were seeking to determine what medications he was taking, what the potential side effects were, and whether his actions were influenced by the medications or their side effects.^{Footnote 4643} All of these reasons were specifically referred to by the investigators during their testimony and were listed in the request for the medical records.^{Footnote 4644} The only aspect not specifically mentioned was the need to confirm the medications were issued by the CF.

Question 3: “Why does the Certificate of the Alberta Medical Examiner erroneously state that Stuart had been suffering with discipline issues?”

317. The Fynes had complained about this issue in previous meetings with the CFNIS, but had been unable to obtain details about the statements made to the ME by the CFNIS investigators.^{Footnote 4645} The response provided through Col Blais contains more information. It explains the ME had requested clarification about the meaning of the term “defaulters” and had been told a defaulter was a CF member who demonstrated poor or improper discipline, but had not been told Cpl Langridge was a defaulter.^{Footnote 4646} It then states it was believed “the ME on his own accord and without influence or direction from the Lead Investigator annotated on the ME Certificate that Corporal Langridge suffered from discipline issues.”^{Footnote 4647}

318. The Fynes were not satisfied with this answer.^{Footnote 4648} In their complaint to this Commission, they specifically alleged the CFNIS provided inaccurate rationales to justify its actions by taking the position “it was not their responsibility if the ME overheard things during the processing of the scene and made his inaccurate comment about the disciplinary issues on that basis.”^{Footnote 4649}

319. The evidence before the Commission has revealed the CFNIS investigators were not, in fact, responsible for the comment included in the ME Certificate. They did mention to the ME Investigator that they had received information indicating Cpl Langridge may have been on defaulters, but they specified the information was unconfirmed, and they provided further clarification when they learned additional information.^{Footnote 4650} In testimony, the ME Investigator recognized the mention of disciplinary issues included in the Certificate was the result of his own interpretation and not of statements made by the CFNIS members^{Footnote 4651} The answer provided through Col Blais is accurate, and the Fynes’ allegations with respect to this issue are not well founded.

Question 4: “Why was the NIS investigation of Stuart’s death closed after three months without return of seized exhibits?”

320. The Fynes had raised this issue in previous meetings with CFNIS members. They had not been given an explanation regarding the delay in returning seized exhibits at the conclusion of the 2008 investigation.^{Footnote 4652} The response provided through Col Blais also fails to provide clarity about the actual reasons for the delay. It focuses on a general description of policies and procedures, not all of which were applicable in this case, and it does not provide information about the facts. It also contains clearly inaccurate information.

321. The response begins by stating items seized as evidence may be held until all investigative activity has been taken, including potential additional investigation.^{Footnote 4653} It notes the legal owner or executor of the estate must be identified prior to the release of property when the time comes.^{Footnote 4654} The response then proceeds to outline MP policies on the return of seized property. It notes property related to, or suspected of being related to, an offence may be seized as evidence until it is no longer required as evidence and/or authority for its disposal has been received.^{Footnote 4655} It states Senior MP Advisors, Case Managers and investigators “shall institute procedures to track returns and diary dates on requests for extensions to retain seized items.”^{Footnote 4656} It explains evidence disposal begins when the Senior MP Advisor requests disposal instructions from the disposal authority.^{Footnote 4657} It notes this occurs when “the time within which an appeal may be commenced has expired, or, when no judicial proceeding has commenced on a case, and the owner cannot be identified, within one year after the investigation was concluded or suspended.”^{Footnote 4658} The response then concludes stating, “With respect to this specific case, the ownership of property between Corporal Langridge’s parents and his common-law spouse at the time of the suicide had not been clearly determined.”^{Footnote 4659}

322. The Fynes were particularly dissatisfied with this response.^{Footnote 4660} As part of their allegations about inaccurate rationales being provided to justify CFNIS actions, they complained “NIS members advised the complainants that, under MP policies, they were allowed to retain the exhibits for a period of one year to provide for an appeal period.”^{Footnote 4661} In testimony, Mr. Fynes explained:

When I questioned why they held Stuart’s property the response that I got back from Ottawa was to quote me an exhibit retention policy in the event of an appeal. There was nothing to appeal. There was no criminal offence and there were no charges.^{Footnote 4662} [Emphasis added]

323. While many of the policies described in the response were in force at the time,^{Footnote 4663} they were not particularly applicable to the facts in this case and did not, in fact, play any role in delaying the return of the exhibits. In testimony, Maj Dandurand recognized the reference to the policy regarding the appeal period had no relevance to explaining what happened with the exhibits in this case.^{Footnote 4664} He speculated it had been included for Maj Bolduc’s information, with the expectation it would be deleted if it was not appropriate to include it in the response provided to the Fynes.^{Footnote 4665} In general, Maj Dandurand felt the description of the MP policies included in the response “seems to be an attempt to answer the question not specific to the case file itself, but from a common practice point of view.”^{Footnote 4666} He recognized it was “not ideal” to attempt to answer a question about a specific situation by referring to a general practice.^{Footnote 4667}

324. Aside from its description of general practices, the response does not answer the Fynes’ question. After reviewing this response during his testimony, Maj Bolduc, the CFNIS DCO, was still unable to answer the question, as he did not know why the final step to return the exhibits was not completed.^{Footnote 4668} The evidence before this Commission has revealed the reason the exhibits were not returned immediately at the conclusion of the 2008 investigation was the absence of adequate processes in place at the Detachment for the return of exhibits.^{Footnote 4669} As a result, it was not uncommon for exhibits to remain in the Detachment evidence room for years, with no steps being taken for their return.^{Footnote 4670} In this case, steps were eventually taken to return the exhibits only as a result of a request from the Director of Estates.^{Footnote 4671} The response provided through Col Blais contains no information at all about any of these facts. By referring to all of the policies related to the return of exhibits, the response appears to imply these policies were the reason the exhibits were not returned immediately upon the conclusion of the investigation. In fact, this was not the case.

325. In addition to failing to answer the question, the response also contains inaccurate information. It states the ownership of property had not been clearly determined between the Fynes and Ms. A and implies this contributed to explaining the delay in its return.^{Footnote 4672} When they received the answer, the Fynes noted this was a “falsehood.”^{Footnote 4673} They stated there was never any question about Mrs. Fynes being the beneficiary of the estate, and noted the executor had been identified prior to the conclusion of the 2008 investigation.^{Footnote 4674} Indeed, as recognized by Maj Dandurand in testimony, there were no questions about the ownership of Cpl Langridge’s property when the 2008 investigation was concluded.^{Footnote 4675} MWO Barry Watson, who was involved at the time of the events, specifically testified concern over the ownership of Cpl Langridge’s property was not a factor in delaying the release of the seized items.^{Footnote 4676} It is not known how this inaccurate information came to be included in the response. Its presence, however, was certainly capable of heightening the Fynes’ concerns about inaccurate rationales being provided to justify CFNIS actions.

Question 5: “Why has a subsequent investigation into the insertion of a non-designated next of kin been stalled for fourteen months and call backs to our family discontinued?”

326. This was the only question not related to the 2008 investigation and not previously asked by the Fynes. The response was added after MWO Eisenmenger handed in his draft answers and was likely prepared by Maj Dandurand himself.^{Footnote 4677} It contains limited information. It begins by stating the 2009 investigation was not stalled, but rather remained in progress.^{Footnote 4678} It maintains the investigation was approaching its conclusion as of January 15, 2011, and indicates a final case file briefing was being prepared to brief the family on the outcome of the 2009 and 2010 investigations.^{Footnote 4679} It concludes by recognizing a commitment had been made to contact the family every two weeks, but explains:

Commencing in the fall of 2010, it was determined that the investigation was near completion and calls were no longer warranted until the CFNIS were prepared to announce to the family that a final briefing was available. Unfortunately, the lapse in time was not noticed and several months passed since the last call to the family. This was not done with intent, it was an oversight for which the CFNIS apologizes. A briefing to the family will be conducted as soon as possible after the investigation closes.^{Footnote 4680} [Emphasis added]

327. This response does not provide a complete answer to the Fynes’ question, and the accuracy of some of the statements it contains is questionable. Aside from the blanket statement asserting the investigation was not stalled, no information is provided to explain why the investigation took so long or what still needed to be done to conclude it. It was not technically inaccurate to state the investigation was still “in progress” as of January 15, 2011. In fact, however, the last interviews had been conducted in November 2010, and the lead investigator had been instructed to prepare a briefing to the command team on December 10, 2010.^{Footnote 4681} The only activity that remained “in progress” was to determine the availability of the Detachment commander to receive the briefing.^{Footnote 4682}

328. With respect to the lack of contact, the explanation provided is generally consistent with the explanation provided by Maj Dandurand during his testimony in this hearing.^{Footnote 4683} However, the reference to a determination being made in the fall of 2010 that the investigation was near completion and calls were no longer warranted is perplexing. In fact, after the command team received a briefing about Sgt Shannon’s preliminary assessment of the matter, they directed him to conduct interviews with policy witnesses.^{Footnote 4684} Those interviews proceeded on November 16 and 17, 2010, and, in December 2010, Sgt Shannon was instructed to prepare a briefing to the command team about his conclusions.^{Footnote 4685} The determination the investigation was about to be concluded could not have been made before mid-to-late-November 2010.

329. When he reviewed this answer during his testimony, Maj Dandurand indicated it did “coincide completely with my view at the time.”^{Footnote 4686} However, when he explained the reasons why the Fynes were not contacted during the investigation, he did not mention any determination having been made not to contact them because the file was near completion. Instead, he testified, after Mrs. Fynes’ press conference in late October 2010, he issued a direction to the investigators not to make contact with the Fynes because he felt he should be contacting them personally.^{Footnote 4687} He then failed to make contact because he “lost track of time.”^{Footnote 4688} As a result, it is not clear the answer provided through Col Blais to explain the lack of contact was entirely accurate.

330. Further, while it was appropriate for the CFNIS to apologize in the response for its failure to contact the Fynes, it is surprising the receipt of this question did not prompt the CFNIS members to make contact, now that the matter was specifically brought to their attention. Instead, a further period of more than a month went by without any contact being made with the Fynes after this question was received.^{Footnote 4689} It was only on February 24, 2011 that the Fynes were finally contacted to schedule a final briefing about the investigations.^{Footnote 4690}

Question 6: “Why is still it not understood [sic] by the NIS that there was no legitimate justification for suppression and improper retention of a suicide note written by Stuart?”

331. The Fynes had been asking this question and complaining about the failure to disclose Cpl Langridge’s suicide note to them ever since they learned about the note’s existence in late May 2009.^{Footnote 4691} They had never been provided an explanation of what happened in this case and what led to the CFNIS’ failure to disclose the note at the time of the events.^{Footnote 4692} The response sent to them through Col Blais continues to provide little clarity about the matter. Some of the statements it contains are inaccurate. Its overall tone and content appear to be aimed at justifying at least part of the CFNIS’ actions and fail to convey any recognition on the part of the CFNIS of the seriousness of its failure in this case and of the significant impact on the Fynes.

332. The original response was drafted by MWO Eisenmenger.^{Footnote 4693} Additional content was then added, likely by Maj Dandurand, before the response was provided to the Fynes.^{Footnote 4694} The response begins by stating, while the suicide note should have been provided to the executor of the estate at the conclusion of the investigation, it would have only been released following a review of the evidence held and a determination it no longer had a bearing on ruling out foul play.^{Footnote 4695} The response then continues:

The usage of the word “suppression” is not correct. The suicide note found with Corporal Langridge was seized as part of the criminal investigation into the sudden death. Upon conclusion of the investigation, the suicide note was intended to be released to the decedent’s parents. However, this was not conducted as expediently [sic] as it could have been.^{Footnote 4696} [Emphasis added]

333. The response finally indicates the release of a suicide note fourteen months after the fact “is not normal practice.”^{Footnote 4697} It states the CFNIS had formally apologized to the family and indicates this occurrence had “led to the revision and ‘tightening’ of the Standing Operating Procedure associated with this topic.” ^{Footnote 4698} As a result, the response concludes the likelihood of a similar event recurring was “even more remote.”^{Footnote 4699}

334. This response is problematic in several respects.

335. First, some of the information it contains is clearly inaccurate. The description of the facts of the case implies the failure to return the note was caused by a mere lack of promptness and specifically states there was intent to return the note. This is not consistent with the evidence before this Commission. The evidence reveals the note was only disclosed to the Fynes in 2009 because of the BOI’s intervention.^{Footnote 4700} There is no evidence the investigators intended to return the note at the end of the investigation. Indeed, there is no evidence that by then they remembered the note even existed.^{Footnote 4701} The statement about the relevant SOP having been revised and “tightened” is also inaccurate. While there had been revisions to the SOP for family briefings, nothing relating to the disclosure of suicide notes was added to any SOP until July 2011, well after this response was sent to the Fynes.^{Footnote 4702} As detailed elsewhere in this report, there were changes made to the practices being followed.^{Footnote 4703} However, the response, as formulated, refers to a revision of the actual SOP and, in this respect, the information provided does not align with the facts.

336. More importantly, the response, as drafted, continues to maintain there was justification for the failure to disclose the existence of the note to the Fynes prior to the conclusion of the investigation. The reference to the timing for when the note should have been disclosed – i.e., “at the conclusion of the investigation, following a review of the evidence held” or “when it was deemed to have no bearing on the investigation (ie: ruling out of foul play or relevance of the note in this regard)”^{Footnote 4704} – was in line with the views of some of the CFNIS members.^{Footnote 4705} It certainly was in line with Maj Dandurand’s own view and therefore was a truthful explanation of his perspective^{Footnote 4706} However, to the extent it implied it was necessary to go through a lengthy process, or to wait for official confirmation about the cause of death or for the conclusion of the investigation, the response was not in line with the proper approach to determining when the CFNIS ought to disclose the existence of suicide notes.^{Footnote 4707} The fact members of the CFNIS chain of command continued to maintain this view so long after the events, and presented it to the Fynes as the official CFNIS response, seems to reflect a failure by the CFNIS to appreciate the lessons to be learned from this episode. It also reflects the consequential failure to ensure an adequate common understanding of the procedures to be followed for the disclosure of suicide notes was developed and disseminated throughout the organization.^{Footnote 4708}

337. On the whole, the response transmitted through Col Blais continued to leave the Fynes with no adequate explanation for one of the most important CFNIS failures in this case. It also contributed to fuelling the Fynes’ perception – justified in many cases – of inaccurate rationales being provided to explain or justify CFNIS behaviour.^{Footnote 4709} The Fynes had posed a clearly rhetorical question by asking why it was “still … not understood by the NIS that there was no legitimate justification for suppression and improper retention of a suicide note written by Stuart?”^{Footnote 4710} By answering the question as they did, the CFNIS members seem to have confirmed they in fact did not understand there was no legitimate justification for failing to disclose the note in the days following Cpl Langridge’s death.

Continued Failure to Provide Information

338. On the whole, most of the CFNIS answers provided through Col Blais were inadequate. While a few were consistent with the evidence heard in this hearing, many contained clearly inaccurate information. Most did not actually answer the Fynes’ questions. In general, the answers were similar to those provided during the November 2009 briefing.^{Footnote 4711} They focused on general information not necessarily related to the facts of this case and often appeared to be aimed at justifying the CFNIS’ handling of the case, rather than providing factual information about what was done.

339. The inaccuracies and the failure to provide information do not appear to have resulted from any intentional attempt by CFNIS members to mislead the Fynes. At the same time, the evidence also reveals the efforts made to provide accurate answers were extremely limited. The individual in charge of compiling the information, MWO Eisenmenger, had no involvement in the actual investigation.^{Footnote 4712} There is no evidence he had any prior knowledge of the file.^{Footnote 4713} He had approximately three days to prepare the draft answers.^{Footnote 4714} There is no indication any of the CFNIS members actually involved at the time of the events were consulted or even contacted when the responses were prepared.^{Footnote 4715} The only source of information available to MWO Eisenmenger would have been the 714-page investigative file.^{Footnote 4716} Under the circumstances, it is not surprising the answers were not always complete or accurate. Maj Dandurand and Maj Bolduc, the only other CFNIS members who reviewed the answers and had an opportunity to provide input, also had no direct knowledge of the facts as far as the 2008 investigation was concerned, because they were not at all involved in the case at the time of the events.^{Footnote 4717}

340. While the failure to provide accurate information was not intentional, the failure to make appropriate efforts to gather the information was unacceptable. There could be no legitimate justification for continuing to provide the same non-responsive and inaccurate answers in January 2011 as had been provided in November 2009. By then, the CFNIS members were well aware of the Fynes’ questions and, in some cases, had specifically undertaken to provide answers, but had failed to do so.^{Footnote 4718} By then, the Fynes had also been left without any updates, information, or contact from the CFNIS for approximately four full months, despite explicit commitments to the contrary.^{Footnote 4719} Under the circumstances, the least the CFNIS members could do was to make all necessary efforts to finally answer the Fynes’ questions in a complete and accurate manner. The answers provided do not give evidence of any such efforts.

4.5.7 Conclusion

341. From the beginning of the 2008 investigation, all the way through to the end of the 2009 and 2010 investigations a little over three years later, the CFNIS did not treat the Fynes properly. The Fynes were not kept informed, were not contacted regularly, and they were not provided with adequate information. Their son’s suicide note was kept from them, and they received no immediate apology or explanation when this fact came to light. Even subsequently, the Fynes were never provided with an explanation as to what happened. Furthermore, throughout the CFNIS’ interactions with the Fynes, the practice of providing only general information not related to the specifics of the case, and the failure to advise the Fynes when earlier plans changed, often left the Fynes with inaccurate perceptions about the investigative work. The CFNIS did nothing to correct those perceptions or to ensure the Fynes knew what was happening. As a result, the Fynes felt they were being misled, and this was not an unreasonable perception under the circumstances.

342. Considering how the CFNIS treated them throughout the investigations, it is not surprising the Fynes ended up doubting everything the CFNIS did and said. Mr. Fynes testified, “The outcome of their investigation and all of our contacts has been just a web or a construct of deliberate deceit, as far as I’m concerned. We were distanced.”^{Footnote 4720}

343. While the CFNIS members involved did not intentionally seek to deceive the Fynes, their conduct in interacting with them made it impossible to establish any relationship of confidence and trust. They did not appear to understand that providing information and support to victims and complainants is an integral part of their role and responsibilities as police officers.

344. It is likely this serious mishandling of communications played a role in the Fynes’ ultimate decision to pursue their complaints before this Commission. The CFNIS certainly missed every opportunity to resolve issues and address the Fynes’ concerns appropriately. It can only be hoped the CFNIS will learn lessons from the totality of events in this case and will take measures to ensure such mistakes will not be repeated.

4.6 CFNIS Independence and Impartiality

Introduction

1. The first and most serious group of allegations made in this complaint challenges the CFNIS’ ability to conduct independent and impartial investigations.^{Footnote 4721} In essence, the Fynes allege the CFNIS members involved in the investigations were not attempting to uncover the truth in an objective and detached manner – and were not capable of doing so – because they were influenced by a desire to protect the interests and reputation of the CF as an institution. The Fynes claim this was the result both of actual influence exerted by members of the CF on the CFNIS members through various interactions or coordinated activities related to the case, and of the CFNIS members’ own biases or desire to “protect the uniform.”^{Footnote 4722} They allege the CFNIS members were incapable of being objective by virtue of the very fact they were members of the CF as well as of the Military Police, but also because, in this case, the alleged wrongdoing they were asked to investigate related to actions taken or decisions made or supported by the CF Chain of Command (CoC), as opposed to some isolated act of wrongdoing by an individual CF member.^{Footnote 4723}

2. These allegations are extremely serious. They are the most serious allegations that can be made about any police force or police officer because the ability to investigate allegations to the fullest without external interference or bias is essential to the ability of a police force to fulfill its basic role and retain its exceptional powers. When made about the CFNIS, the allegations raise special concern. The CFNIS is an internal police force in charge of investigating serious and sensitive offences within the military.^{Footnote 4724} Alleging it is not capable of carrying out its investigations without interference by or bias in favour of the military amounts to putting in question its raison d’être and its very ability to carry out its core mandate and functions.

3. In this case, the evidence heard by this Commission provides no indication of any overt interference or attempt by CF members to dictate or influence the conduct of the three CFNIS investigations or their ultimate conclusions. There is also no evidence of any bias or desire to protect CF interests in the conduct of the investigations or the conclusions reached. In fact, many of the Fynes’ allegations about these issues were not supported by any evidence at all. It is clear the Fynes were not satisfied with the result of the investigations. It is also clear, as detailed elsewhere in this report, there were deficiencies and errors made during the investigations.^{Footnote 4725} The complainants appeared to believe any such errors made or any conclusions reached with which they were not satisfied, were the result of lack of independence or bias. Underlying many of their allegations was an assumption that, because the results of the investigations tended to exonerate the military of any culpability, this was proof these results were intended by the investigators all along. In other words, they mistake outcome for intention. The evidence in this case demonstrates this assumption was faulty. The vast majority of the problems observed during the investigations appear to be entirely unrelated to lack of independence or to bias.

4. There were, to be sure, a few instances giving rise to some concerns about maintaining confidence in CFNIS independence. On the whole, these concerns relate to the fundamental problems that can result when an organization seeks to investigate itself. As an internal police force, the CFNIS will always face additional challenges to demonstrate its independence. These challenges are further heightened in a case like the present, where the allegations of wrongdoing do not relate to isolated behaviour by one or more individuals, but to broader allegations of malfeasance perpetrated or supported by the CoC and the CF as an institution. In such cases, there may inevitably be a residual suspicion the internal police force, because it is part of the very institution it must investigate, will not pursue the investigation as vigorously or will not be as inclined to find wrongdoing. This suspicion may be present regardless of the CFNIS’ actual intent or actions. As a result, the CFNIS bears the additional – and perhaps at times unfair – burden of demonstrating absolute probity in all actions related to the conduct of such investigations. Unless the CFNIS is able to demonstrate it conducted its investigation of alleged institutional wrongdoing in an exceptionally scrupulous and above-board manner in every respect, confidence in its independence can be compromised. In this case, there were some instances where the CFNIS members’ conduct fell short of this extremely high standard, and these might well, in turn, fuel suspicion of lack of independence.

5. There is no evidence of any actual impact on the conclusions reached in the investigations. However, in some cases, there were consequences for the CFNIS’ interactions with the complainants or with the public, and as such, there was a risk of creating negative perceptions.

6. Because of the importance of maintaining confidence in the police, appearances do matter when it comes to independence, especially where an internal police force is concerned. For this reason, the Commission has identified some of the issues of concern arising in this case with a view to assisting the CFNIS in better addressing such matters in the future. However, it should be kept in mind those concerns are of a fundamentally different nature from those identified in the complainants’ allegations. As such, discussion of the concerns should not be viewed in any way as detracting from the Commission’s findings that the specific allegations of lack of independence and bias made in this case are unsubstantiated.

Allegations of CFNIS Bias and Lack of Independence

7. The Fynes have alleged, as a general complaint, the three investigations in this case were not conducted in an independent manner, and they have further alleged the CFNIS is not set up with the necessary independence to conduct such investigations.^{Footnote 4726}

8. They have also made more specific allegations and raised concerns in testimony about certain conduct or interactions, which they allege demonstrate a lack of CFNIS independence. In particular, they have raised concerns about the use of the CF’s BOI and SI investigations in support of the CFNIS investigations and about the sharing of information with those bodies.^{Footnote 4727} They claim the CFNIS “participated in broader CF efforts to provide explanations and justifications in response to the complainants’ concerns,” including by sharing the Fynes’ concerns with the CF CoC, participating in public affairs coordination and participating in a CF-wide Task Force constituted to address the case.^{Footnote 4728} They also claim the CFNIS participated in efforts to withhold information from them, alleging the CFNIS’ decisions about whether and when to communicate with them and how much information to provide, were dictated or influenced by the CF CoC or legal advisors or by concerns about the CF’s litigation interests.^{Footnote 4729}

9. The Fynes also allege the CFNIS members involved in the investigations were biased in favour of the CF or Regiment CoC. They allege the investigations were aimed at exonerating the CF of any responsibility rather than objectively uncovering the truth.^{Footnote 4730} They claim the CFNIS members selected only information favourable to CF interests and made findings or statements for the purpose of exonerating the CF CoC and attacking Cpl Stuart Langridge’s character.^{Footnote 4731}

10. Together, these allegations show the Fynes believe the CFNIS members, intentionally or not, had preconceived ideas about both Cpl Langridge and his Regiment when the first investigation began. As a result, they believe the CFNIS members, at a minimum, refrained from investigating, or at worst, sought to cover-up certain matters or information in an effort to protect the CF’s institutional reputation or interests.^{Footnote 4732}

11. The Fynes also appear to believe the CFNIS will always seek to “protect the uniform” because of corporate identification with the CF and will be naturally sceptical of any allegations involving wrongdoing by the CoC or by the CF as an institution.^{Footnote 4733} Mr. Fynes testified he believes the CFNIS members have a “default position” to defend the CF as a result of their “military training and being indoctrinated into the ways of the Canadian Armed Forces.”^{Footnote 4734} He also stated the CFNIS has a default bias “because they are military first and they are police second.”^{Footnote 4735}

12. The subjects of the complaint forcefully denied these allegations.^{Footnote 4736} Some were shocked or disappointed to hear such allegations.^{Footnote 4737} Others indicated, in no uncertain terms, they thought the allegations were “false” or could not be substantiated, and they insisted CFNIS members would never behave in this manner.^{Footnote 4738} WO Ross Tourout “totally disagreed” with the notion the CFNIS, as an organization, would “work in the interests of the CF”, calling the allegation “discouraging.”^{Footnote 4739}

13. The CFNIS members took great pride in their independence and denied they would ever let external influences affect their investigations.^{Footnote 4740} MCpl David Mitchell testified independence is:

[…] something that military police in general and the NIS hold very dear. We will fight to the death in order to keep that independence intact. Without that, then essentially there is not even a possibility of justice.

So, at no time was this investigation aimed at exonerating the chain of command or the CF in general. No.”^{Footnote 4741} [Emphasis added]

14. Similarly, PO2 Eric McLaughlin affirmed:

We don’t work for our base commander […] I answer to my own chain of command, the OC answers to the CO of the NIS and that's a very straight line right up to the VCDS-CDS, as I understand it.

[…] I have never been coerced into doing anything. At the end of the day, and this is a rule…explained to me from the day I joined the NIS up till this day, the investigation is the priority, always will be.^{Footnote 4742} [Emphasis added]

15. LCol Gilles Sansterre testified he is “a policeman first” and noted, although the CFNIS are “loyal to the Canadian Forces,” this loyalty “does not interfere with our honesty and our integrity.”^{Footnote 4743}

The Conceptual View: What Does Police Independence Mean and Why Is It Important?

16. The basic concept of police independence is related to the need to avoid a “police state” situation where political or Government actors can direct police to investigate their enemies or to refrain from investigating their friends.^{Footnote 4744} At the same time, there is also a recognition police must be held accountable.^{Footnote 4745} To achieve this, it has been recognized democratically elected representatives must be able to provide general policy or management guidance to police and must, at times, answer for police actions.^{Footnote 4746} Otherwise, there would be a danger for a different type of “police state” to emerge, one where police could simply take arbitrary or uncontrolled actions without having to answer to anyone.^{Footnote 4747}

17. Professor Kent Roach provided a paper and testified before this Commission about the concept of police independence. In his view, police independence requires a balancing of competing considerations.^{Footnote 4748} Police must be held accountable but must also be able to carry out their core law enforcement functions free from political or bureaucratic interference.^{Footnote 4749} The core functions recognized as requiring independence from arbitrary interference include decisions about the conduct of investigations and the laying of charges: whom to investigate; how much investigation to carry out; when to begin, end or continue an investigation; and whether and when to bring or recommend charges.^{Footnote 4750} In these functions, police should be guided only by the rule of law and should not receive direction from or exchange detailed information with Government representatives.^{Footnote 4751}

18. In the military context, there are additional challenges because the MP are part of the CF.^{Footnote 4752} On the one hand, the need for the CF to be able to command its members, exchange information, and provide policy and managerial guidance is heightened because of the need to ensure military operations are not compromised.^{Footnote 4753} On the other hand, the dangers of improper command influence or interference are also heightened because the MP do not have a separate structure or corporate identity, and they are ultimately subject to the CF CoC.^{Footnote 4754} The Somalia inquiry provided a chilling lesson of the dangers which can arise when independence is compromised.^{Footnote 4755} Since then, there has been a growing recognition of the need to protect MP independence.^{Footnote 4756} The creation of the CFNIS, whose members have always reported directly to the CFPM rather than to CF Commanders, was one of the results of this recognition.^{Footnote 4757}

19. The need to make police independence visible is also heightened in the military context.^{Footnote 4758} Because the MP are part of the broader CF, in order to maintain public confidence in the military police,^{Footnote 4759} it is essential they be seen to have the freedom to conduct their own independent investigations and come to their own independent conclusions.^{Footnote 4760}

Specific Allegations or Concerns

The Summary Investigation and the 2009 Investigation

20. At the outset of their investigation into the Fynes’ allegations of negligence in the designation of Cpl Langridge’s PNOK, the CFNIS learned the CF Brigade in charge of Cpl Langridge’s Regiment intended to conduct a Summary Investigation (SI) into many of the same issues.^{Footnote 4761} Despite an initial attempt by the CFNIS to have the SI stopped because of its potential to hamper the criminal investigation, the SI nevertheless proceeded first.^{Footnote 4762} The CFNIS then reviewed the SI report and evidence as part of its own investigation.^{Footnote 4763}

21. The SI was not neutral in purpose or intent. Its Terms of Reference specified it was being conducted “in anticipation of litigation” to prepare the CF’s defence to an eventual lawsuit by the Fynes.^{Footnote 4764} The legal advisor to the SI, LCol Bruce King, had been involved in discussions with the Fynes and their counsel about the potential litigation and its settlement, and he might well have been perceived as acting in an adversarial capacity towards the Fynes in representing the CF’s interests.^{Footnote 4765} The legal advisor had also been identified by the CFNIS as a potential suspect in the investigation, although this was likely due to an inaccurate understanding of his role and involvement in the PNOK decision.^{Footnote 4766} After the SI was completed, the CF CoC provided strongly worded comments supporting the appropriateness of all actions taken by the Regiment in this case.^{Footnote 4767} Those comments were reviewed by CFNIS members during their investigation.^{Footnote 4768}

22. Under the circumstances, it is clear the CFNIS could not rely on the SI to come to its own conclusions without risking compromising its independence.^{Footnote 4769} The SI was an internal investigation done by the CF to protect its own litigation interests. The CFNIS was asked to investigate allegations of institutional wrongdoing by the CF in connection with the same facts. If the CFNIS ended up simply adopting the CF investigation’s conclusions or, worse, the CF CoC’s conclusions and views about the matter, its investigation could not be said to be independent.

23. There are also other, more complex questions raised by this situation. Even if the CFNIS did not adopt the CF’s conclusions, could it undermine the CFNIS investigation if it relied for its own purposes on evidence collected by the CF? Could the mere review of these materials cast doubt on the CFNIS’ independence? Was the CFNIS’ failure to stop the SI from proceeding in the first place the result of a lack of independence?

24. The complainants allege both the review of the SI and the failure to stop it are evidence of lack of independence.^{Footnote 4770}

The failure to stop the SI

25. When Maj Daniel Dandurand, the OC for the CFNIS WR Detachment, learned about the Brigade’s intent to conduct an SI, he was concerned about the possibility the SI “could taint our criminal investigation.”^{Footnote 4771} He immediately requested a meeting with the Brigade Commander, Col K.A. Corbould, “[i]n order to determine whether the SI need[ed] to be stopped” in light of the “likely overlap” with the CFNIS investigation.^{Footnote 4772} On November 25, 2009, he wrote to the investigating officer in charge of conducting the SI, Maj Derek Chenette, indicating:

I came to learn of your SI by chance and I am of the strongest belief that matters being looked into by your team will overlap with our criminal investigation.

I am meeting with Comd 1 CMBG in the morning to discuss this matter and all I ask for now is that you do not proceed with any further activity on this SI until we can determine if your activity could taint our criminal investigation. [...] Once you are back in Edmonton, I think it would be best for us to meet and discuss the way ahead.^{Footnote 4773} [Emphasis added]

26. Maj Chenette responded he would await word from the Commander before proceeding but noted he could not “afford to lose too many days” if he was instructed to proceed.^{Footnote 4774}

27. Maj Dandurand could not recall what was discussed with the Brigade Commander or what was done to address his concerns.^{Footnote 4775} He explained his intent going into the meeting was to ensure the SI would not encroach on the CFNIS investigation.^{Footnote 4776} He could not recall what assurances he received from Col Corbould, if any, but he testified he had no remaining concerns after the meeting and believed his intent had been achieved.^{Footnote 4777} He explained, if he had requested measures to be taken by a CF Commander to protect a criminal investigation and those measures were not forthcoming, he would have flagged the issue to the CO CFNIS immediately.^{Footnote 4778}

28. On the basis of this evidence, it appears Maj Dandurand either was satisfied the SI would not proceed or was satisfied it would proceed in a manner that would not impact the CFNIS investigation.^{Footnote 4779}

29. As it turns out, the SI proceeded the day after Maj Dandurand’s meeting with the Brigade Commander.^{Footnote 4780} It is not known whether Maj Dandurand was aware at the time that the SI proceeded despite his concerns.^{Footnote 4781} There is no evidence Maj Dandurand took any additional steps to stop the SI, nor evidence any steps were taken to ensure the SI did not, in fact, encroach on the CFNIS investigation. Maj Dandurand’s concerns were never put in writing in any official correspondence to the CF Brigade, and there was no follow-up.

30. In the end, the SI was completed before the CFNIS investigation even began and turned out to be much more extensive than the investigation eventually conducted by the CFNIS. The SI conducted numerous interviews with witnesses who had knowledge relevant to the CFNIS investigation before the CFNIS had a chance to interview those witnesses.^{Footnote 4782} The very first witness interviewed by the SI was one of the main subjects of the Fynes’ complaint to the CFNIS.^{Footnote 4783}

31. This created a risk for the integrity of the police investigation. It prevented the CFNIS from getting “first crack” at interviewing key witnesses, as Maj Dandurand thought it should have.^{Footnote 4784} It meant witnesses could be “contaminated” before the CFNIS had an opportunity to speak to them.^{Footnote 4785} From the issues being pursued, the types of questions being asked, or the manner in which the questions were asked, there was a risk the witnesses could have formed beliefs or understandings about what the CF’s position was about the issues or what the CF policies or expected behaviours were in this situation. This, in turn, could affect the witnesses’ perceptions, recollection or even willingness to provide information to the CFNIS. The CFNIS’ failure to take sufficient steps to stop the SI could create the perception they did not take these risks seriously, or they were unwilling or unable to protect their investigation.

32. While there is no evidence the failure to stop the SI resulted from interference by CF members, it did contribute to creating the impression the CF’s investigation was the most important investigation conducted in this case. Because the CFNIS subsequently conducted only a limited investigation, the end result could lead to a perception it was merely “rubberstamping” the CF’s more extensive investigation. This was not likely to inspire confidence in the CFNIS’ independence.

Review of the SI materials

33. During the course of their investigation, the CFNIS members obtained and reviewed the SI report, the SI Annexes, as well as policy materials gathered during the SI.^{Footnote 4786} The Annexes contained 593 pages of documentary evidence.^{Footnote 4787} They included documents recording the answers provided by the 18 witnesses interviewed during the SI.^{Footnote 4788}

34. Sgt Scott Shannon also reviewed a copy of comments made about the SI by the Commanders of the Brigade and Area in charge of Cpl Langridge’s Regiment.^{Footnote 4789} These documents included forceful and categorical views by high-ranking members of the CF CoC about some of the matters under investigation by the CFNIS. Col Corbould, the Brigade Commander, indicated he was satisfied the various “possible administrative errors” had not been caused by “intentional neglect” on the part of Regiment staff, and he concluded the matter had been “dwelled into enough” and now considered it “to be closed.”^{Footnote 4790} BGen Michael Jorgensen, the LFWA Commander, commented it was not unreasonable to treat Cpl Langridge’s common-law spouse as his NOK,^{Footnote 4791} and concluded:

[…] any reasonable and objective outside observer would find that Cpl Langridge’s post-death administration was properly executed by the CF. To review, the CF acted correctly in all important issues. [...] clearly, the CF cannot and should not assume responsibility for everything the Fynes believe went wrong.^{Footnote 4792} [Emphasis added]

35. All of the CFNIS members involved in the investigation denied they relied on the SI materials to come to their own conclusions about the complaint.^{Footnote 4793} Sgt Shannon also insisted he was not influenced by the Brigade and Area Commanders’ comments.^{Footnote 4794} There is no evidence otherwise indicating the CFNIS members’ conclusions were based on or influenced by the SI, and there is no reason to doubt their testimony on this issue.

36. In light of this, the question before the Commission is whether the mere review of these materials nevertheless raises concerns in terms of CFNIS independence. Was the review of the investigation conducted by the CF about many of the same issues investigated by the CFNIS^{Footnote 4795} liable to create doubts about the independence of the CFNIS investigation? This issue relates to the danger of creating negative perceptions and to the steps necessary to maintain confidence in CFNIS independence. There is cause for concern about this for two reasons.

37. First, if a decision had been made to proceed with charges, the review could have impacted the admissibility of the evidence gathered in the CFNIS’ own investigation. LCol Bruce MacGregor, a JAG Legal Officer who acted as the Director of Military Prosecutions for several years,^{Footnote 4796} explained, where witnesses are compelled to provide evidence in a BOI or SI, any evidence obtained by police as a direct result of those statements would likely be found inadmissible in criminal or disciplinary proceedings.^{Footnote 4797} As a result, the best approach is to ensure CFNIS investigators interview witnesses before they give evidence in BOIs or SIs.^{Footnote 4798} Otherwise, there is a risk to “really taint some evidence.”^{Footnote 4799} From the evidence, it is not clear the CFNIS members involved in this case understood this risk.^{Footnote 4800} However, the perception they were willing to take this risk could have an impact on overall confidence in the CFNIS’ independence.

38. Second, it is not clear the investigation conducted by the CFNIS in this case was sufficiently extensive to provide a tangible demonstration of its independence. Because this case involved allegations of wrongdoing by the CF as an institution, and the CFNIS had reviewed an investigation conducted by the CF to protect its own interests, it was important for the CFNIS to “take every effort, and be seen to have taken every effort, to make clear that they have reached their own independent law enforcement conclusions.”^{Footnote 4801}

39. Maj Dandurand had specifically assured the Fynes the information from the SI would not be taken at face value. He had told them the CFNIS would conduct its own interviews with the SI witnesses using its own methods.^{Footnote 4802} This was important because the evidence gathered during the SI would have been shaped by the SI’s purpose, which was to defend the CF’s interest in potential litigation. Indeed, some of the questions asked during the SI could be interpreted as providing “hints” about the appropriate answers or the issues at stake from the CF’s perspective.^{Footnote 4803} As a result, it was particularly important for the CFNIS investigators to conduct their own interviews in order to be able to show they investigated the matter independently. This was what MCpl Mitchell planned to do.^{Footnote 4804}

40. However, the CFNIS ended up interviewing only three fact witnesses compared to the 18 who were interviewed during the SI.^{Footnote 4805} When Sgt Shannon assumed the lead for the investigation, he relied on the documentary record to come to his conclusions and did not interview any fact witnesses.^{Footnote 4806} As a result, none of the members of the Regiment CoC who may have been involved in the PNOK decision, and none of the potential suspects in the investigation were questioned.^{Footnote 4807}

41. Because most of the key witnesses were not interviewed separately by the CFNIS, an appearance could be created that the CFNIS relied on the CF’s investigation to come to its conclusions. Although the subjects’ testimony in this hearing has demonstrated this was not the case, the factual investigation they conducted was not sufficiently robust to promote full confidence in their independence. Especially in light of the assurances they had provided to the Fynes, and the fact they had reviewed an investigation conducted by the CF to protect the CF’s own interests, it would have been preferable for them to have conducted a more comprehensive factual investigation, sufficient to put them in a position to demonstrate every aspect was investigated fully and independently by the CFNIS.

Conclusions about the use of the SI during the 2009 Investigation

42. The Commission finds there is no evidence the SI impacted the CFNIS’ ultimate conclusions. As such, it cannot be concluded the CFNIS lacked independence simply because it accessed and reviewed this CF investigation. However, there was a risk the CFNIS could be seen as deferring to the CF in allowing it to conduct a much more extensive investigation first. In addition, considering the heightened need to demonstrate allegations of institutional wrongdoing were investigated to the fullest, the limited investigation conducted by the CFNIS after its members reviewed the SI materials could raise concerns in terms of maintaining confidence in its independence.

The BOI Report and the 2010 Investigation

43. A Board of Inquiry (BOI) into the circumstances surrounding Cpl Langridge’s death was constituted by the Brigade in charge of Cpl Langridge’s Regiment. During the 2010 criminal negligence investigation, the CFNIS reviewed a draft of the BOI report.^{Footnote 4808}

44. The BOI was an internal CF investigation.^{Footnote 4809} Its legal advisor was the same legal officer who was involved in discussions with the Fynes’ counsel in connection with anticipated litigation and was subsequently appointed as counsel to the SI.^{Footnote 4810} Many of the issues examined during the BOI were directly relevant to the “ultimate issues” the CFNIS was asked to investigate in the 2010 investigation.^{Footnote 4811}

45. Unlike the SI, the BOI was not conducted for the purpose of advancing CF interests in any anticipated litigation. However, the Fynes were firmly of the view its entire process was biased and aimed at protecting CF interests. They alleged the witness answers were manipulated and suggested the BOI “started from a conclusion, and then made everything fit.”^{Footnote 4812} They specifically made the CFNIS aware of those concerns and repeatedly raised them during their meetings and correspondence with the investigators.^{Footnote 4813}

46. The CFNIS investigators obtained only the draft report and not the underlying evidence gathered during the BOI.^{Footnote 4814} They reviewed neither the transcripts of the actual witness testimony at the BOI nor the documentary evidence filed. As a result, they were not in a position to make their own assessment of the evidence and level of probing that took place during the BOI. They only had access to the BOI’s description of the evidence considered relevant to support its conclusions.

47. The complainants allege the use of the BOI report during the 2010 investigation is evidence of the CFNIS’ lack of independence.^{Footnote 4815} They are particularly concerned about the interaction between the BOI and the CFNIS.^{Footnote 4816} They believe there was “cross-contamination” between the two organizations.^{Footnote 4817} In essence, their concerns arise from what they perceive as information “going in a circle.”^{Footnote 4818} The circle involved the BOI obtaining the 2008 CFNIS investigation report (which the Fynes believed contained biased and incorrect findings^{Footnote 4819}), using it to question witnesses and to derive its own conclusions (which the Fynes again believed to be biased and inaccurate^{Footnote 4820}), and then passing the report back to the CFNIS for use in the 2010 investigation.^{Footnote 4821} The 2010 investigation was opened in response to the Fynes’ specific request for a separate investigation into the negligence they believed was committed by the CF in connection with their son’s death.^{Footnote 4822} This closed circle would render its status as a separate investigation meaningless.

48. The issue before the Commission is largely similar to the issue raised with respect to the review of the SI materials. If the CFNIS simply adopted the CF’s conclusions, its independence could be compromised. Even if the CFNIS did not rely on the CF’s conclusions, questions nevertheless would remain about whether sufficient investigative steps were taken to demonstrate its investigation was independent in light of its having conducted a review of the CF’s conclusions.

Reliance placed on the BOI report

49. In the 2010 file, the CFNIS was presented with serious allegations of institutional wrongdoing by the CoC of a CF Regiment. It is clear, if it was to conduct an independent investigation of the matter, it could not simply turn around and adopt the CF’s own conclusions about its lack of negligence without further probing or questioning.

50. Relying on the BOI’s conclusions would be particularly problematic in this case because the Fynes had raised concerns about the process, and the CFNIS had promised to conduct its own investigation.^{Footnote 4823}

51. The BOI report also contained several controversial conclusions and findings. The CF Reviewing Authority and the Approving Authority each took issue with some of the findings and questioned whether they were accurate or supported by sufficient evidence.^{Footnote 4824}

52. One of the reasons cited in the BOI report in support of the conclusion the Regiment had acted appropriately by requiring Cpl Langridge to remain at the base prior to receiving further treatment for his addiction issues, was that, if this had not been done, Cpl Langridge could have committed suicide while at the treatment center.^{Footnote 4825} Considering Cpl Langridge did commit suicide precisely during this period, this surprising statement, at a minimum, required further explanation. The issue was directly relevant to the CFNIS’ investigation as the CFNIS was asked to investigate whether the Regiment’s and the CF medical community’s decisions about Cpl Langridge’s treatment were negligent and contributed to causing his death.^{Footnote 4826}

53. It is not within this Commission’s mandate to pass judgment on the BOI’s conclusions, nor is it the Commission’s intent. However, the fact the report contained several controversial or unexplained conclusions and findings, the accuracy of which was being questioned even within the CF, meant it should have been clear to the CFNIS members they needed to make their own assessment of the evidence and conduct their own investigation. Without independently reviewing the BOI evidence, they could not assess, use or rely on the BOI’s conclusions.

54. The evidence before the Commission is not entirely clear as to what reliance, if any, was placed on the BOI report in the conduct of the 2010 investigative assessment. Both the investigators involved reviewed the BOI report, but did not specifically explain whether and how it was used in conducting their assessment of the file and reaching their conclusions.^{Footnote 4827} Other members involved in supervising the investigation at the Detachment and HQ levels appeared to believe some limited reliance could be placed on the BOI’s conclusions or, at least, on its failure to report any suspicion of criminal activity.^{Footnote 4828} However, their testimony did not provide insight as to whether the BOI’s conclusions were, in fact, relied on in conducting the assessment in this case. Counsel for the subjects of the complaint argued there was no basis for the CFNIS to conclude the BOI was improper or unreliable but did not make specific submissions about what reliance, if any, was placed on it in this case.^{Footnote 4829}

55. Further complicating matters, legal advice was obtained in support of the investigative assessment. Because issues of solicitor-client privilege intervened, it was more difficult for the Commission to obtain precise information about exactly what materials were reviewed and relied on.^{Footnote 4830}

56. On the whole, the evidence does not support a conclusion that the CFNIS compromised its independence by adopting the BOI’s conclusions. Other materials were reviewed during the 2010 assessment, and the investigators did perform their own analysis of the elements of the offence.^{Footnote 4831} Considering the BOI was included in the materials reviewed, there are questions about the exact source of some of the facts the investigators relied on in making their assessment.^{Footnote 4832} There is, however, no positive evidence they relied on the facts as found by the BOI to come to their conclusions. As such, it cannot be concluded the allegations of lack of independence resulting from the use of the BOI report are well founded.

57. From the perspective of maintaining confidence in the CFNIS’ independence, however, it is of concern that not all CFNIS members appeared to have a clear understanding that relying on the CF’s conclusions and findings would be problematic.

Demonstrating independence

58. The review of the BOI report during the 2010 assessment gave rise to a risk the CFNIS could be viewed as simply adopting the CF’s conclusions. It is not clear the limited activity undertaken and the limited materials reviewed by the CFNIS in this case were sufficient to dispel this notion and provide the necessary demonstration of the CFNIS’ independence.

59. LCol Sansterre testified he would see no issue with CFNIS investigators reviewing information provided during an SI or BOI, but noted they would still have to “come up with their own findings” as the CFNIS “do separate investigations.”^{Footnote 4833} He explained:

I would have a problem if they only relied on the findings of the BOI, didn't do any investigation to confirm whether they have any suspicion or have any evidence to support the allegations.^{Footnote 4834} [Emphasis added]

60. In many ways, the CFNIS members involved in the 2010 investigation did precisely what LCol Sansterre stated should be avoided. A BOI report containing findings about the same issues they were asked to investigate was included in the materials they reviewed in support of their investigative assessment, and they conducted no apparent factual investigation of their own to support their conclusions.^{Footnote 4835}

61. Their assessment was not limited to reviewing the BOI report, but the materials they had were limited. Essentially, there were the Fynes’ allegations, the 2008 investigation report, and the BOI report.^{Footnote 4836} To assess whether the allegations required investigation, the CFNIS members had to apply their analysis to a fact scenario. Some of the facts referred to in Sgt Shannon’s final presentation about the case were contrary to the Fynes’ allegations.^{Footnote 4837} The source for this understanding of the facts had to come from the materials reviewed. The 2008 investigation report contained a wealth of relevant information. However, many negligence-related issues had not been investigated properly or at all in that case.^{Footnote 4838} As such, the limited work performed in the 2010 file and the limited materials available left the door open for a perception to arise the CFNIS relied on the BOI’s factual findings to support some of its own analysis. The evidence did not positively demonstrate this was actually the case. However, the work done by the CFNIS was also not sufficient to provide a clear demonstration this was not the case. As such, confidence in its independence could be diminished.

62. The Fynes, having raised their own concerns about the BOI process, had been specifically assured an independent investigation would be conducted, and the BOI evidence and witnesses would be revisited.^{Footnote 4839} It is not surprising their own confidence in the CFNIS’ independence was further diminished when they learned the CFNIS did no investigation and included the BOI’s findings – but not the evidence supporting those findings – in the materials reviewed to assess their complaint.

Conclusions about the use of the BOI report during the 2010 Investigation

63. While the evidence is not sufficient to establish the CFNIS’ conclusions were based on those of the BOI, the Commission notes a clearer separation between the two processes, and a clearer record of a factual investigation capable of supporting the conclusions reached by the CFNIS, would have assisted in fostering greater confidence in the CFNIS’ independence.

Contacts Between the CFNIS and the CF

64. The Fynes make a number of complaints about improper or inappropriate contacts between the CFNIS and other parts of the CF. They allege the CFNIS discussed some of the Fynes’ concerns with members of the CF CoC “for the purpose of participating in CF efforts to explain and justify their actions” and not for the purpose of conducting a police investigation.^{Footnote 4840} They also express great concern about the CFNIS’ alleged participation in a CF-wide Task Force to handle the Langridge matter, which they believe demonstrates the CFNIS’ lack of independence.^{Footnote 4841}

65. Essentially, these allegations raise questions about whether interference or improper influence was exerted by the CF on the CFNIS. Communication by the CFNIS with other CF organizations is entirely appropriate and expected. General exchange of information and even guidance provided by the CF on broader organizational issues does not compromise CFNIS independence.^{Footnote 4842} Police independence concerns would arise only if the exchanges went further and involved an attempt to direct or influence the conduct of CFNIS investigations or the conclusions reached.^{Footnote 4843} Concern could also arise if there was evidence the CFNIS was pressured or influenced into adjusting its perspective or activities to advance the CF’s interests. No such evidence was presented in this case.

The LFWA meeting

66. On April 16, 2010, Maj Dandurand and other members of the CFNIS Detachment met with members of the CoC for the Brigade (1 CMBG) and Area (LFWA) in charge of Cpl Langridge’s Regiment.^{Footnote 4844}

67. The meeting was held at LFWA’s request. The main purpose was to exchange information about the different CF organizations’ responsibility for different aspects of the case.^{Footnote 4845} At the time, the SI was under review at LFWA, the BOI draft report had been submitted to the CDS’ office for approval, and the CFNIS’ 2009 investigation was ongoing.^{Footnote 4846}

68. One of the reasons the LFWA wished to obtain information about the CFNIS investigation was to evaluate its impact on its own activities and, in particular, on the approval process for the BOI at the CDS level.^{Footnote 4847} LFWA wanted to provide a comprehensive information package for the CDS, which would address all of the different investigations.^{Footnote 4848} Prior to the meeting, Maj M.H. (Mike) Hertwig-Jaksch, a member of the LFWA staff, explained:

The G1 LFWA has asked me to arrange a meeting at which we could discuss and assess the impact of the findings of the CFNIS investigation on the Cpl Langridge case as a whole.

As you are aware, the BOI is currently being reviewed at NDHQ. It is known that the Langridge family is already at disagreement over some findings of the BOI. Although the subsequent SI and CFNIS investigation are separate from the BOI, their impact will successively be felt by the Langridge family.

It would be important, therefore, to manage their expectations in a wholistic [sic], rather than piece-meal approach. In particular, the G1 considers it important that the CDS be aware of all aspects of the case (incl the SI and CFNIS investigation) when he authors his Approving Authority comments. That way, he will not be blind-sided by subsequent developments or be placed in a situation where he would have to correct himself vis-a-vis the family after the fact.^{Footnote 4849} [Emphasis added]

69. During the meeting, Maj Dandurand provided general information to notify LFWA about the CFNIS investigation but did not discuss the details of the CFNIS investigation.^{Footnote 4850} He explained he was required to “hold back” because of the relationships between the officers being investigated and those he would inform.^{Footnote 4851} He advised LFWA the CFNIS would use “normal channels” to provide notification to the CF CoC once the investigation was concluded.^{Footnote 4852}

70. Maj Dandurand also used this opportunity to raise with LFWA a number of the concerns the Fynes had communicated to him in earlier meetings. These pertained to administrative matters unrelated to the CFNIS investigation or the CFNIS’ law enforcement functions. Maj Dandurand provided detailed information to the Fynes in a subsequent meeting about the issues he had discussed with LFWA.^{Footnote 4853} They included matters “peripheral” to the criminal investigation such as the condition of Cpl Langridge’s Jeep when it was shipped to the Fynes by the Regiment, missing items in the inventory of Cpl Langridge’s effects prepared by the Regiment, issues raised by the Fynes about the BOI process, and issues surrounding the awarding of the memorial cross to the Fynes.^{Footnote 4854}

71. The discussions at the LFWA meeting do not raise any police independence concerns. For the CFNIS to provide information about its investigation to the CF CoC is in line with the legitimate exchange of information described by Prof Roach as compatible with police independence.^{Footnote 4855} The exchanges here were compatible with the briefing protocols in place and did not fall outside the normal exchange of information to be expected in military policing.^{Footnote 4856} There is no evidence indicating there was any pressure on the CFNIS to provide more information than it believed appropriate or to reach certain conclusions. On the contrary, Maj Dandurand provided only general information. No details about the CFNIS investigation were shared, and its integrity was protected.

72. The initial LFWA message did mention an intent to “manage [the family’s] expectations” in a holistic way.^{Footnote 4857} If the CFNIS were seen as participants in a CF-wide approach to managing communications with the complainants or presenting unified CF corporate positions, concerns about maintaining confidence in CFNIS independence could arise.^{Footnote 4858} However, the evidence indicates the CFNIS did not participate in any such CF enterprise.^{Footnote 4859}

73. There was nothing inappropriate about the LFWA personnel’s concern with the eventual impact of the CFNIS investigation on the BOI approval process. One of the legitimate purposes of information sharing with the military police is to allow the CF to evaluate the impact on all aspects of its activities. It was only natural, and certainly legitimate, for the CF CoC to be concerned about the CDS being blind-sided and to wish to ensure any public pronouncements he made about the case were consistent with the eventual findings of the different investigations.

74. In subsequent correspondence and during his testimony, Maj Dandurand made it clear he shared the concerns about ensuring the CDS was made aware of the CFNIS investigation before making public pronouncements on the case.^{Footnote 4860} Those concerns are focused on avoiding embarrassment for the CF and its leadership. They have nothing to do with the interests of the police investigation or any of the CFNIS’ law enforcement activities. However, this does not necessarily mean they were improper or constitute evidence of a lack of CFNIS independence.

75. It is inevitable for CFNIS members, who are also part of the broader CF organization, to be aware and supportive of the organization’s broader interests. Independence concerns would arise if they allowed such interests to influence the conduct of their investigations or the conclusions reached. There is no evidence this happened in this case. On the contrary, Maj Dandurand wanted the CDS to hold off on making public pronouncements precisely because he believed the results of the CFNIS’ 2009 investigation could include findings of wrongdoing by the CF, contrary to what other CF investigations had found. Maj Dandurand in no way suggested he intended to adjust the CFNIS’ findings or investigative activities to suit the CF’s interests.

76. There was also no impropriety in Maj Dandurand discussing the administrative matters raised by the Fynes with the CF CoC. When they first learned Maj Dandurand had brought their concerns to the CoC’s attention, the Fynes were grateful and did not express any concerns about independence or improper contact.^{Footnote 4861} Yet, they subsequently complained about this same issue before the Commission.^{Footnote 4862} In testimony, Mr. Fynes explained one of his concerns related to the fact the CFNIS did not investigate how Cpl Langridge’s Jeep had been damaged yet somehow managed to discuss the issue with the CF CoC.^{Footnote 4863} However, the evidence indicates, at the time of the events, the Fynes had not brought the issue of the damage to their son’s Jeep to the attention of the CFNIS for purposes of requesting a police investigation.^{Footnote 4864} In any event, it is doubtful such a matter would fall within the CFNIS mandate to conduct “serious and sensitive” investigations.^{Footnote 4865}

77. Maj Dandurand cannot be faulted for attempting to assist the Fynes by bringing their concerns to the attention of the CoC. One of the matters he raised related to the Fynes’ costs for correcting the registration of death for Cpl Langridge and the CF’s potential responsibility to cover these costs.^{Footnote 4866} This was more closely linked to the issues under investigation in the 2009 file.^{Footnote 4867} However, the evidence shows Maj Dandurand kept the discussions with LFWA limited to issues surrounding the administrative and financial aspects of the matter and did not discuss any substantive issues related to the CFNIS investigation.^{Footnote 4868} There is no evidence the discussions about this issue resulted in any attempt by the LFWA CoC to influence or interfere with the CFNIS investigation. In fact, the CF Brigade and Area were already well aware of the Fynes’ concerns about this issue as this was addressed in the SI.^{Footnote 4869}

The CF Task Force

78. In August 2010, the VCDS Chief of Staff instructed a CF Task Force be established to address the Fynes’ eventual legal action against the CF.^{Footnote 4870} The purpose was to ensure the CF adopted a “cohesive approach” to the litigation and the approval process for the BOI report, which was still pending.^{Footnote 4871} LFWA and staff from the Director of Army Public Affairs were to be involved in the Task Force or, at least, to maintain awareness of the situation.^{Footnote 4872}

79. The Fynes believed the CFNIS participated in the CF Task Force and came to view all of the CFNIS’ prior and subsequent actions as attempts to advance CF interests or CF corporate positions.^{Footnote 4873} They doubted the CFNIS could investigate their complaints independently and objectively if they were concurrently involved in efforts to protect the CF’s reputation and interests in connection with the case. Mr. Fynes testified:

And I know, and I’m deeply disturbed, that there was a task force in place involving Public Affairs officers and NIS, et cetera, to deal with the Langridge matter […]

[...]

The NIS were set up to be independent of a chain of command, they were to be given authority to conduct their internal investigations unhampered and unfettered by any concern for rank or the organizational structure or undue or inappropriate influence.

To see them in lock-step with another entity or other areas of the Canadian Forces whose intention is to protect the brand and to protect the uniform and to manage an affair and protect possibly from litigation, they have absolutely failed in their mandate.^{Footnote 4874} [Emphasis added]

80. To be sure, for the CFNIS to participate in a Task Force constituted to advance the CF’s litigation interests or present the CF’s corporate positions to the public, even while it was tasked with investigating alleged institutional wrongdoing by the CF, would be incompatible with the principles of police independence. It is most unfortunate the Fynes were left with the impression the CFNIS was involved.

81. The evidence before the Commission shows the CFNIS did not participate in the Task Force.^{Footnote 4875} In fact, when Maj Dandurand learned about it, he specifically told his HQ he was concerned and sought authorization to advise the Task Force about the CFNIS investigations to ensure “there is no possibility of them inadvertently stepping into our lanes.”^{Footnote 4876} He then advised the individuals involved in the communications about the Task Force that there were ongoing CFNIS investigations and that the CFNIS would have to be consulted before statements were made or inquiries about the case answered.^{Footnote 4877}

82. From a police independence perspective, there is nothing improper about Maj Dandurand’s wish to advise the Task Force about the CFNIS investigations and to ensure the Task Force did not interfere. The evidence suggests this was the CFNIS’ only contact with the eventual Task Force.^{Footnote 4878}

Pressure to conclude the investigations?

83. In February 2011, the Director of the CF’s Casualty Support Management Unit, Col Gerard Blais, wrote to the CFNIS DCO, Maj Francis Bolduc, to transmit information received from the Fynes.^{Footnote 4879} In this message, he outlined the importance of getting the CFNIS investigations “signed off as quickly as possible” and the family briefed, in order to avoid a “circular exchange with the family.”^{Footnote 4880}

84. If the CF attempted to provide direction to the CFNIS about when to conclude its investigations, police independence concerns could arise.^{Footnote 4881} On the other hand, it is entirely legitimate for the CF to have an interest in knowing about the anticipated timing for the conclusion of CFNIS investigations. It is also to be expected the CF CoC, having an interest in the result of the CFNIS’ investigations, will generally wish to see them completed as early as possible. Most complainants are likely to have similar concerns and this is part of the day-to-day reality of police work. In this case, the Fynes were certainly concerned about the timing, and Col Blais’ inquiries resulted from their complaints about this issue to his staff.^{Footnote 4882}

85. In this context, it is clear Col Blais’ comments were not improper. The evidence establishes they were not intended to issue a directive to the CFNIS, to apply pressure or to interfere with the investigations in any way.^{Footnote 4883} They were also not interpreted or perceived by the CFNIS members as pressure to hasten the conclusion of the investigations.^{Footnote 4884}

Conclusions about information exchange between the CF and the CFNIS

86. The Commission finds the interactions between the CF and the CFNIS do not raise police independence concerns in this case. The Commission saw no evidence indicating improper discussions took place.

Release of Information and Communication with the Public and the Complainants

87. Many of the Fynes’ allegations of lack of independence relate to the CFNIS’ communications with them or with the media.^{Footnote 4885} Essentially, the Fynes allege the CFNIS was involved in direct coordination with the CF, or was influenced by CF interests, in making decisions about the information to release to the public or to the complainants.

88. These complaints do not relate to alleged interference in actual CFNIS investigations or other core law enforcement functions. However, this does not mean police independence concerns cannot arise. If the CFNIS is seen to act in concert with the CF in preparing messages for the public or complainants, or in deciding what information to provide, confidence in its ability to carry out independent investigations can be diminished. In order to be able to carry out its investigations, the CFNIS requires the cooperation of potential complainants and witnesses who may have knowledge of CF wrongdoing. These individuals must be able to come forward with full confidence the CFNIS will act independently.

89. For these reasons, the CFNIS must be able to demonstrate its independence by maintaining a separation from the CF in its communications with the public and, to an even greater extent, with complainants who have brought allegations to its attention.^{Footnote 4886}

Communication with the complainants

90. The Fynes make a number of complaints about their contacts with the CFNIS and the nature of the information provided to them by the CFNIS. They allege the CFNIS’ decisions about what information to provide to them, as well as the timing and format, were influenced directly or indirectly by members of the CF CoC or CF legal advisors or by concerns about CF interests.^{Footnote 4887} In particular, they claim this influence caused the CFNIS to withhold information from them; to fail to maintain regular contact with them; to cancel a planned verbal briefing as a direct result of anticipated litigation between them and the CF; and to give insufficient information in the written briefing provided in replacement.^{Footnote 4888}

Failure to provide updates

91. The Fynes allege the CFNIS’ failure to maintain regular contact with them amounted to participation in broader CF efforts to prevent them from communicating with CF members. They believe the lack of contact was related to a “no contact” letter sent to their counsel by CF representatives in connection with anticipated litigation.^{Footnote 4889}

92. The correspondence was sent on September 21, 2010, by LCdr Gordon Thomson, counsel for the DOJ’s Office of the DND/CF Legal Advisor. It reads:

It is on this basis that I must request that you immediately inform Mrs Fynes not to have any further direct contact with members of the Canadian Forces, Department of National Defence, or Department of Justice with respect to any matters relating to the claims she has demanded from the Crown. I note that Mrs Fynes has been in contact with several sections of these offices apparently seeking compensation for the claims sought in your firm’s demand letter of 16 March 2009. All further contact with the Crown must be through you or your office to me unless you formally, and in writing, withdraw as counsel. All sections of the above mentioned organizations have been informed not to have any further direct contact with Mrs Fynes but to address the issues through this office.^{Footnote 4890} [Emphasis added]

93. When this letter was sent, there were two CFNIS investigations still ongoing. The CFNIS failed to make any contact with the Fynes between September 2010 and February 2011, despite promises to provide them regular updates about the investigations.^{Footnote 4891}

94. However, the evidence before the Commission has revealed this was unrelated to the CF’s correspondence.^{Footnote 4892} The CFNIS was not involved in the decision to send this letter, nor were they consulted about it or even aware of it.^{Footnote 4893} Had they known about the letter, it is clear the CFNIS members involved in the investigations would not have viewed it as precluding them from contacting the Fynes in any way.^{Footnote 4894} On its face, it is also doubtful the CF’s correspondence could be interpreted as seeking to limit the Fynes’ contact with the CFNIS, since such contact would not be related to any claims demanded from the Crown.^{Footnote 4895}

95. While the CFNIS’ failure to maintain regular contact with the Fynes was unfortunate,^{Footnote 4896} there is no evidence it was the result of CF influence or concern about the CF’s interests.

Cancelled briefing

96. In February 2011, the CFNIS offered to provide a verbal briefing to the Fynes about the outcome of the 2009 and 2010 investigations.^{Footnote 4897} When the Fynes requested that their lawyer be present at the briefing, CFNIS HQ decided to cancel the briefing and provide a letter instead.^{Footnote 4898}

97. The Fynes were outraged by this decision. They believed it was made as a direct result of their anticipated litigation with the CF, and they viewed it as a clear instance of the CFNIS being influenced by a desire to protect CF interests.^{Footnote 4899} Mr. Fynes testified:

I was astounded by that because if a victim asks the police to investigate potentially a criminal matter and they just refuse to tell them anything as to an outcome or a result or where their investigative processes were, the complainant or the victim is just absolutely left in the dark and then to find out that they’re doing -- they’re hiding all of this in fear of possible litigation speaks to protection of the Canadian Forces, it speaks to protection of the image and of the brand; it doesn’t speak to police work and, in my understanding of police work or the independence of police work, to conduct a fair and impartial investigation.^{Footnote 4900} [Emphasis added]

98. From the evidence before the Commission, it is clear the decision to cancel the briefing was made because the CFNIS was reluctant to become involved in the civil litigation process.^{Footnote 4901} This, in itself, does not raise police independence concerns. Although the Commission has found the decision was not appropriate in terms of fulfilling the CFNIS’ commitments and obligations to the complainants, this is unrelated to independence, and the CFNIS did have good reasons for not wanting to be pulled into the civil litigation.^{Footnote 4902} The question which does arise, from an independence perspective, is whether the reluctance to get involved related to litigation in general or whether it was specifically tied to the fact the litigation involved the CF. If the decision was directly influenced by CF members or by a desire to protect the CF’s interests in the litigation, concerns would arise in terms of maintaining confidence in the CFNIS’ independence.

99. The evidence shows there was no direct influence or interference by CF members or advisors. The CF was not involved in, and likely not even aware of, the CFNIS’ decision to cancel the briefing.^{Footnote 4903}

100. The evidence is less clear about the motivation for the decision and whether it could have been related to a desire to protect CF interests as opposed to a general aversion by police for involvement in civil litigation. The decision was made by the CFNIS DCO, Maj Bolduc, in consultation with LCol Sansterre and Maj Dandurand.^{Footnote 4904} The explanations provided by Maj Bolduc during his testimony focused solely on the impact of the presence of a lawyer on the conduct of the briefing and on the CFNIS members involved.^{Footnote 4905} LCol Sansterre’s focus was similar.^{Footnote 4906} He was not aware what the litigation was about and did not express a view about whether the fact of litigation against the CF was a sufficient reason to cancel the briefing.^{Footnote 4907} Maj Dandurand shared the same concerns,^{Footnote 4908} but he also testified he was concerned about the potential impact on the CF’s position in the eventual litigation:

MR. FREIMAN: [...] Why does the NIS care whether there is litigation by an individual against the Canadian Forces?

MAJ DANDURAND: I don't.

MR. FREIMAN: [...] What was it about the fact of litigation that was inhibiting a presentation in the presence of counsel?

MAJ DANDURAND: Because my question at the time that I had posed, having never experienced this before, was; is it my position as a Canadian Forces Officer to possibly compromise the Canadian Forces' position in preparation for civil litigation through the process of a discussion that would otherwise perhaps occur during discovery.

MR. FREIMAN: Okay. So, if I understand correctly, your concern was in your role as a Canadian Forces Officer, not in your role as an NIS investigator?

MAJ DANDURAND: Correct.^{Footnote 4909} [Emphasis added]

101. This illustrates the challenges faced by CFNIS members in maintaining strict independence while also being members of the broader CF organization.^{Footnote 4910} In this instance, the dual membership may have created confusion for the CFNIS members about their role. This confusion and the desire to fulfill broader duties as members of the CF are understandable but dangerous. They can compromise the CFNIS’ ability to foster confidence in its independence. In his testimony, Prof Roach explained:

[…] it is a challenge with respect to the military police to make sure that when they are within the core of police independence, that is, when they are exercising law enforcement discretion that they put on their policing hat really to the exclusion of their Canadian Forces hat.^{Footnote 4911} [Emphasis added]

102. When it comes to interacting with complainants, CFNIS members should not be wearing their CF hats.

103. The totality of the evidence does not establish the decision to cancel the briefing to the Fynes was motivated by a desire to protect the CF’s interests. However, Maj Dandurand’s testimony raises the possibility that the need to protect the CF’s interests was one of the factors considered in making the decision. This possibility, and the fact the CFNIS might be believed to have changed its behaviour in interacting with complainants because of the CF’s interests, can diminish confidence in CFNIS independence.

Written briefing

104. The Fynes allege the written briefing provided in lieu of the cancelled briefing did not contain sufficient information and claim this was the result of CF influence or CFNIS concern over the CF’s interests.^{Footnote 4912}

105. There is no evidence to support this allegation. The written briefing did contain insufficient information.^{Footnote 4913} However, this was not the result of an attempt to protect the CF or of influence by CF members.

106. The initial draft for the briefing was prepared by Sgt Shannon, one of the CFNIS members involved in the investigations.^{Footnote 4914} The draft letter was reviewed and approved by CFNIS HQ and then sent to the Fynes under Maj Dandurand’s signature.^{Footnote 4915} The evidence indicates the briefing was not reviewed by anyone outside of the CFNIS before it was sent to the Fynes.^{Footnote 4916} The evidence also indicates the reasons for including so little detail in the briefing had nothing to do with the civil litigation or the CF’s interests.^{Footnote 4917} It was simply the result of Sgt Shannon’s attempt to keep the correspondence simple and brief, pursuant to his understanding of the “typical rules” for drafting correspondence.^{Footnote 4918}

107. While the failure to provide more information in the written briefing was unfortunate for other reasons,^{Footnote 4919} it is not evidence of a lack of CFNIS independence.

Joint CFNIS/BOI briefing and Col Blais communications

108. The Fynes allege the CFNIS agreed to participate in a common briefing about its investigations and the BOI.^{Footnote 4920}

109. For obvious reasons, if such a briefing had been contemplated in this case, it could have impacted on the CFNIS’ ability to maintain confidence in its independence. However, the Commission found no evidence a common briefing was ever planned or offered. There is also no indication the CFNIS ever agreed or intended to participate in such a briefing. The only briefing offered to the Fynes by the CFNIS related solely to the CFNIS’ own investigations.^{Footnote 4921}

110. It appears the Fynes’ impression there was a plan to brief them on all major CF investigations at a common briefing may have arisen as a result of their communications with Col Blais, who had been named as the point of contact to answer their questions on behalf of the CF.^{Footnote 4922} These communications included several discussions relating to the briefings or updates to be provided about the BOI, the SI and the CFNIS investigations.^{Footnote 4923} As the issues were discussed together,^{Footnote 4924} it may have appeared to the Fynes the briefings would also be joined. Fortunately, this impression turned out to be mistaken. However, the communications with Col Blais about CFNIS issues opened the door to creating this confusion about the CFNIS’ role and involvement in other CF processes. In this, as well as in other respects, they were problematic in terms of maintaining confidence in CFNIS independence.

111. Col Blais acted as a conduit to provide information to the Fynes.^{Footnote 4925} He provided answers to a series of their questions about the CF’s handling of the case in a single document.^{Footnote 4926} The answers had been obtained from various CF organizations, including the CFNIS.^{Footnote 4927}

112. The end result of using this process was that information about the CFNIS’ ongoing investigations into serious allegations of wrongdoing by the CF was provided to the Fynes through the CF itself and was included alongside responses setting out the CF’s own position about the matters under investigation.^{Footnote 4928} These responses were provided by the CF organizations ultimately responsible for the CF members whose conduct was being investigated.^{Footnote 4929} This was not likely to assist in bolstering confidence in the CFNIS’ independence.

113. Further, the Fynes were told by Col Blais that all responses, including those from the CFNIS, were being vetted by DND legal advisors prior to being provided to the Fynes.^{Footnote 4930} In actual fact, only minor edits were made to the CFNIS answers.^{Footnote 4931} The edits did not alter the content of the information.^{Footnote 4932} They were done without the CFNIS’ knowledge or consent.^{Footnote 4933}

114. Maj Dandurand testified it caused him “some concern” to learn the CFNIS’ answers were being edited or changed while being transmitted to the family.^{Footnote 4934} Indeed, the CF should not be allowed to modify or influence in any way, however minor, the information provided by the CFNIS to complainants. This type of intervention impacted on the CFNIS’ ability to demonstrate its independence.

115. Overall, it is clear the appointment of Col Blais as a point of contact was only meant to assist the Fynes by simplifying their dealings with the CF. It was also in this spirit that the CFNIS agreed to participate in this process and provide answers through Col Blais about its investigations.^{Footnote 4935} It should be kept in mind the CF is a large organization. The complainants were aware of this from their own experience, and they understood Col Blais would obtain the answers to their questions about the CFNIS investigations directly from the CFNIS.

116. Nevertheless, the global CF response received by the Fynes would not have made it clear to them the CFNIS’ processes were being kept separate, and information about its ongoing investigations was not being freely shared with those under investigation. The impression could have been created that the CFNIS was involved in preparing and presenting a common CF position about the issues even while it was supposed to be investigating them. This was especially the case since the Fynes were told CFNIS information was being vetted by the CF. At a minimum, the global response was liable to send the wrong message about the appropriate separation between the CFNIS and the CF.

Conclusions about communication with the complainants

117. There was no evidence to support allegations of CFNIS lack of independence in its communications with the Fynes. The decision to cancel the verbal briefing and the decision to communicate with the Fynes through Col Blais did, however, impact on the CFNIS’ ability to demonstrate its independence.

118. To avoid such situations in the future, it would be advisable for the CFNIS to maintain its own separate communications with complainants, particularly in cases where there is tension or conflict between the complainants and the CF. The CFNIS, as a police service, should be mindful of its special status and make its own decisions about whether, when and how to communicate with complainants and about what information to provide.^{Footnote 4936} Concerns over the CF’s interests should not impact, nor be seen to impact, the CFNIS’ decisions about such matters.

Release of the 2008 investigative file and the ATI process

119. The Fynes allege the CFNIS withheld information about their 2008 investigation into Cpl Langridge’s death. They claim an overly redacted copy of the report for the investigation was provided to them without any specific or satisfactory explanation for the redactions.^{Footnote 4937} They allege this was the result of CF influence or concern about the CF’s interests.^{Footnote 4938}

120. The evidence before the Commission has revealed most of the decisions about the redactions applied to the copies of the 2008 investigation report provided to the Fynes were not made by the CFNIS. They were made by a separate DND organization, the Director of Access to Information and Privacy (DAIP).^{Footnote 4939} This was done pursuant to the usual process in place to address all requests for access to information or documents in the possession of any CF organization, including the MP.^{Footnote 4940} This process still applies today.^{Footnote 4941}

121. It is clear there is no sinister intent behind this process. It is simply a delegation of authority to the DAIP to make decisions about the application of access to information and privacy legislation to all requests for the release of DND or CF information.^{Footnote 4942} There are similar processes in place in most other Government departments.^{Footnote 4943} However, when applied to decisions about the release of CFNIS information, this process raises police independence concerns.

122. The most important concern is that the process in place does not allow the CFNIS to make final decisions about what information needs to be redacted to protect its ongoing investigations or police methods. The CFNIS can identify such information and recommend it not be released, but it does not have the authority to make the final decision.^{Footnote 4944} While, in practice, the CFNIS’ recommendations have been followed by DAIP and no issue has arisen,^{Footnote 4945} the framework in place does not give the CFNIS the necessary authority to make final decisions to protect its investigations and law enforcement activities. As such, the process creates risks for the CFNIS’ independence as it allows a separate DND organization to make decisions, which could impact on the conduct of its core policing functions.^{Footnote 4946}

123. Another important concern is the impact on the CFNIS’ ability to demonstrate its independence. Pursuant to the process in place, DAIP is free to add more redactions than those recommended by the CFNIS.^{Footnote 4947} In such cases, no consultation occurs, and the CFNIS is generally not even aware of the final redactions applied to its reports before they are released.^{Footnote 4948}

124. This case illustrates the concern well. When the Fynes complained to the CFNIS about the redactions made to the investigation report, the CFNIS members could neither explain nor change the redactions. They could only tell the Fynes those decisions were not made by the CFNIS.^{Footnote 4949} DAIP had applied extensive redactions, many difficult to understand or justify, on the basis of its own determination about what information was not necessary or not in the family’s interest to receive.^{Footnote 4950} Those determinations were made without consulting the CFNIS or the family.^{Footnote 4951}

125. It is incongruous, especially in a case involving allegations of institutional wrongdoing by the CF, for the police force in charge of investigating those allegations to have to tell the complainants the CF or DND is making decisions about what parts of the police report can be disclosed to them. This can create the impression the institutions under investigation have an opportunity to hide information about the investigations from the complainants. The Fynes certainly were under the impression information was being deliberately withheld.^{Footnote 4952} While there is no evidence any of the redactions were, in fact, made for the purpose of covering up information or protecting CF interests, and the Commission has found they were not,^{Footnote 4953} the process in place can diminish confidence in CFNIS independence.

126. MP and CFNIS witnesses who testified before the Commission had different views about the impact of the process on CFNIS independence. Some witnesses believed no concerns arose,^{Footnote 4954} while others saw potential issues, at least in terms of maintaining confidence in CFNIS independence, but believed any problems could be addressed in practice by entering into discussions with DAIP on a case-by-case basis.^{Footnote 4955}

127. There were internal discussions about the possibility of allowing the MP to assume control over the release of its own information, but the issue was never addressed in formal discussions between the MP and CF/DND leaderships.^{Footnote 4956} The application of access to information and privacy legislation is complex, and there would be significant resource implications and risk management issues if the MP were to take over decision-making authority over the release of their information.^{Footnote 4957} As a result, MP and CFNIS leaderships decided to “pick [their] battles” and did not pursue the issue by way of a formal proposal to CF leadership because it was not seen as giving rise to serious issues in practice.^{Footnote 4958} However, the experience in this case shows issues can and do arise.

Conclusions about release of CFNIS information

128. The official process currently in place allows a non-police organization to overrule the redactions recommended by the MP to protect ongoing investigations or police methods. Although this does not appear to have happened in practice, the process itself is not compatible with police independence principles. At a minimum, the MP should have final decision-making authority to refuse to release its information where it believes release could compromise its core law enforcement functions.

129. In order to foster confidence in its independence, it would also be preferable for the MP to have the authority to make its own decisions about the release of its information in all cases.^{Footnote 4959} This will be particularly important where the request is made by complainants or victims who have a direct relationship with the MP or CFNIS. The Commission recognizes the difficulties involved for both the MP and the CF/DND. Because of the complexity of the matter and the potential resource implications, high level discussions between the MP and CF/ DND leaderships would be necessary to address the issues.

Public affairs

130. As part of their complaints alleging the CFNIS “participated in broader CF efforts to provide explanations and justifications in response to the complainants’ concerns,” the Fynes take issue with CFNIS participation in public affairs coordination with the CF.^{Footnote 4960}

131. The manner in which messages about the CFNIS’ activities are conveyed to the public can have a significant impact on confidence in CFNIS independence, which can, in turn, impact on the CFNIS’ ability to carry out its policing functions.

132. If the CFNIS is not seen to be in control of the information and messages released about its investigations, if it is believed to be “speaking with one voice” with the military institutions it is charged to investigate, or if the military is believed to control the information provided to the public about CFNIS investigations, confidence in CFNIS independence will be diminished.^{Footnote 4961}

Release of CFNIS information to the public: who decides?

133. The evidence in this case has shown, in practice, it was generally the CFNIS who decided what information would be released about its investigations. This information was often released through the CFNIS’ own Media Response Lines (MRLs), which were prepared by the CFNIS Public Affairs Officer (PAO) and approved by the CFPM.^{Footnote 4962} When information about CFNIS investigations or activities was included in CF MRLs, the CFNIS PAO was consulted.^{Footnote 4963}

134. The evidence has also shown the CFNIS was consulted and was involved in the coordination of the CF’s public affairs response to the Fynes matter, both after its first investigation was concluded and while its two subsequent investigations were ongoing.^{Footnote 4964} This, in itself, would not necessarily raise police independence concerns. Exchanging information about what information each organization plans to release is not inappropriate, and there is no indication the CFNIS was obliged even to provide this information in cases where this could compromise an investigation.

135. The problem that can arise with consultation and coordination about public relations is, depending on how the consultations are done, they could risk creating the impression the CF is controlling the message for its police force.

136. In this case, the consultations were extensive. They involved significant time and resources devoted to discussing messages and approach.^{Footnote 4965} According to the evidence, this was not unusual.^{Footnote 4966} Coordinated efforts involving the CF and the CFNIS happened “extremely often” in the preparation of media responses.^{Footnote 4967} One of the goals was to ensure the different sections of the CF, including the CFNIS, did not contradict each other when providing information.^{Footnote 4968}

137. The coordination and consultations in this case occurred among the PAOs for the different CF organizations involved, including the CFNIS PAO.^{Footnote 4969} While final products required approval by the CFNIS CoC and the CFPM, the process relied entirely on the PAOs to identify and report any issues impacting on CFNIS independence. According to the witness testimony, had there been disagreements between the PAOs about information or lines related to the CFNIS, the CFPM would have been advised, and the issue could have been resolved at that level and discussed with the VCDS if necessary.^{Footnote 4970}

138. However, there was no official framework or policies governing the consultations. While many witnesses spoke of a general practice requiring CF PAOs to consult with the CFNIS before releasing any information about CFNIS investigations or activities,^{Footnote 4971} no one could point to any CF policy or directive formalizing this arrangement.^{Footnote 4972} Similar to what was done in the ATIP process, issues were dealt with on a case-by-case basis.^{Footnote 4973} This meant, although in practice other CF organizations tended to defer to the CFNIS’ decisions about the release of its information most of the time,^{Footnote 4974} they had no actual obligation to do so. Because this requirement was not formalized, the CFNIS’ ability to make decisions about its messages was not protected.

139. The overall result of this informal consultation and coordination process was that it risked creating the impression the CF was in control of all messages and the CFNIS was participating in delivering a unified message in service of a public relations strategy devised to protect the CF’s interests. This was precisely the impression formed by the Fynes in this case.^{Footnote 4975} Although the evidence does not indicate it was, in fact, what the CFNIS did, having clear and transparent policies would minimize the risk of creating such perceptions, which can be seriously damaging to any attempt to foster confidence in CFNIS independence.

Who should be the messenger?

140. Having spokespersons from the CF speak on behalf of the CFNIS can also give rise to concerns in terms of the CFNIS’ ability to demonstrate its independence. It is difficult to send the appropriate message about the separation between the CF and the CFNIS if they are seen to speak on each other’s behalf.

141. In this case, the appropriate separation was often not maintained. The CFNIS was generally consulted about the information to be released about its investigations, but it was not always the messenger. CFNIS messages were often included in global CF MRLs or public statements and ended up being delivered to the public by CF spokespersons.^{Footnote 4976} When the CF became aware of the potential for litigation and the case began to attract more media attention, the PAOs for the legal side had “the lead,” meaning they were in charge of collating the information from different CF organizations, including the CFNIS, and responding to media inquiries.^{Footnote 4977} Even the CFPM’s official public apology for the failure to disclose the suicide note was not delivered directly but was included in a statement by the CDS made on behalf of the CF as a whole.^{Footnote 4978}

142. The former CFNIS CO, LCol (Ret’d) William Garrick, testified it was not a usual or appropriate practice for the CFNIS to participate in joint briefing packages or media lines with the CF, as the CFNIS would generally do its own media lines.^{Footnote 4979} Maj Dandurand indicated the CFNIS would generally have the lead on public affairs matters where there are ongoing investigations.^{Footnote 4980} However, he also testified the appropriateness of including CFNIS messages in CF-wide briefings or MRLs would still be determined on a case-by-case basis.^{Footnote 4981} In this case, the CFNIS did participate in common responses while investigations were ongoing, and it did not always have the lead on the responses.

143. The CFNIS also, on occasion, included messages solely related to protecting the CF’s interests or reputation in its own media lines. The “key message” stating “[t]he Department of National Defence and the Canadian Forces care deeply about its personnel and their families and aspires to treat all members of the CF family with respect” was included in CFNIS MRLs, including the draft MRLs prepared following the conclusion of the 2009 and 2010 investigations.^{Footnote 4982} This message was unrelated to the CFNIS’ investigations or activities.^{Footnote 4983} As Maj Dandurand testified, it reflected “my Canadian Forces’ hat as opposed to my military police hat.”^{Footnote 4984} This is precisely what can cause concern in terms of maintaining confidence in CFNIS independence. For the CFNIS to deliver a general message about the CF’s conduct in all cases could give the impression the CFNIS has pre-conceived ideas about the CF and about any allegations of institutional misconduct by the CF it is asked to investigate.

144. From the evidence, it is clear there was no nefarious intent on the part of any of the PAOs or CF and CFNIS CoC members. Joint MRLs and statements were prepared as a matter of course, because the case involved many different CF issues, and efforts were made, in practice, to ensure the CFNIS retained control over messages about its activities, even when the messages were being delivered by the CF. However, in terms of fostering confidence in CFNIS independence, this practice was problematic.^{Footnote 4985} It risked creating the perception the CFNIS was participating in a coordinated CF effort to convey certain messages.^{Footnote 4986} Further, it opened the door for messages conveying the CF’s own position about the matters under investigation to be included in media lines or public statements alongside messages from the CFNIS, which created a risk the CFNIS would be seen as endorsing the CF’s positions even while it was still investigating the issues.

CF comments about matters under investigation

145. Another question before the Commission is whether the CF high command’s own separate messages or comments about matters under investigation by the CFNIS can have an impact on confidence in CFNIS independence.

146. In this case, while the CFNIS’ 2009 and 2010 investigations were still ongoing, the CDS wrote a letter to the editor, published in the Edmonton Journal, which contained comments about some of the issues being investigated.^{Footnote 4987} He wrote:

The case of Cpl. Stuart Langridge is a tragedy that affects us all. Canadian Forces (CF) personnel who suffer from mental health conditions deserve the best possible care, indeed the same high standards of support as if they suffered physical injury. Langridge received sound medical care from the best that our provincial and military medical systems can provide. Sadly, despite the efforts of many assisting health-care professionals, his close friends, and the leaders of his regiment, it was not enough. Last week I apologized for the mishandling of communications with the family of Langridge. I was not apologizing for the comprehensive medical care he received from some of the finest civilian and military practitioners the country has to offer, nor for the CF's actions to respect and fulfil his last will and wishes. The CF has a caring medical system focused on supporting and rehabilitating those who serve their country so valiantly, along with the families that support them. We will continue to improve. A death diminishes us all, no matter what the circumstances. It is my duty to care for the sons and daughters of Canada -- a duty I take seriously.^{Footnote 4988} [Emphasis added]

147. The CFNIS did not participate in preparing or issuing these comments, and the evidence clearly shows the comments had no impact on the CFNIS’ conduct of the investigations or the ultimate conclusions reached.^{Footnote 4989} However, a concern arises in terms of the perception which can be created, because the CFNIS, as an organization internal to the CF, is subject to the CDS’ overall authority. As such, there is a potential risk the CDS’ comments could be viewed as being made not only on behalf of the CF organization being investigated but also on behalf of the internal police force conducting the investigations. There may even be a risk for the comments to be viewed as either directing or influencing the CFNIS members involved in the investigations.

148. That being said, the CF is entitled to present its own positions to the public about matters under investigation.^{Footnote 4990} The CFNIS is not responsible for the public comments the CF chooses to make. It does not have the authority to prevent public comment by the CF high command. Nor would it be reasonable to expect such comments to be prohibited in the name of police independence,^{Footnote 4991} especially in a case like this one, where the Fynes made public comments and allegations about the conduct of the CF and its members, and the CF was entitled to respond publicly.^{Footnote 4992}

149. In fact, if the independence safeguards put in place continue to function properly, it should be expected public comments about matters under investigation by the CF high command will continue to be made from time to time, as the CDS’ office will not be aware of the exact scope of each investigation carried out by the CFNIS and may well comment on certain matters without knowing they are under investigation.

150. The best way for the CFNIS to minimize the risk of creating negative perceptions when such comments are made by the CF is to ensure its participation in public relations coordination with the CF is appropriately limited and its messages are delivered separately from any CF messages. If this is done consistently, there will be less risk for the CF’s comments to be viewed as being made on behalf of the police force and less confusion about the role and perspectives of the different organizations.

Conclusions about public relations coordination

151. The evidence does not support a conclusion that the CFNIS participated in efforts to present the CF’s perspective to the public. There is no evidence the CF exerted any control or influence over the CFNIS’ messages, nor is there any evidence the CFNIS modified its messages about its investigations to serve the CF’s interests or public relations strategy.

152. However, the coordination that took place, the lack of formal processes to frame the discussions, and the manner in which messages were delivered all contributed to creating perceptions detrimental to maintaining public confidence in CFNIS independence.

153. As suggested by Prof Roach, it would be preferable for consultations about public relations to occur at a higher level.^{Footnote 4993} This would help ensure they are more transparent and involve officials who are accountable and have an understanding of the requirements of police independence.^{Footnote 4994} Having clear policies governing such matters, rather than relying on a general practice, which may or may not be known or adhered to by all CF PAOs, would also provide more effective safeguards.^{Footnote 4995}

154. The CFNIS should deliver its own messages to the public, separately from the CF.^{Footnote 4996} If the CFNIS is careful not to speak on behalf of the CF and is careful not to allow the CF to speak on its behalf, a clearer demonstration of its independence will be provided.

Legal Advice

155. In their complaint before this Commission, the Fynes specifically refer to the role of CF legal advisors and allege they participated in influencing the CFNIS’ decisions, in particular about their contacts with the complainants.^{Footnote 4997}

156. The basic issue raised by this allegation is whether consultation by the CFNIS of legal advisors who are members of the CF, and who answer to a CoC separate from the Military Police’s, raises issues about independence.

157. As Prof Roach explained, if the advice is obtained from military or civilian prosecutors, no concerns are raised since these actors have duties to uphold the rule of law similar to the police’s duties.^{Footnote 4998} If advice was sought from CF legal advisors who are not prosecutors or from DOJ counsel representing the interests of the Government, independence issues could arise, depending on the content of the advice.^{Footnote 4999}

158. There is very little evidence before this Commission about specific legal advice received by the CFNIS in connection with the issues raised in the Fynes’ complaint.^{Footnote 5000} Because of solicitor-client privilege, it cannot be known exactly what advice was obtained and from whom.^{Footnote 5001} However, the evidence has shown the general practice followed by the CFNIS is to obtain legal advice from military prosecutors or from its embedded legal advisor, who is also a member of the JAG’s Director of Military Prosecutions.^{Footnote 5002} There is no indication any derogation from this practice took place in this case. Based on the evidence available, it does not appear any independence concerns arise as a result of any legal advice sought or obtained by the CFNIS.

159. Questions were raised during the hearing about the possibility inappropriate legal consultations might have taken place. In an affidavit filed before the Commission, DND/CF Ombudsman Investigator Patrick Martel stated he was told by the CFNIS members involved in the 2009 investigation they had received advice from LCol King respecting certain issues relevant to the investigation.^{Footnote 5003} LCol King is not a member of the prosecution service.^{Footnote 5004} He was directly involved in providing advice to the CF about the case in his role as legal advisor to the BOI and the SI, and he was directly involved in representing the CF in litigation discussions with the Fynes’ counsel.^{Footnote 5005} He had also been identified as a potential suspect in the 2009 investigation.^{Footnote 5006} Had advice been sought from him by the CFNIS during the conduct of the investigation, it certainly could have raised concerns. However, the evidence clearly established no such advice was, in fact, ever sought or obtained.^{Footnote 5007} It appears Mr. Martel’s belief such contact had occurred was simply the result of a misunderstanding.^{Footnote 5008}

CFNIS Impartiality and Allegations of Systemic Bias

160. The Fynes believe the CFNIS investigations were biased. They make a number of general complaints alleging the investigations were aimed at exonerating the CF and attacking Cpl Langridge’s character.^{Footnote 5009} They also specifically allege the 2008 investigation findings were inaccurate and biased, and they claim the information obtained during that investigation was not selected in an objective and impartial manner.^{Footnote 5010} They complain the CFNIS members allowed their initial investigation to be “tainted” by meetings with CF members even before attending the scene of Cpl Langridge’s death and provided inaccurate information to the ME about Cpl Langridge’s disciplinary status.^{Footnote 5011} They further allege inaccurate statements were made about Cpl Langridge’s place of residence for the purpose of exonerating the Regiment CoC.^{Footnote 5012}

161. Having studied a large body of testimony and documentation, the Commission is convinced the totality of this evidence does not support the allegations of bias on the part of the CFNIS members involved in the investigations. Deficiencies in all of the investigations conducted are detailed elsewhere in this report. These deficiencies were, for the most part, related to inexperience, faulty assumptions and inadequate supervision.^{Footnote 5013} However, the evidence has shown the CFNIS members all sought to complete their tasks to the best of their ability. Although they did not always succeed, it is clear they had no intent to cover up anything. The Commission saw no evidence indicating any dishonesty or inappropriate motivations on the part of any of the CFNIS members involved in the investigations.

162. Further, the evidence has revealed many of the events did not happen as the Fynes believed they had.

163. It is clear there was no meeting with members of the LDSH Regiment prior to attending the scene of Cpl Langridge’s death.^{Footnote 5014} Thus, there was no opportunity for the investigation to be tainted as alleged by the Fynes.^{Footnote 5015} Contrary to the Fynes’ belief, there is no evidence the CFNIS members who attended at the scene had any preconceived views about Cpl Langridge, nor were they subsequently influenced by any CF views of Cpl Langridge as a “defaulter.”^{Footnote 5016}

164. The information provided to the ME about Cpl Langridge’s possible status as a defaulter was also not a manifestation of any bias on the part of the CFNIS members. When they arrived at the base following Cpl Langridge’s death, the investigators obtained information from local MP members indicating Cpl Langridge may have been on defaulters^{Footnote 5017} and then discussed this information with the ME investigator.^{Footnote 5018} They made it clear the information was not confirmed.^{Footnote 5019} When the ME investigator inquired about the meaning of the term “defaulters,” the CFNIS members provided explanations.^{Footnote 5020} The ME investigator testified he interpreted this as meaning Cpl Langridge had disciplinary issues and, as a result, mentioned this in his report.^{Footnote 5021} This led to a notation in the ME Certificate indicating Cpl Langridge “had disciplinary issues,” to which the Fynes took great offence.^{Footnote 5022}

165. It is very clear, however, this mention was not the result of any inappropriate action by the CFNIS or its members. It was entirely appropriate for the investigators to provide the ME investigator with all information available to them at the time. They never indicated Cpl Langridge had disciplinary issues, and they made it clear the information about Cpl Langridge potentially having been on defaulters was unconfirmed. The lead investigator subsequently provided clarification to the ME investigator indicating Cpl Langridge was “free to come and go” and not under official “formal custody.”^{Footnote 5023}

166. Similarly, the CFNIS members did not make inaccurate statements about Cpl Langridge’s place of residence for the purpose of exonerating the Regiment CoC as alleged by the Fynes.^{Footnote 5024} During his second meeting with the Fynes, MCpl Mitchell did discuss his belief, based on his initial review of the SI materials, Cpl Langridge resided at the Duty Desk only for a few days after he returned from the hospital until a room could be made available for him in the barracks.^{Footnote 5025} This information was not accurate. However, it is clear MCpl Mitchell’s statements were simply based on an honest misunderstanding and not made with any sinister intentions or bias.^{Footnote 5026} MCpl Mitchell made it clear during the meeting he intended to verify the information found in the SI materials and was not relying on it to draw conclusions about Cpl Langridge’s place of residence or any other issue.^{Footnote 5027}

167. Mrs. Fynes testified she believed there was more discussion about the issue of her son’s place of residence than what is found on the recordings of the interview that are in evidence before this Commission.^{Footnote 5028} However, the evidence has refuted the allegation the recordings of the interview had been tampered with or were incomplete.^{Footnote 5029} As such, the Commission finds the transcript in evidence contains all of the exchanges with MCpl Mitchell about Cpl Langridge’s place of residence. These exchanges do not indicate any bias on MCpl Mitchell’s part, nor any intent to misrepresent or conceal information.

168. Likewise, the use of a former address for Cpl Langridge in the “entities” section of the 2008 GO file was not the result of any intention to attack Cpl Langridge’s reputation or to exonerate the CF.^{Footnote 5030} The evidence indicates the notation resulted from information previously entered in the system used by the MP.^{Footnote 5031}

169. It appears the Fynes had doubts about the CFNIS’ impartiality from the beginning.^{Footnote 5032} They did not believe CF members could investigate other CF members objectively.^{Footnote 5033} In some instances, the approaches adopted by CFNIS members during the course of the investigations may have contributed to reinforcing those doubts.

170. One example is the apparent difference in tone and approach for the interviews of higher ranking members of the Regiment during the 2008 investigation.^{Footnote 5034} For interviews with members of a lower rank, the witnesses were addressed by their first name, the interviews were conducted at the CFNIS Detachment, and the interviews were longer and more detailed.^{Footnote 5035} By contrast, the interviews with the Regimental Sergeant-Major, CWO Douglas Ross, and with the Acting Base Surgeon, Capt Richard Hannah, were shorter and less detailed, the witnesses were addressed as “Sir,” and the interviews were conducted in their offices.^{Footnote 5036}

171. Other examples include: the apparent failure of the CFNIS investigators to question, in a more searching, in-depth or critical manner, the decisions or statements made by the Regiment CoC, or as Mr. Fynes put it, the CFNIS’ apparent willingness to accept “cursory explanations […] without any further inquiry” despite obvious contradictions;^{Footnote 5037} the CFNIS members’ apparent difficulty in understanding and investigating how negligence by the Regiment could have occurred in this case;^{Footnote 5038} the CFNIS’ failure to obtain medical records and interview medical personnel from civilian hospitals, limiting information available about Cpl Langridge’s condition and treatment to military medical records and the views of military medical personnel;^{Footnote 5039} the CFNIS’ formulation of the Concluding Remarks for the 2008 investigation, which were not supported by the evidence, and which the Fynes believed were biased and “spoke to a mind-set that was exculpatory for the military and passing blame to the victim”;^{Footnote 5040} and the modification by CFNIS supervisors of the Case Summary for the 2008 investigation to remove most mentions of the investigation of the suicide watch issue, which the Fynes alleged demonstrated the CFNIS was involved in a “cover up.”^{Footnote 5041}

172. These various circumstances might have left the Fynes with the impression the CFNIS members were concerned with maintaining good relations with the chain of command, or “not rocking the boat,” further confirming the Fynes’ initial perception about the CFNIS’ predispositions. However, while these deficiencies in the CFNIS investigations were unfortunate and have been addressed in detail elsewhere in this report,^{Footnote 5042} there is absolutely no evidence indicating they were caused by any bias on the part of the investigators.

Conclusion

173. The allegations of bias and lack of independence made in this case are not supported by the evidence. The Commission found no attempt by the CF or its legal advisors to influence the conduct of the CFNIS investigations. The CFNIS was capable of conducting independent investigations in this case and did conduct these investigations. The decisions made by the CFNIS members about the conduct of the investigations, and the ultimate conclusions they reached, were not influenced by the CF or the CF’s interests. The subjects of the complaint acted honestly and attempted to conduct impartial investigations to the best of their ability. There is no evidence they ever took or failed to take any investigative step for the purpose of exonerating the CF or attacking Cpl Langridge’s character.

174. However, the evidence has also demonstrated some of the events in this case did raise concerns about the CFNIS’ ability to demonstrate its independence. In particular, some of the policies and practices in place leave the door open for CF influence to be exercised or for suspicions it has been. To continue to protect their independence and to foster public confidence in the MP, CFNIS and MP leadership must address the issues identified and must ensure policies and practices allow them both to act independently and be seen to act independently.

175. This case, and in particular the allegations of bias and lack of independence made by the Fynes, should be viewed as a caution flag for the CFNIS. Being an internal police force, there will always be a risk the CFNIS will be perceived by complainants as being predisposed to favour CF interests. This risk will be particularly acute where complainants bring forward allegations implicating the CF CoC or challenging the CF’s institutional positions. In such cases, complainants are likely to be already significantly suspicious of the CF and its members, as was the case for the Fynes. As such, it will be important for the CFNIS, in order to gain the complainants’ trust, to conduct vigorous investigations, which will dispel any suspicion they may be biased or predisposed to advance CF interests.

176. On the basis of the evidence, it appears CFNIS members receive strong indoctrination and training on the need to conduct robust investigations into individual behaviour by CF members regardless of rank or position.^{Footnote 5043} From their testimony before this Commission and the examples they provided, this ethos appears to have been deeply ingrained in the CFNIS members.^{Footnote 5044}

177. However, it is not as clear the particular importance of conducting especially vigorous investigations into allegations attacking the CF’s institutional decisions has been equally ingrained. In order to ensure allegations are brought forward without fear by complainants who are at odds with the CF as an institution, it is important for the CFNIS to be able to demonstrate such allegations will be investigated to the fullest, and official CF decisions will be critically examined and questioned by the CFNIS. In this respect, it can certainly be said the investigations in this case could have been more complete and rigorous.^{Footnote 5045} Although this failure did not result from any bias or lack of independence, it did have the impact of further fuelling the Fynes’ suspicions, concerns and fears.

Footnotes

Footnote 604

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 625.

Return to footnote 604 referrer

Footnote 605

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 150-152.

Return to footnote 605 referrer

Footnote 606

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 2.

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Footnote 607

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 3.

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Footnote 608

Exhibit P-134, doc. 1400, p. 2.

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Footnote 609

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 3.

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Footnote 610

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 13-14; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 9.

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Footnote 611

Exhibit P-134, doc. 1400, p. 3.

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Footnote 612

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 3.

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Footnote 613

Exhibit P-134, doc. 1400, p. 3.

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Footnote 614

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 3-4.

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Footnote 615

Exhibit P-134, doc. 1400, p. 3.

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Footnote 616

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 6.

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Footnote 617

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 5.

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Footnote 618

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 2.

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Footnote 619

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 3.

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Footnote 620

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 3.

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Footnote 621

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 10.

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Footnote 622

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 4-5.

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Footnote 623

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 5.

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Footnote 624

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 5.

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Footnote 625

Exhibit P-135, doc. 1401, p. 3.

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Footnote 626

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 9-10.

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Footnote 627

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 17.

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Footnote 628

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 5-6.

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Footnote 629

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 17.

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Footnote 630

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 6.

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Footnote 631

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 9.

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Footnote 632

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 15.

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Footnote 633

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 29.

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Footnote 634

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 15-16.

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Footnote 635

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 625.

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Footnote 636

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 5-6.

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Footnote 637

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 7.

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Footnote 638

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 2.

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Footnote 639

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 21.

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Footnote 640

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 2.

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Footnote 641

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 2-3.

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Footnote 642

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 3.

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Footnote 643

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 3.

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Footnote 644

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 21.

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Footnote 645

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 21.

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Footnote 646

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 4.

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Footnote 647

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 7.

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Footnote 648

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 286.

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Footnote 649

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 6-7.

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Footnote 650

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 6-7.

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Footnote 651

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 6-7.

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Footnote 652

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 11.

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Footnote 653

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 33-35.

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Footnote 654

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 12.

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Footnote 655

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 8.

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Footnote 656

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 17.

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Footnote 657

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 9.

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Footnote 658

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 9.

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Footnote 659

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 10.

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Footnote 660

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 17.

Return to footnote 660 referrer

Footnote 661

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 13-14.

Return to footnote 661 referrer

Footnote 662

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 14.

Return to footnote 662 referrer

Footnote 663

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 73.

Return to footnote 663 referrer

Footnote 664

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 524.

Return to footnote 664 referrer

Footnote 665

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 72.

Return to footnote 665 referrer

Footnote 666

Exhibit P-178, doc. 1458, p. 1.

Return to footnote 666 referrer

Footnote 667

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 72.

Return to footnote 667 referrer

Footnote 668

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 72.

Return to footnote 668 referrer

Footnote 669

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 72.

Return to footnote 669 referrer

Footnote 670

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 73.

Return to footnote 670 referrer

Footnote 671

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 73-74.

Return to footnote 671 referrer

Footnote 672

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 74.

Return to footnote 672 referrer

Footnote 673

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 3.

Return to footnote 673 referrer

Footnote 674

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 1-2.

Return to footnote 674 referrer

Footnote 675

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 2.

Return to footnote 675 referrer

Footnote 676

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 2.

Return to footnote 676 referrer

Footnote 677

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 3.

Return to footnote 677 referrer

Footnote 678

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 3.

Return to footnote 678 referrer

Footnote 679

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1369.

Return to footnote 679 referrer

Footnote 680

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 113-114.

Return to footnote 680 referrer

Footnote 681

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 10-11.

Return to footnote 681 referrer

Footnote 682

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 3.

Return to footnote 682 referrer

Footnote 683

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 3; Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 37.

Return to footnote 683 referrer

Footnote 684

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 3; Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 37.

Return to footnote 684 referrer

Footnote 685

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 3-4.

Return to footnote 685 referrer

Footnote 686

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 4.

Return to footnote 686 referrer

Footnote 687

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 8.

Return to footnote 687 referrer

Footnote 688

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 8-9.

Return to footnote 688 referrer

Footnote 689

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 37.

Return to footnote 689 referrer

Footnote 690

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 4.

Return to footnote 690 referrer

Footnote 691

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 4.

Return to footnote 691 referrer

Footnote 692

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 9-10.

Return to footnote 692 referrer

Footnote 693

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 37.

Return to footnote 693 referrer

Footnote 694

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 13-14; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 55; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 294 and 1369.

Return to footnote 694 referrer

Footnote 695

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 133-134; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 2.

Return to footnote 695 referrer

Footnote 696

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 56; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 140.

Return to footnote 696 referrer

Footnote 697

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 6.

Return to footnote 697 referrer

Footnote 698

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 6.

Return to footnote 698 referrer

Footnote 699

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 6.

Return to footnote 699 referrer

Footnote 700

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 6.

Return to footnote 700 referrer

Footnote 701

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 201; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 32.

Return to footnote 701 referrer

Footnote 702

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 104-105.

Return to footnote 702 referrer

Footnote 703

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 13.

Return to footnote 703 referrer

Footnote 704

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 13.

Return to footnote 704 referrer

Footnote 705

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p, 14; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 2.

Return to footnote 705 referrer

Footnote 706

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 2.

Return to footnote 706 referrer

Footnote 707

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 101.

Return to footnote 707 referrer

Footnote 708

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 101.

Return to footnote 708 referrer

Footnote 709

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 12-13; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 101.

Return to footnote 709 referrer

Footnote 710

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 102.

Return to footnote 710 referrer

Footnote 711

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 39.

Return to footnote 711 referrer

Footnote 712

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1370.

Return to footnote 712 referrer

Footnote 713

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1101 and 1198.

Return to footnote 713 referrer

Footnote 714

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 115-116; Exhibit P-2, Collection B, vol. 1, tab 1, doc.1087, p. 1058.

Return to footnote 714 referrer

Footnote 715

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 65.

Return to footnote 715 referrer

Footnote 716

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 65; Exhibit P-5, Collection E, vol. 2, tab 11, doc. 1144, p. 45.

Return to footnote 716 referrer

Footnote 717

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 65-66.

Return to footnote 717 referrer

Footnote 718

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 45.

Return to footnote 718 referrer

Footnote 719

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 66.

Return to footnote 719 referrer

Footnote 720

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 66.

Return to footnote 720 referrer

Footnote 721

Exhibit P-2, Collection B, vol. 1, tab 1, doc.1087, p. 1370.

Return to footnote 721 referrer

Footnote 722

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 293.

Return to footnote 722 referrer

Footnote 723

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 66; Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 45.

Return to footnote 723 referrer

Footnote 724

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 66-67.

Return to footnote 724 referrer

Footnote 725

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 67-68.

Return to footnote 725 referrer

Footnote 726

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 68-69.

Return to footnote 726 referrer

Footnote 727

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 73-74.

Return to footnote 727 referrer

Footnote 728

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 89-90.

Return to footnote 728 referrer

Footnote 729

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 3 and 9; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 6.

Return to footnote 729 referrer

Footnote 730

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 9.

Return to footnote 730 referrer

Footnote 731

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 10.

Return to footnote 731 referrer

Footnote 732

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 165-167.

Return to footnote 732 referrer

Footnote 733

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 1.

Return to footnote 733 referrer

Footnote 734

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 1-2

Return to footnote 734 referrer

Footnote 735

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 2; Exhibit P-115, tab 11, doc. 1388, p. 3.

Return to footnote 735 referrer

Footnote 736

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 2; Exhibit P-115, tab 11, doc. 1388, p. 3.

Return to footnote 736 referrer

Footnote 737

Exhibit P-115, tab 11, doc. 1388, pp. 2-3.

Return to footnote 737 referrer

Footnote 738

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 3.

Return to footnote 738 referrer

Footnote 739

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 3; Exhibit P-115, tab 11, doc. 1388, p. 3.

Return to footnote 739 referrer

Footnote 740

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 3; Exhibit P-115, tab 11, doc. 1388, pp. 2-3.

Return to footnote 740 referrer

Footnote 741

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 3-4.

Return to footnote 741 referrer

Footnote 742

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 4.

Return to footnote 742 referrer

Footnote 743

Exhibit P-115, tab 11, doc. 1388, pp. 2-3.

Return to footnote 743 referrer

Footnote 744

Exhibit P-115, tab 11, doc. 1388, p. 1.

Return to footnote 744 referrer

Footnote 745

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 12.

Return to footnote 745 referrer

Footnote 746

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 12-13.

Return to footnote 746 referrer

Footnote 747

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 13.

Return to footnote 747 referrer

Footnote 748

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 9; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 6.

Return to footnote 748 referrer

Footnote 749

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 2; Exhibit P-115, tab 9, doc. 1386, p. 2.

Return to footnote 749 referrer

Footnote 750

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 3-4; Exhibit P-115, tab 9, doc. 1386, p. 2.

Return to footnote 750 referrer

Footnote 751

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 4; Exhibit P-115, tab 9, doc. 1386, pp. 1-2.

Return to footnote 751 referrer

Footnote 752

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 4; Exhibit P-115, tab 9, doc. 1386, p. 1.

Return to footnote 752 referrer

Footnote 753

Exhibit P-115, tab 9, doc. 1386, p. 2.

Return to footnote 753 referrer

Footnote 754

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 4-5; Exhibit P-115, tab 9, doc. 1386, p. 1.

Return to footnote 754 referrer

Footnote 755

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 5-6.

Return to footnote 755 referrer

Footnote 756

Exhibit P-115, tab 9, doc. 1386, p. 1.

Return to footnote 756 referrer

Footnote 757

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 6-7; Exhibit P-115, tab 9, doc. 1386, p. 1.

Return to footnote 757 referrer

Footnote 758

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 2; Exhibit P-5, Collection E, vol. 2, tab 12, doc. 1145, p. 3.

Return to footnote 758 referrer

Footnote 759

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 197.

Return to footnote 759 referrer

Footnote 760

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 197-199.

Return to footnote 760 referrer

Footnote 761

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 200; Exhibit P-115, tab 9, doc. 1386, p. 2.

Return to footnote 761 referrer

Footnote 762

Exhibit P-115, tab 9 doc. 1386, p. 2.

Return to footnote 762 referrer

Footnote 763

Exhibit P-115, tab 9 doc. 1386, p. 1.

Return to footnote 763 referrer

Footnote 764

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 6; Exhibit P-115, tab 8, doc. 1385.

Return to footnote 764 referrer

Footnote 765

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 9-10.

Return to footnote 765 referrer

Footnote 766

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 9-10.

Return to footnote 766 referrer

Footnote 767

Exhibit P-136, doc. 1402, p. 1.

Return to footnote 767 referrer

Footnote 768

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 115.

Return to footnote 768 referrer

Footnote 769

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 2.

Return to footnote 769 referrer

Footnote 770

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 2; Exhibit P-136, doc. 1402, p. 2.

Return to footnote 770 referrer

Footnote 771

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 2-3.

Return to footnote 771 referrer

Footnote 772

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 3.

Return to footnote 772 referrer

Footnote 773

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 3; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 125.

Return to footnote 773 referrer

Footnote 774

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 3; Exhibit P-136, doc. 1402, p. 1.

Return to footnote 774 referrer

Footnote 775

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 3; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 127; Exhibit P-136, doc. 1402, p. 1.

Return to footnote 775 referrer

Footnote 776

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 3; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 127-128.

Return to footnote 776 referrer

Footnote 777

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 128.

Return to footnote 777 referrer

Footnote 778

Exhibit P-136, doc. 1402, p. 1.

Return to footnote 778 referrer

Footnote 779

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 131.

Return to footnote 779 referrer

Footnote 780

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 55-56.

Return to footnote 780 referrer

Footnote 781

Exhibit P-136, doc. 1402, p. 1.

Return to footnote 781 referrer

Footnote 782

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 4; Exhibit P-136, doc. 1402, p. 2.

Return to footnote 782 referrer

Footnote 783

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 4-7.

Return to footnote 783 referrer

Footnote 784

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 5-6; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 8.

Return to footnote 784 referrer

Footnote 785

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 4; Exhibit P-136, doc. 1402, p. 2.

Return to footnote 785 referrer

Footnote 786

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 4; Exhibit P-136, doc. 1402, p. 2.

Return to footnote 786 referrer

Footnote 787

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 6; Exhibit P-115, tab 10, doc. 1387.

Return to footnote 787 referrer

Footnote 788

Exhibit P-115, tab 10, doc. 1387.

Return to footnote 788 referrer

Footnote 789

Exhibit P-5, Collection E, vol. 2, tab 24, doc. 1144, p. 11.

Return to footnote 789 referrer

Footnote 790

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 4-5; Exhibit P-115, tab 10, doc. 1387.

Return to footnote 790 referrer

Footnote 791

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 5.

Return to footnote 791 referrer

Footnote 792

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 5.

Return to footnote 792 referrer

Footnote 793

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 5.

Return to footnote 793 referrer

Footnote 794

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 5.

Return to footnote 794 referrer

Footnote 795

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 5.

Return to footnote 795 referrer

Footnote 796

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 6.

Return to footnote 796 referrer

Footnote 797

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 6.

Return to footnote 797 referrer

Footnote 798

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 3.

Return to footnote 798 referrer

Footnote 799

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 3-4.

Return to footnote 799 referrer

Footnote 800

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 4.

Return to footnote 800 referrer

Footnote 801

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, pp. 3-4.

Return to footnote 801 referrer

Footnote 802

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 5.

Return to footnote 802 referrer

Footnote 803

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 203.

Return to footnote 803 referrer

Footnote 804

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 203.

Return to footnote 804 referrer

Footnote 805

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 138.

Return to footnote 805 referrer

Footnote 806

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 147.

Return to footnote 806 referrer

Footnote 807

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 188.

Return to footnote 807 referrer

Footnote 808

Testimony of MCpl Bruce-Hayes, Transcript of Proceedings, vol. 37, 20 June 2012, p. 6.

Return to footnote 808 referrer

Footnote 809

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 188.

Return to footnote 809 referrer

Footnote 810

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 190.

Return to footnote 810 referrer

Footnote 811

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 147.

Return to footnote 811 referrer

Footnote 812

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 148.

Return to footnote 812 referrer

Footnote 813

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 189.

Return to footnote 813 referrer

Footnote 814

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 146.

Return to footnote 814 referrer

Footnote 815

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 149.

Return to footnote 815 referrer

Footnote 816

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 150.

Return to footnote 816 referrer

Footnote 817

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 5-6.

Return to footnote 817 referrer

Footnote 818

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 19-20.

Return to footnote 818 referrer

Footnote 819

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 121.

Return to footnote 819 referrer

Footnote 820

Testimony of MCpl Bruce-Hayes, Transcript of Proceedings, vol. 37, 20 June 2012, p. 6.

Return to footnote 820 referrer

Footnote 821

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 128.

Return to footnote 821 referrer

Footnote 822

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 122.

Return to footnote 822 referrer

Footnote 823

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 22-23.

Return to footnote 823 referrer

Footnote 824

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 23-24.

Return to footnote 824 referrer

Footnote 825

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 25-26.

Return to footnote 825 referrer

Footnote 826

Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 826 referrer

Footnote 827

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 155.

Return to footnote 827 referrer

Footnote 828

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 27-28; Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 828 referrer

Footnote 829

Fatality Inquiries Act, R.S.A. 2000,c. F-9.

Return to footnote 829 referrer

Footnote 830

Fatality Inquiries Act, R.S.A. 2000,c. F-9., s. 10(2).

Return to footnote 830 referrer

Footnote 831

Fatality Inquiries Act, R.S.A. 2000,c. F-9., s. 19(1).

Return to footnote 831 referrer

Footnote 832

Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 832 referrer

Footnote 833

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 18-19.

Return to footnote 833 referrer

Footnote 834

Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 834 referrer

Footnote 835

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 24.

Return to footnote 835 referrer

Footnote 836

Final Submissions of the Subjects, pp. 49-50.

Return to footnote 836 referrer

Footnote 837

Final Submissions of the Subjects, p. 53.

Return to footnote 837 referrer

Footnote 838

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 156.

Return to footnote 838 referrer

Footnote 839

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, April 5, 2012, pp. 97-98.

Return to footnote 839 referrer

Footnote 840

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 501-502.

Return to footnote 840 referrer

Footnote 841

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 24.

Return to footnote 841 referrer

Footnote 842

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 27-28.

Return to footnote 842 referrer

Footnote 843

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 27-28.

Return to footnote 843 referrer

Footnote 844

Exhibit P-147, tab 1, doc. 1422, p. 134; Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 26-27.

Return to footnote 844 referrer

Footnote 845

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 52-53.

Return to footnote 845 referrer

Footnote 846

Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 846 referrer

Footnote 847

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 42-43.

Return to footnote 847 referrer

Footnote 848

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 43.

Return to footnote 848 referrer

Footnote 849

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 88.

Return to footnote 849 referrer

Footnote 850

See, generally, Testimony of Det. Insp. Olinyk, Insp. Fitzpatrick and S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 163-306.

Return to footnote 850 referrer

Footnote 851

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, p. 175.

Return to footnote 851 referrer

Footnote 852

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 178-181.

Return to footnote 852 referrer

Footnote 853

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 181-182.

Return to footnote 853 referrer

Footnote 854

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 184-185.

Return to footnote 854 referrer

Footnote 855

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, p. 186-187.

Return to footnote 855 referrer

Footnote 856

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, p. 192.

Return to footnote 856 referrer

Footnote 857

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 193-194.

Return to footnote 857 referrer

Footnote 858

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 222-223.

Return to footnote 858 referrer

Footnote 859

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 193-194.

Return to footnote 859 referrer

Footnote 860

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, p. 195.

Return to footnote 860 referrer

Footnote 861

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, p. 196.

Return to footnote 861 referrer

Footnote 862

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 197-198.

Return to footnote 862 referrer

Footnote 863

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, p. 199.

Return to footnote 863 referrer

Footnote 864

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 227-228.

Return to footnote 864 referrer

Footnote 865

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 207-208.

Return to footnote 865 referrer

Footnote 866

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 227-228.

Return to footnote 866 referrer

Footnote 867

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 201-202.

Return to footnote 867 referrer

Footnote 868

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 198-199.

Return to footnote 868 referrer

Footnote 869

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 201-202.

Return to footnote 869 referrer

Footnote 870

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 198-199.

Return to footnote 870 referrer

Footnote 871

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 199-200.

Return to footnote 871 referrer

Footnote 872

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 315-317.

Return to footnote 872 referrer

Footnote 873

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 53.

Return to footnote 873 referrer

Footnote 874

Fatality Inquiries Act, R.S.A. 2000,c. F-9., s. 19(1).

Return to footnote 874 referrer

Footnote 875

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 216-217.

Return to footnote 875 referrer

Footnote 876

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 51-52.

Return to footnote 876 referrer

Footnote 877

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 216-217.

Return to footnote 877 referrer

Footnote 878

National Defence Act, RSC 1985, c N-5.

Return to footnote 878 referrer

Footnote 879

National Defence Act, RSC 1985, c N-5, s. 156.

Return to footnote 879 referrer

Footnote 880

Criminal Code, RSC 1985, c C-46.

Return to footnote 880 referrer

Footnote 881

Criminal Law Amendment Act, 1972, SC 1972, c 13.

Return to footnote 881 referrer

Footnote 882

R. v. Nolan, [1987] 1 SCR 1212 at 1222-1223.

Return to footnote 882 referrer

Footnote 883

R. v. Nolan, [1987] 1 SCR 1212.

Return to footnote 883 referrer

Footnote 884

Final Submissions of the Subjects, p. 51.

Return to footnote 884 referrer

Footnote 885

Final Submissions of the Subjects, pp. 53-54.

Return to footnote 885 referrer

Footnote 886

See Final Submissions of the Subjects, pp. 17-18 and 47-52.

Return to footnote 886 referrer

Footnote 887

Exhibit P-2, Collection B, vol. 2, tab 1, doc 1087-B, pp. 129-132.

Return to footnote 887 referrer

Footnote 888

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 30-32.

Return to footnote 888 referrer

Footnote 889

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 30-31.

Return to footnote 889 referrer

Footnote 890

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 30-32.

Return to footnote 890 referrer

Footnote 891

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 32-33.

Return to footnote 891 referrer

Footnote 892

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 43.

Return to footnote 892 referrer

Footnote 893

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 50.

Return to footnote 893 referrer

Footnote 894

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 51-52.

Return to footnote 894 referrer

Footnote 895

Fatality Inquiries Act, R.S.A 2000,c.F-9, ss.5(3), 5(4), 19(1)

Return to footnote 895 referrer

Footnote 896

Fatality Inquiries Act, R.S.A. 2000,c. F-9., s. 21(1).

Return to footnote 896 referrer

Footnote 897

Fatality Inquiries Act, R.S.A. 2000,c. F-9., ss. 9(1) and 9(2).

Return to footnote 897 referrer

Footnote 898

Fatality Inquiries Act, R.S.A. 2000,c. F-9., ss. 9(1) and 9(2).

Return to footnote 898 referrer

Footnote 899

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 50-51.

Return to footnote 899 referrer

Footnote 900

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 92-93.

Return to footnote 900 referrer

Footnote 901

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 179-181; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 101-102.

Return to footnote 901 referrer

Footnote 902

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 24 and 65; Fatality Inquiries Act, RSA 2000, c F-9, s. 31.

Return to footnote 902 referrer

Footnote 903

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 180-182.

Return to footnote 903 referrer

Footnote 904

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 10.

Return to footnote 904 referrer

Footnote 905

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 178-180, 241-243, and 247-248; Testimony of Det. Insp. William Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 188-193 and 269-271; Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 196-199 and 203-205.

Return to footnote 905 referrer

Footnote 906

Exhibit P-148, tab 3, doc. 1428, p. 4.

Return to footnote 906 referrer

Footnote 907

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 313-315.

Return to footnote 907 referrer

Footnote 908

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 91-92.

Return to footnote 908 referrer

Footnote 909

Exhibit P-6, Collection F, vol. 1, tab 44, doc. 1191, p. 3.

Return to footnote 909 referrer

Footnote 910

Exhibit P-148, tab 3, doc. 1428, p. 4.

Return to footnote 910 referrer

Footnote 911

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 53-64 and 87-89; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 193-194; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 56-57, 235-236 and 274-275.

Return to footnote 911 referrer

Footnote 912

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 42.

Return to footnote 912 referrer

Footnote 913

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 63.

Return to footnote 913 referrer

Footnote 914

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 23-24.

Return to footnote 914 referrer

Footnote 915

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 35-38.

Return to footnote 915 referrer

Footnote 916

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 23-24.

Return to footnote 916 referrer

Footnote 917

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 26.

Return to footnote 917 referrer

Footnote 918

Exhibit P-147, tab 1, doc. 1422, p. 136.

Return to footnote 918 referrer

Footnote 919

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1

Return to footnote 919 referrer

Footnote 920

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 51-52.

Return to footnote 920 referrer

Footnote 921

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 221.

Return to footnote 921 referrer

Footnote 922

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1

Return to footnote 922 referrer

Footnote 923

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1

Return to footnote 923 referrer

Footnote 924

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 247-248.

Return to footnote 924 referrer

Footnote 925

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, p. 249.

Return to footnote 925 referrer

Footnote 926

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 124.

Return to footnote 926 referrer

Footnote 927

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 26-27.

Return to footnote 927 referrer

Footnote 928

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 26.

Return to footnote 928 referrer

Footnote 929

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 25-26.

Return to footnote 929 referrer

Footnote 930

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 25-26.

Return to footnote 930 referrer

Footnote 931

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 25.

Return to footnote 931 referrer

Footnote 932

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 25.

Return to footnote 932 referrer

Footnote 933

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 219-220.

Return to footnote 933 referrer

Footnote 934

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 219-220.

Return to footnote 934 referrer

Footnote 935

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 219-220; “Livor mortis,” online: http://en.wikipedia.org/wiki/Lividity; Part 3 Investigation of Death, “The Roles of Police Officers and Coroners,” online: http://www.in.gov/ctb/files/section301.pdf , p. 98, cited in Reply Submissions of the Subjects (8 January, 2013), pp. 3 and 20-28.

Return to footnote 935 referrer

Footnote 936

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 25-26.

Return to footnote 936 referrer

Footnote 937

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 189.

Return to footnote 937 referrer

Footnote 938

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 151.

Return to footnote 938 referrer

Footnote 939

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 25-27.

Return to footnote 939 referrer

Footnote 940

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 42-42.

Return to footnote 940 referrer

Footnote 941

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 56-57.

Return to footnote 941 referrer

Footnote 942

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 63.

Return to footnote 942 referrer

Footnote 943

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 60.

Return to footnote 943 referrer

Footnote 944

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 42.

Return to footnote 944 referrer

Footnote 945

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 53-55 and 87-88.

Return to footnote 945 referrer

Footnote 946

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 59-60.

Return to footnote 946 referrer

Footnote 947

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 150-151.

Return to footnote 947 referrer

Footnote 948

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 277-278.

Return to footnote 948 referrer

Footnote 949

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 163.

Return to footnote 949 referrer

Footnote 950

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 950 referrer

Footnote 951

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 253-254.

Return to footnote 951 referrer

Footnote 952

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 254-255.

Return to footnote 952 referrer

Footnote 953

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 265-266.

Return to footnote 953 referrer

Footnote 954

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 265-266.

Return to footnote 954 referrer

Footnote 955

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 258-259.

Return to footnote 955 referrer

Footnote 956

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 261-262.

Return to footnote 956 referrer

Footnote 957

Exhibit P-147, tab 1, doc. 1422, p. 135.

Return to footnote 957 referrer

Footnote 958

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 151.

Return to footnote 958 referrer

Footnote 959

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 151.

Return to footnote 959 referrer

Footnote 960

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 101.

Return to footnote 960 referrer

Footnote 961

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 69-70.

Return to footnote 961 referrer

Footnote 962

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 151.

Return to footnote 962 referrer

Footnote 963

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 104-106.

Return to footnote 963 referrer

Footnote 964

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 631-633.

Return to footnote 964 referrer

Footnote 965

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 70-71.

Return to footnote 965 referrer

Footnote 966

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 183-184.

Return to footnote 966 referrer

Footnote 967

Exhibit P-5, Collection E, vol. 6, tab 13, doc.1246-B, p. 28.

Return to footnote 967 referrer

Footnote 968

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 253-254; Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 265-266; Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 261-262.

Return to footnote 968 referrer

Footnote 969

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 40-41.

Return to footnote 969 referrer

Footnote 970

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 41.

Return to footnote 970 referrer

Footnote 971

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 41-42.

Return to footnote 971 referrer

Footnote 972

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 91-92.

Return to footnote 972 referrer

Footnote 973

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 90-91.

Return to footnote 973 referrer

Footnote 974

See Section 4.1.3, The Investigation Plan.

Return to footnote 974 referrer

Footnote 975

Exhibit P-2, Collection B, vol. 2, tab1, doc 1087-B, pp. 134-135.

Return to footnote 975 referrer

Footnote 976

Final Submissions of the Complainants, pp. 7-8.

Return to footnote 976 referrer

Footnote 977

estimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 185.

Return to footnote 977 referrer

Footnote 978

Exhibit P-4, Collection D, vol. 7, tab 67, doc. 591, pp. 1-2; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 185-186.

Return to footnote 978 referrer

Footnote 979

Exhibit P-2, Collection B, vol. 2, tab1, doc 1087-B, pp. 129-132.

Return to footnote 979 referrer

Footnote 980

Exhibit P-4, Collection D, vol. 1, tab 29, doc 032, pp. 2-3.

Return to footnote 980 referrer

Footnote 981

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 198-199 and 213-216.

Return to footnote 981 referrer

Footnote 982

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 216-221.

Return to footnote 982 referrer

Footnote 983

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 208-212.

Return to footnote 983 referrer

Footnote 984

Fatality Inquiries Act, R.S.A. 2000,c. F-9., ss. 10(1) and 10(2).

Return to footnote 984 referrer

Footnote 985

Fatality Inquiries Act, R.S.A. 2000,c. F-9., s. 19(1).

Return to footnote 985 referrer

Footnote 986

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 37-40.

Return to footnote 986 referrer

Footnote 987

Fatality Inquiries Act, R.S.A. 2000,c. F-9., s. 22(1).

Return to footnote 987 referrer

Footnote 988

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 37-40.

Return to footnote 988 referrer

Footnote 989

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 36-37.

Return to footnote 989 referrer

Footnote 990

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 37-40.

Return to footnote 990 referrer

Footnote 991

Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 991 referrer

Footnote 992

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 26-27.

Return to footnote 992 referrer

Footnote 993

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 43.

Return to footnote 993 referrer

Footnote 994

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 52-53.

Return to footnote 994 referrer

Footnote 995

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 59-60.

Return to footnote 995 referrer

Footnote 996

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 60.

Return to footnote 996 referrer

Footnote 997

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 60-62.

Return to footnote 997 referrer

Footnote 998

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 39.

Return to footnote 998 referrer

Footnote 999

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 46-47.

Return to footnote 999 referrer

Footnote 1000

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 43.

Return to footnote 1000 referrer

Footnote 1001

Exhibit P-147, tab 1, doc. 1422, p. 135.

Return to footnote 1001 referrer

Footnote 1002

Exhibit P-147, tab 1, doc. 1422, pp. 135-136.

Return to footnote 1002 referrer

Footnote 1003

Exhibit P-147, tab 1, doc. 1422, p. 136.

Return to footnote 1003 referrer

Footnote 1004

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 32-33.

Return to footnote 1004 referrer

Footnote 1005

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 68-69.

Return to footnote 1005 referrer

Footnote 1006

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 124.

Return to footnote 1006 referrer

Footnote 1007

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 43-44.

Return to footnote 1007 referrer

Footnote 1008

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 44-45.

Return to footnote 1008 referrer

Footnote 1009

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 51-52.

Return to footnote 1009 referrer

Footnote 1010

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 35.

Return to footnote 1010 referrer

Footnote 1011

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 35-36.

Return to footnote 1011 referrer

Footnote 1012

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 35-36.

Return to footnote 1012 referrer

Footnote 1013

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 65-66.

Return to footnote 1013 referrer

Footnote 1014

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 28.

Return to footnote 1014 referrer

Footnote 1015

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 33.

Return to footnote 1015 referrer

Footnote 1016

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 30-31.

Return to footnote 1016 referrer

Footnote 1017

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 30-31.

Return to footnote 1017 referrer

Footnote 1018

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 33.

Return to footnote 1018 referrer

Footnote 1019

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 61-62.

Return to footnote 1019 referrer

Footnote 1020

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 189.

Return to footnote 1020 referrer

Footnote 1021

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 189.

Return to footnote 1021 referrer

Footnote 1022

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 81-82.

Return to footnote 1022 referrer

Footnote 1023

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 60-62.

Return to footnote 1023 referrer

Footnote 1024

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 79-80.

Return to footnote 1024 referrer

Footnote 1025

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 53-54.

Return to footnote 1025 referrer

Footnote 1026

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 53.

Return to footnote 1026 referrer

Footnote 1027

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 277-278.

Return to footnote 1027 referrer

Footnote 1028

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 262.

Return to footnote 1028 referrer

Footnote 1029

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 28.

Return to footnote 1029 referrer

Footnote 1030

Final Submissions of the Subjects, p. 53.

Return to footnote 1030 referrer

Footnote 1031

Final Submissions of the Subjects, p. 51-52.

Return to footnote 1031 referrer

Footnote 1032

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 221-224.

Return to footnote 1032 referrer

Footnote 1033

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, p. 195.

Return to footnote 1033 referrer

Footnote 1034

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 211-212.

Return to footnote 1034 referrer

Footnote 1035

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 227-245

Return to footnote 1035 referrer

Footnote 1036

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 237-238.

Return to footnote 1036 referrer

Footnote 1037

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 37-40.

Return to footnote 1037 referrer

Footnote 1038

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, p. 251.

Return to footnote 1038 referrer

Footnote 1039

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, p. 252.

Return to footnote 1039 referrer

Footnote 1040

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 37-39.

Return to footnote 1040 referrer

Footnote 1041

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 235; Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 258.

Return to footnote 1041 referrer

Footnote 1042

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 39.

Return to footnote 1042 referrer

Footnote 1043

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 54-55.

Return to footnote 1043 referrer

Footnote 1044

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 53-55.

Return to footnote 1044 referrer

Footnote 1045

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 244-245.

Return to footnote 1045 referrer

Footnote 1046

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 245-246.

Return to footnote 1046 referrer

Footnote 1047

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 246-247.

Return to footnote 1047 referrer

Footnote 1048

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 36-37.

Return to footnote 1048 referrer

Footnote 1049

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 29.

Return to footnote 1049 referrer

Footnote 1050

See Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 22; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 40; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 44; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 188.

Return to footnote 1050 referrer

Footnote 1051

Testimony of MCpl Bruce-Hayes, Transcript of Proceedings, vol. 37, 20 June 2012, pp. 12-13.

Return to footnote 1051 referrer

Footnote 1052

Testimony of MCpl Bruce-Hayes, Transcript of Proceedings, vol. 37, 20 June 2012, pp. 10-11.

Return to footnote 1052 referrer

Footnote 1053

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 23.

Return to footnote 1053 referrer

Footnote 1054

Testimony of Mr. Lackie, Transcript of Proceedings, vol. 50, 19 September 2012, p. 49.

Return to footnote 1054 referrer

Footnote 1055

Final Submissions of the Subjects, p. 53.

Return to footnote 1055 referrer

Footnote 1056

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 49-50.

Return to footnote 1056 referrer

Footnote 1057

Testimony of MCpl (Ret’d) Hurlburt, Transcript of Proceedings, vol. 45, 11 September 2012, p. 78.

Return to footnote 1057 referrer

Footnote 1058

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 28-29.

Return to footnote 1058 referrer

Footnote 1059

Testimony of MCpl Bruce-Hayes, Transcript of Proceedings, vol. 37, 20 June 2012, p. 10.

Return to footnote 1059 referrer

Footnote 1060

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 51-52.

Return to footnote 1060 referrer

Footnote 1061

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 41.

Return to footnote 1061 referrer

Footnote 1062

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 40-42.

Return to footnote 1062 referrer

Footnote 1063

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 164-165.

Return to footnote 1063 referrer

Footnote 1064

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 90-91.

Return to footnote 1064 referrer

Footnote 1065

Exhibit P-6, Collection F, vol. 1, tab 44, doc. 1191, p. 1; Exhibit P-148, tab 3, doc. 1428, p. 1.

Return to footnote 1065 referrer

Footnote 1066

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 20-21.

Return to footnote 1066 referrer

Footnote 1067

Exhibit P-4, Collection D, vol. 1, tab 29, doc 032, pp. 2-3.

Return to footnote 1067 referrer

Footnote 1068

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, pp. 630-713.

Return to footnote 1068 referrer

Footnote 1069

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 140-142.

Return to footnote 1069 referrer

Footnote 1070

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 91-92.

Return to footnote 1070 referrer

Footnote 1071

Exhibit P-4, Collection D, vol. 1, tab 29, doc 032, pp. 2-3.

Return to footnote 1071 referrer

Footnote 1072

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189.

Return to footnote 1072 referrer

Footnote 1073

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, pp. 2-4 and 8-12.

Return to footnote 1073 referrer

Footnote 1074

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 44-45.

Return to footnote 1074 referrer

Footnote 1075

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 187.

Return to footnote 1075 referrer

Footnote 1076

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 188-190.

Return to footnote 1076 referrer

Footnote 1077

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, p. 180.

Return to footnote 1077 referrer

Footnote 1078

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 46-47.

Return to footnote 1078 referrer

Footnote 1079

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 280-281.

Return to footnote 1079 referrer

Footnote 1080

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 146 and 148.

Return to footnote 1080 referrer

Footnote 1081

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 147 and 157.

Return to footnote 1081 referrer

Footnote 1082

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 149.

Return to footnote 1082 referrer

Footnote 1083

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 43-44.

Return to footnote 1083 referrer

Footnote 1084

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 49.

Return to footnote 1084 referrer

Footnote 1085

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 49-50.

Return to footnote 1085 referrer

Footnote 1086

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, pp. 4-11.

Return to footnote 1086 referrer

Footnote 1087

Exhibit P-147, tab 1, doc. 1422, p. 142.

Return to footnote 1087 referrer

Footnote 1088

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, pp. 9-10.

Return to footnote 1088 referrer

Footnote 1089

Exhibit P-147, tab 1, doc. 1422, p. 139.

Return to footnote 1089 referrer

Footnote 1090

Exhibit P-5, Collection E, vol. 6, tab 13, doc.1246-B, p. 12.

Return to footnote 1090 referrer

Footnote 1091

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 50-51.

Return to footnote 1091 referrer

Footnote 1092

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 301-302.

Return to footnote 1092 referrer

Footnote 1093

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 299-301.

Return to footnote 1093 referrer

Footnote 1094

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 298-299.

Return to footnote 1094 referrer

Footnote 1095

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 11.

Return to footnote 1095 referrer

Footnote 1096

“Then I saw a new heaven and a new earth, for the first heaven and the first earth had passed away, and there was no longer any sea. I saw the Holy City, the new Jerusalem, coming down out of heaven from God, prepared as a bride beautifully dressed for her husband. And I heard a loud voice from the throne saying, ‘Now the dwelling of God is with men, and he will live with them. They will be his people, and God himself will be with them and be their God. He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away.’” Biblica, The Holy Bible (New International Version, Rev. 21) (Grand Rapids: Zondervan, 1973) [Emphasis indicating passages underlined by Cpl Langridge].

Return to footnote 1096 referrer

Footnote 1097

Exhibit P-148, tab 3, doc. 1428, p. 1.

Return to footnote 1097 referrer

Footnote 1098

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 178-186 and 236-239.

Return to footnote 1098 referrer

Footnote 1099

Exhibit P-148, tab 3, doc. 1428, p. 1; Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 1.

Return to footnote 1099 referrer

Footnote 1100

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 53-55; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 57; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 13 and 68-69.

Return to footnote 1100 referrer

Footnote 1101

See Section 4.1.2, Investigating Negligence.

Return to footnote 1101 referrer

Footnote 1102

Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, p. 204.

Return to footnote 1102 referrer

Footnote 1103

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 277-278.

Return to footnote 1103 referrer

Footnote 1104

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 34.

Return to footnote 1104 referrer

Footnote 1105

Exhibit P-4, Collection D, vol. 14, tab 1, doc. 1202, p. 1.

Return to footnote 1105 referrer

Footnote 1106

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 272.

Return to footnote 1106 referrer

Footnote 1107

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 54.

Return to footnote 1107 referrer

Footnote 1108

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 88-89.

Return to footnote 1108 referrer

Footnote 1109

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 1109 referrer

Footnote 1110

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 89.

Return to footnote 1110 referrer

Footnote 1111

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 54-56; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 18-19; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 123-124; Exhibit P-148, tab 3, doc. 1428, p. 1, p. 4; Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 1.

Return to footnote 1111 referrer

Footnote 1112

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 66; Exhibit P-1, Collection A, vol. 2, tab 3, doc 001-E, p. 31.

Return to footnote 1112 referrer

Footnote 1113

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 267.

Return to footnote 1113 referrer

Footnote 1114

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 132-133 and 269.

Return to footnote 1114 referrer

Footnote 1115

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 267.

Return to footnote 1115 referrer

Footnote 1116

Testimony of Mr. Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 48-50.

Return to footnote 1116 referrer

Footnote 1117

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 193-194.

Return to footnote 1117 referrer

Footnote 1118

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 566-568 and 590-592.

Return to footnote 1118 referrer

Footnote 1119

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 611-613.

Return to footnote 1119 referrer

Footnote 1120

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 614-616.

Return to footnote 1120 referrer

Footnote 1121

See Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C.

Return to footnote 1121 referrer

Footnote 1122

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 113-114.

Return to footnote 1122 referrer

Footnote 1123

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 52.

Return to footnote 1123 referrer

Footnote 1124

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 38-39.

Return to footnote 1124 referrer

Footnote 1125

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 48.

Return to footnote 1125 referrer

Footnote 1126

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 47-51.

Return to footnote 1126 referrer

Footnote 1127

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 150-152.

Return to footnote 1127 referrer

Footnote 1128

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 103.

Return to footnote 1128 referrer

Footnote 1129

Final Submissions of the Subjects of the Complaint, p. 59.

Return to footnote 1129 referrer

Footnote 1130

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F.

Return to footnote 1130 referrer

Footnote 1131

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G.

Return to footnote 1131 referrer

Footnote 1132

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H.

Return to footnote 1132 referrer

Footnote 1133

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I.

Return to footnote 1133 referrer

Footnote 1134

See: 4.1.2, Investigating Negligence.

Return to footnote 1134 referrer

Footnote 1135

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 100-101.

Return to footnote 1135 referrer

Footnote 1136

See: 4.1.2, Investigating Negligence.

Return to footnote 1136 referrer

Footnote 1137

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 148-149; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 126, 130-131, and 137-138.

Return to footnote 1137 referrer

Footnote 1138

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 88-89; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 1138 referrer

Footnote 1139

Exhibit P-4, Collection D, vol. 10, tab 99, doc. 923.

Return to footnote 1139 referrer

Footnote 1140

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 278-279 and 281-282.

Return to footnote 1140 referrer

Footnote 1141

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 227-232.

Return to footnote 1141 referrer

Footnote 1142

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 69-70.

Return to footnote 1142 referrer

Footnote 1143

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 70.

Return to footnote 1143 referrer

Footnote 1144

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 184-185; Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 204-205.

Return to footnote 1144 referrer

Footnote 1145

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 193-194.

Return to footnote 1145 referrer

Footnote 1146

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 533-535.

Return to footnote 1146 referrer

Footnote 1147

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 85-86.

Return to footnote 1147 referrer

Footnote 1148

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 34-35 and 81-83.

Return to footnote 1148 referrer

Footnote 1149

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 592.

Return to footnote 1149 referrer

Footnote 1150

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 74-76.

Return to footnote 1150 referrer

Footnote 1151

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 93.

Return to footnote 1151 referrer

Footnote 1152

Exhibit P-105, doc. 1382, p. 16; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 274.

Return to footnote 1152 referrer

Footnote 1153

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 235 [Emphasis added].

Return to footnote 1153 referrer

Footnote 1154

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 93-94.

Return to footnote 1154 referrer

Footnote 1155

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 69-70.

Return to footnote 1155 referrer

Footnote 1156

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 77-80.

Return to footnote 1156 referrer

Footnote 1157

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 103-104.

Return to footnote 1157 referrer

Footnote 1158

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 53-54.

Return to footnote 1158 referrer

Footnote 1159

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 25.

Return to footnote 1159 referrer

Footnote 1160

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 258-261.

Return to footnote 1160 referrer

Footnote 1161

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 91.

Return to footnote 1161 referrer

Footnote 1162

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 68 and 91.

Return to footnote 1162 referrer

Footnote 1163

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 12-13.

Return to footnote 1163 referrer

Footnote 1164

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, p. 42.

Return to footnote 1164 referrer

Footnote 1165

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 26 and 52-53.

Return to footnote 1165 referrer

Footnote 1166

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 18 and 26.

Return to footnote 1166 referrer

Footnote 1167

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, p. 29.

Return to footnote 1167 referrer

Footnote 1168

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 68-72.

Return to footnote 1168 referrer

Footnote 1169

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 623-624.

Return to footnote 1169 referrer

Footnote 1170

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 158-160; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 624.

Return to footnote 1170 referrer

Footnote 1171

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 624.

Return to footnote 1171 referrer

Footnote 1172

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 624.

Return to footnote 1172 referrer

Footnote 1173

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 506-510.

Return to footnote 1173 referrer

Footnote 1174

Final submissions of the complainants, pp. i-vi, 4-5, 17-19 and 29.

Return to footnote 1174 referrer

Footnote 1175

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 160-171; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 93-95; Section 4.1.3, The Investigation Plan; Section 4.1.1, Investigating the Sudden Death.

Return to footnote 1175 referrer

Footnote 1176

Exhibit P-148, tab 3, doc. 1428.

Return to footnote 1176 referrer

Footnote 1177

Exhibit P-148, tab 3, doc. 1428, p. 1.

Return to footnote 1177 referrer

Footnote 1178

See e.g., Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 178-186 and 236-239.

Return to footnote 1178 referrer

Footnote 1179

Exhibit P-148, tab 3, doc. 1428, p. 2.

Return to footnote 1179 referrer

Footnote 1180

Exhibit P-148, tab 3, doc. 1428, p. 1.

Return to footnote 1180 referrer

Footnote 1181

Exhibit P-148, tab 3, doc. 1428, pp. 2-3.

Return to footnote 1181 referrer

Footnote 1182

E.g. Fatality Inquiries Act, RSA 2000, c F-9, s. 10.

Return to footnote 1182 referrer

Footnote 1183

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 181-182.

Return to footnote 1183 referrer

Footnote 1184

Cpl Hurlburt remained at the scene and was present when MCpl Ritco arrived, but it is unknown if he was actually isolated by the MP members. Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 140.

Return to footnote 1184 referrer

Footnote 1185

Exhibit P-148, tab 3, doc. 1428, p. 3.

Return to footnote 1185 referrer

Footnote 1186

Exhibit P-148, tab 3, doc. 1428, p. 4.

Return to footnote 1186 referrer

Footnote 1187

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 140-141, 238-239 and 263-264.

Return to footnote 1187 referrer

Footnote 1188

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 140-141, 238-239, 263-264, 274-276 and 620-622.

Return to footnote 1188 referrer

Footnote 1189

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 140-141, 193-194, 208-209 and 263-264.

Return to footnote 1189 referrer

Footnote 1190

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 140-141, 181-183, 193-195, 263-264 and 620-622.

Return to footnote 1190 referrer

Footnote 1191

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 140-141, 238-239, 263-264, 274-276 and 620-622.

Return to footnote 1191 referrer

Footnote 1192

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 19-21.

Return to footnote 1192 referrer

Footnote 1193

See: Section 4.1.2, Investigating Negligence.

Return to footnote 1193 referrer

Footnote 1194

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, pp. 9-15.

Return to footnote 1194 referrer

Footnote 1195

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 9; compare to Exhibit P-148, tab 3, doc. 1428, p. 1: “All deaths will be handled [in accordance with] the same stringent standards as homicide.”

Return to footnote 1195 referrer

Footnote 1196

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 9.

Return to footnote 1196 referrer

Footnote 1197

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 9.

Return to footnote 1197 referrer

Footnote 1198

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 10.

Return to footnote 1198 referrer

Footnote 1199

Fatality Inquiries Act, RSA 2000, c F-9, s. 19(1).

Return to footnote 1199 referrer

Footnote 1200

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 13.

Return to footnote 1200 referrer

Footnote 1201

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 13.

Return to footnote 1201 referrer

Footnote 1202

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 30-32; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 170.

Return to footnote 1202 referrer

Footnote 1203

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 168-170.

Return to footnote 1203 referrer

Footnote 1204

Fatality Inquiries Act, RSA 2000, c F-9, s. 21(1).

Return to footnote 1204 referrer

Footnote 1205

Coroners Act, RSO 1990, c C.37, s. 16(3).

Return to footnote 1205 referrer

Footnote 1206

Fatality Inquiries Act, RSA 2000, c F-9, s. 21(1).

Return to footnote 1206 referrer

Footnote 1207

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, pp. 11-12.

Return to footnote 1207 referrer

Footnote 1208

Testimony of S/Sgt Clark, Insp. Fitzpatrick and Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 163-305.

Return to footnote 1208 referrer

Footnote 1209

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 11.

Return to footnote 1209 referrer

Footnote 1210

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 10.

Return to footnote 1210 referrer

Footnote 1211

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, p. 186.

Return to footnote 1211 referrer

Footnote 1212

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 178-180, 241-243 and 247-248; Testimony of Det. Insp. William Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 188-193 and 269-271; Testimony of Insp. Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 196-199 and 203-205.

Return to footnote 1212 referrer

Footnote 1213

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 12.

Return to footnote 1213 referrer

Footnote 1214

Testimony of S/Sgt Clark, Insp. Fitzpatrick and Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 163-305.

Return to footnote 1214 referrer

Footnote 1215

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 9.

Return to footnote 1215 referrer

Footnote 1216

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 12.

Return to footnote 1216 referrer

Footnote 1217

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 138-141.

Return to footnote 1217 referrer

Footnote 1218

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 14.

Return to footnote 1218 referrer

Footnote 1219

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 14.

Return to footnote 1219 referrer

Footnote 1220

See: Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 1220 referrer

Footnote 1221

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 14 and 15, p. 3.

Return to footnote 1221 referrer

Footnote 1222

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 254.

Return to footnote 1222 referrer

Footnote 1223

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 16, 5 Sept 2012, pp. 176-177.

Return to footnote 1223 referrer

Footnote 1224

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 14 and 17, pp. 3-4.

Return to footnote 1224 referrer

Footnote 1225

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 5, p. 1.

Return to footnote 1225 referrer

Footnote 1226

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 2, p. 1.

Return to footnote 1226 referrer

Footnote 1227

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 17, p. 4.

Return to footnote 1227 referrer

Footnote 1228

Final Submissions of the Complainants, p. 27.

Return to footnote 1228 referrer

Footnote 1229

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 15, p. 3.

Return to footnote 1229 referrer

Footnote 1230

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 16, pp. 3-4.

Return to footnote 1230 referrer

Footnote 1231

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 16, pp. 3-4.

Return to footnote 1231 referrer

Footnote 1232

Final Submissions of the Subjects, p. 60.

Return to footnote 1232 referrer

Footnote 1233

Final Submissions of the Subjects, p. 60.

Return to footnote 1233 referrer

Footnote 1234

Final Submissions of the Subjects, p. 60.

Return to footnote 1234 referrer

Footnote 1235

Final Submissions of the Subjects, pp. 60-61.

Return to footnote 1235 referrer

Footnote 1236

Final Submissions of the Subjects, pp. 61-62.

Return to footnote 1236 referrer

Footnote 1237

Final Submissions of the Subjects, pp. 61-62.

Return to footnote 1237 referrer

Footnote 1238

Final Submissions of the Subjects, p. 61.

Return to footnote 1238 referrer

Footnote 1239

Final Submissions of the Subjects, p. 62.

Return to footnote 1239 referrer

Footnote 1240

Final Submissions of the Subjects, pp. 62-63.

Return to footnote 1240 referrer

Footnote 1241

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 180.

Return to footnote 1241 referrer

Footnote 1242

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 134-135.

Return to footnote 1242 referrer

Footnote 1243

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 134-135.

Return to footnote 1243 referrer

Footnote 1244

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 134-135.

Return to footnote 1244 referrer

Footnote 1245

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 138-139.

Return to footnote 1245 referrer

Footnote 1246

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 184-185.

Return to footnote 1246 referrer

Footnote 1247

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 138-139 and 184-185.

Return to footnote 1247 referrer

Footnote 1248

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 138-139 and 186-187.

Return to footnote 1248 referrer

Footnote 1249

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 138-139 and 186-187.

Return to footnote 1249 referrer

Footnote 1250

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 52-53 and 138-139.

Return to footnote 1250 referrer

Footnote 1251

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 53-54 and 138-139.

Return to footnote 1251 referrer

Footnote 1252

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 217-220.

Return to footnote 1252 referrer

Footnote 1253

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 217-220.

Return to footnote 1253 referrer

Footnote 1254

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 197.

Return to footnote 1254 referrer

Footnote 1255

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 193-194.

Return to footnote 1255 referrer

Footnote 1256

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 192-193.

Return to footnote 1256 referrer

Footnote 1257

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 192-193.

Return to footnote 1257 referrer

Footnote 1258

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 318-320.

Return to footnote 1258 referrer

Footnote 1259

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-264.

Return to footnote 1259 referrer

Footnote 1260

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 60 and 525; Exhibit P-147, tab 1, doc. 1422, p. 148.

Return to footnote 1260 referrer

Footnote 1261

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-265.

Return to footnote 1261 referrer

Footnote 1262

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 38-40; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 16-17 and 135-137.

Return to footnote 1262 referrer

Footnote 1263

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 53-54; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 194-195; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 38-40, 66-67 and 76-79.

Return to footnote 1263 referrer

Footnote 1264

Final Submissions of the Subjects, pp. 60-61.

Return to footnote 1264 referrer

Footnote 1265

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 264-265.

Return to footnote 1265 referrer

Footnote 1266

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 135-137.

Return to footnote 1266 referrer

Footnote 1267

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 16-17.

Return to footnote 1267 referrer

Footnote 1268

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 135-137.

Return to footnote 1268 referrer

Footnote 1269

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 38-40.

Return to footnote 1269 referrer

Footnote 1270

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 70-72.

Return to footnote 1270 referrer

Footnote 1271

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 70-72.

Return to footnote 1271 referrer

Footnote 1272

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 78-79.

Return to footnote 1272 referrer

Footnote 1273

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 78-79.

Return to footnote 1273 referrer

Footnote 1274

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 38-40.

Return to footnote 1274 referrer

Footnote 1275

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 264-265.

Return to footnote 1275 referrer

Footnote 1276

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 112-113.

Return to footnote 1276 referrer

Footnote 1277

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 264-265.

Return to footnote 1277 referrer

Footnote 1278

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 184-185.

Return to footnote 1278 referrer

Footnote 1279

Exhibit P-147, tab 1, doc. 1422, pp. 132-173.

Return to footnote 1279 referrer

Footnote 1280

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 193-194; Exhibit P-150, tab 1, doc. 1429, p. 3.

Return to footnote 1280 referrer

Footnote 1281

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 161-163.

Return to footnote 1281 referrer

Footnote 1282

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 49 and 59-60.

Return to footnote 1282 referrer

Footnote 1283

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 193-194; Exhibit P-147, tab 1, doc.1422, pp. 152-153.

Return to footnote 1283 referrer

Footnote 1284

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 617-618. There are slight differences between the version Capt Lubiniecki provided the CFNIS at the time of his interview (See Exhibit P-1, Collection A vol. 1, tab 1, doc. 001, pp. 195-196), and the version distributed at the time the conditions were set. The version reproduced above comes from an email from CWO Ross dated March 7, 2008, to Capt Lubiniecki, Maj Jared and Capt Hannah.

Return to footnote 1284 referrer

Footnote 1285

Exhibit P-147, tab 1, doc.1422, pp. 152-153.

Return to footnote 1285 referrer

Footnote 1286

Exhibit P-147, tab 1, doc. 1422, pp. 152-153; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193.

Return to footnote 1286 referrer

Footnote 1287

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193; Exhibit P-147, tab 1, doc. 1422, pp. 152-153.

Return to footnote 1287 referrer

Footnote 1288

Exhibit P-147, tab 1, doc.1422, pp. 152-153.

Return to footnote 1288 referrer

Footnote 1289

Exhibit P-147, tab 1, doc. 1422, pp. 152-153.

Return to footnote 1289 referrer

Footnote 1290

Exhibit P-147, tab 1, doc. 1422, pp. 152-153; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193.

Return to footnote 1290 referrer

Footnote 1291

Exhibit P-147, tab 1, doc. 1422, p. 153.

Return to footnote 1291 referrer

Footnote 1292

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193.

Return to footnote 1292 referrer

Footnote 1293

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193.

Return to footnote 1293 referrer

Footnote 1294

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193.

Return to footnote 1294 referrer

Footnote 1295

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 193.

Return to footnote 1295 referrer

Footnote 1296

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 119-120.

Return to footnote 1296 referrer

Footnote 1297

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 119-120.

Return to footnote 1297 referrer

Footnote 1298

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 117-119.

Return to footnote 1298 referrer

Footnote 1299

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 120-122.

Return to footnote 1299 referrer

Footnote 1300

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, p. 117 [Emphases added].

Return to footnote 1300 referrer

Footnote 1301

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 153-154.

Return to footnote 1301 referrer

Footnote 1302

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 566-568.

Return to footnote 1302 referrer

Footnote 1303

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 6 and 10-12.

Return to footnote 1303 referrer

Footnote 1304

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 85-86.

Return to footnote 1304 referrer

Footnote 1305

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 85-87.

Return to footnote 1305 referrer

Footnote 1306

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 87-88.

Return to footnote 1306 referrer

Footnote 1307

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 88-89.

Return to footnote 1307 referrer

Footnote 1308

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 88-89.

Return to footnote 1308 referrer

Footnote 1309

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 104-108.

Return to footnote 1309 referrer

Footnote 1310

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 106-108.

Return to footnote 1310 referrer

Footnote 1311

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-E, pp. 82-85.

Return to footnote 1311 referrer

Footnote 1312

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 75-76.

Return to footnote 1312 referrer

Footnote 1313

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, p. 82.

Return to footnote 1313 referrer

Footnote 1314

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 75-76.

Return to footnote 1314 referrer

Footnote 1315

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 75-76.

Return to footnote 1315 referrer

Footnote 1316

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 81-83.

Return to footnote 1316 referrer

Footnote 1317

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 89-91.

Return to footnote 1317 referrer

Footnote 1318

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 82-83 and 85-87.

Return to footnote 1318 referrer

Footnote 1319

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 53-54.

Return to footnote 1319 referrer

Footnote 1320

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 53-55.

Return to footnote 1320 referrer

Footnote 1321

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 54-56.

Return to footnote 1321 referrer

Footnote 1322

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 54-55.

Return to footnote 1322 referrer

Footnote 1323

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 59-60.

Return to footnote 1323 referrer

Footnote 1324

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 54-56.

Return to footnote 1324 referrer

Footnote 1325

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, p. 56.

Return to footnote 1325 referrer

Footnote 1326

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, p. 56.

Return to footnote 1326 referrer

Footnote 1327

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 10-12.

Return to footnote 1327 referrer

Footnote 1328

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 21-22.

Return to footnote 1328 referrer

Footnote 1329

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 13-14.

Return to footnote 1329 referrer

Footnote 1330

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 13-14.

Return to footnote 1330 referrer

Footnote 1331

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 14.

Return to footnote 1331 referrer

Footnote 1332

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 64-67.

Return to footnote 1332 referrer

Footnote 1333

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 67-69.

Return to footnote 1333 referrer

Footnote 1334

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 34.

Return to footnote 1334 referrer

Footnote 1335

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 37-38.

Return to footnote 1335 referrer

Footnote 1336

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 35; Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 34-35.

Return to footnote 1336 referrer

Footnote 1337

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 35-36.

Return to footnote 1337 referrer

Footnote 1338

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 35-36 and 39-41.

Return to footnote 1338 referrer

Footnote 1339

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 53-54.

Return to footnote 1339 referrer

Footnote 1340

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 68-70.

Return to footnote 1340 referrer

Footnote 1341

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 198-201.

Return to footnote 1341 referrer

Footnote 1342

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 2-3.

Return to footnote 1342 referrer

Footnote 1343

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 2-3.

Return to footnote 1343 referrer

Footnote 1344

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 9-10.

Return to footnote 1344 referrer

Footnote 1345

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 3-4.

Return to footnote 1345 referrer

Footnote 1346

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 22-24 and 29-31.

Return to footnote 1346 referrer

Footnote 1347

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 2-4.

Return to footnote 1347 referrer

Footnote 1348

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 12 and 14-15.

Return to footnote 1348 referrer

Footnote 1349

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 617-618.

Return to footnote 1349 referrer

Footnote 1350

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 15-16.

Return to footnote 1350 referrer

Footnote 1351

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 15-16.

Return to footnote 1351 referrer

Footnote 1352

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 7-8.

Return to footnote 1352 referrer

Footnote 1353

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 9-10.

Return to footnote 1353 referrer

Footnote 1354

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 8-9.

Return to footnote 1354 referrer

Footnote 1355

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 22-23.

Return to footnote 1355 referrer

Footnote 1356

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 8-9.

Return to footnote 1356 referrer

Footnote 1357

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 9.

Return to footnote 1357 referrer

Footnote 1358

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 10.

Return to footnote 1358 referrer

Footnote 1359

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 21-22.

Return to footnote 1359 referrer

Footnote 1360

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 27-28.

Return to footnote 1360 referrer

Footnote 1361

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 16-17.

Return to footnote 1361 referrer

Footnote 1362

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 15-16.

Return to footnote 1362 referrer

Footnote 1363

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 10-11.

Return to footnote 1363 referrer

Footnote 1364

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 13.

Return to footnote 1364 referrer

Footnote 1365

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 13-14.

Return to footnote 1365 referrer

Footnote 1366

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 11.

Return to footnote 1366 referrer

Footnote 1367

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 11.

Return to footnote 1367 referrer

Footnote 1368

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 5-7.

Return to footnote 1368 referrer

Footnote 1369

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 11-12.

Return to footnote 1369 referrer

Footnote 1370

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 12-13.

Return to footnote 1370 referrer

Footnote 1371

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 11-13.

Return to footnote 1371 referrer

Footnote 1372

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 277ff.

Return to footnote 1372 referrer

Footnote 1373

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 36-38.

Return to footnote 1373 referrer

Footnote 1374

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 38-39.

Return to footnote 1374 referrer

Footnote 1375

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 39-40.

Return to footnote 1375 referrer

Footnote 1376

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 39-40.

Return to footnote 1376 referrer

Footnote 1377

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 40-41.

Return to footnote 1377 referrer

Footnote 1378

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 41-42.

Return to footnote 1378 referrer

Footnote 1379

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 48-50.

Return to footnote 1379 referrer

Footnote 1380

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 25-27.

Return to footnote 1380 referrer

Footnote 1381

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 50-52.

Return to footnote 1381 referrer

Footnote 1382

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 51-53.

Return to footnote 1382 referrer

Footnote 1383

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, p. 54.

Return to footnote 1383 referrer

Footnote 1384

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 525.

Return to footnote 1384 referrer

Footnote 1385

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 535.

Return to footnote 1385 referrer

Footnote 1386

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 75-76.

Return to footnote 1386 referrer

Footnote 1387

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 612-613.

Return to footnote 1387 referrer

Footnote 1388

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 13-14.

Return to footnote 1388 referrer

Footnote 1389

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 568.

Return to footnote 1389 referrer

Footnote 1390

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 35.

Return to footnote 1390 referrer

Footnote 1391

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 208.

Return to footnote 1391 referrer

Footnote 1392

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 27-29.

Return to footnote 1392 referrer

Footnote 1393

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 249-251.

Return to footnote 1393 referrer

Footnote 1394

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 39-40, 66-67 and 72-75.

Return to footnote 1394 referrer

Footnote 1395

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 134-138.

Return to footnote 1395 referrer

Footnote 1396

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 65-67.

Return to footnote 1396 referrer

Footnote 1397

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 84-86.

Return to footnote 1397 referrer

Footnote 1398

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 77-79.

Return to footnote 1398 referrer

Footnote 1399

In civil negligence, a duty of care is “an obligation, recognised by law, to take reasonable care to avoid conduct that entails an unreasonable risk of harm to others.” See Odhavji Estate v. Woodhouse, 2003 SCC 69, [2003] 3 SCR 263 at paras. 45-46. Absent a duty of care, “[a] man is entitled to be as negligent as he pleases towards the whole world [...]”: Le Lievre v. Gould, [1893] 1 Q.B. 491 (C.A.), p. 497, cited in ibid. The duty of care in civil negligence is determined through a two-step analysis first articulated by the House of Lords in Anns v. Merton London Borough Council, [1978] A.C. 728, pp. 751-752: “First one has to ask whether, as between the alleged wrongdoer and the person who has suffered damage there is a sufficient relationship of proximity or neighbourhood such that, in the reasonable contemplation of the former, carelessness on his part may be likely to cause damage to the latter — in which case a prima facie duty of care arises. Secondly, if the first question is answered affirmatively, it is necessary to consider whether there are any considerations which ought to negative, or to reduce or limit the scope of the duty or the class of person to whom it is owed or the damages to which a breach of it may give rise.”

The duty of care for criminal negligence is established by the criminal negligence provisions of the Criminal Code, R.S.C. 1985,c.C-46, s. 219(1)(a): “Every one is criminally negligent who […] in doing anything […] shows wanton or reckless disregard for the lives or safety of other persons.”; and Criminal Code, R.S.C. 1985,c. C-46, s. 219(1)(b): “Every one is criminally negligent who […] in omitting to do anything that it is his duty to do, shows wanton or reckless disregard for the lives or safety of other persons.” See also Ewaschuck, E.G., Criminal Pleadings & Practice in Canada (2d ed.) (Toronto: Canada Law Book, 2013), p. 28-13: “Criminal negligence may be established by acts or omissions (where there is a legal duty) or both where the acts and omissions show a wanton or reckless disregard for the lives or safety of others.”

Return to footnote 1399 referrer

Footnote 1400

See for example Criminal Code, R.S.C. 1985,c.C-46, s. 215(1)(c): “Every one is under a legal duty … to provide necessaries of life to a person under his charge if that person (i) is unable, by reason of detention, age, illness, mental disorder or other cause, to withdraw himself from that charge, and (ii) is unable to provide himself with necessaries of life.”; s. 215(2)(b): “(2) Every one commits an offence who, being under a legal duty within the meaning of subsection (1), fails without lawful excuse, the proof of which lies on him, to perform that duty, if […] with respect to a duty imposed by paragraph (1)(c), the failure to perform the duty endangers the life of the person to whom the duty is owed or causes or is likely to cause the health of that person to be injured permanently.”; See R. v. Peterson, 2005 CanLII 37972 (ON CA), 201 CCC (3d) 220; 34 CR (6th) 120; 203 OAC 364 (leave to appeal dismissed, 2006 CanLII 6167 (SCC)) at para. 34: “The phrase “necessaries of life” includes not only food, shelter, care, and medical attention necessary to sustain life but also appears to include protection of the person from harm: R. v. Popen, (1981), 60 C.C.C. (2d) 232 (Ont. C.A.) at 240. Thus, s. 215(1)(c) obligations are driven by the facts and the context of each case.” Additionally, per section 217 of the Criminal Code, where a person undertakes to do an act, the accused is under a “legal duty” to do so if an omission to do the act is or may be dangerous to life The “duty” may also arise by common law: see Ewaschuck, E.G., Criminal Pleadings & Practice in Canada (2d ed.) (Toronto: Canada Law Book, 2013), pp. 28(-6)-28(-7).

Return to footnote 1400 referrer

Footnote 1401

Criminal Code, R.S.C. 1985,c. C-46, s. 219(1)(b): “Every one is criminally negligent who … in omitting to do anything that it is his duty to do, shows wanton or reckless disregard for the lives or safety of other persons.” See also Ewaschuck, E.G., Criminal Pleadings & Practice in Canada (2d ed.) (Toronto: Canada Law Book, 2013), p. 28-13: “Criminal negligence may be established by acts or omissions (where there is a legal duty) or both where the acts and omissions show a wanton or reckless disregard for the lives or safety of others.”

Return to footnote 1401 referrer

Footnote 1402

Criminal Code, R.S.C. 1985,c. C-46, s. 219(1)(a): “Every one is criminally negligent who […] in doing anything […] shows wanton or reckless disregard for the lives or safety of other persons.” See also Ewaschuck, E.G., Criminal Pleadings & Practice in Canada (2d ed.) (Toronto: Canada Law Book, 2013), p. 28-13: “Criminal negligence may be established by acts or omissions (where there is a legal duty) or both where the acts and omissions show a wanton or reckless disregard for the lives or safety of others.”

Return to footnote 1402 referrer

Footnote 1403

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 48-51.

Return to footnote 1403 referrer

Footnote 1404

See for example, Chapter. 4.1.3, The Investigation Plan; Chapter 4.1.2, Investigating Negligence; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-264.

Return to footnote 1404 referrer

Footnote 1405

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 38-39.

Return to footnote 1405 referrer

Footnote 1406

Exhibit P-5, Collection E, vol. 5, tab 9, doc. 1231, pp. 49-54.

Return to footnote 1406 referrer

Footnote 1407

Exhibit P-5, Collection E, vol. 5, tab 9, doc. 1231, pp. 49-54.

Return to footnote 1407 referrer

Footnote 1408

Exhibit P-5, Collection E, vol. 5, tab 9, doc. 1231, pp. 51-52.

Return to footnote 1408 referrer

Footnote 1409

Testimony of Ms. A, Transcript of Proceedings, vol. 54, 10 May 2012, pp. 79-84 and 100-104.

Return to footnote 1409 referrer

Footnote 1410

Testimony of Ms. A, Transcript of Proceedings, vol. 54, 10 May 2012, pp. 79-84.

Return to footnote 1410 referrer

Footnote 1411

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 80-81.

Return to footnote 1411 referrer

Footnote 1412

Exhibit P-4, Collection D, vol. 14, tab 1, doc. 1202, pp. 121-123, 125, 130 and 136.

Return to footnote 1412 referrer

Footnote 1413

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 80-81.

Return to footnote 1413 referrer

Footnote 1414

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 82-84.

Return to footnote 1414 referrer

Footnote 1415

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 100-104.

Return to footnote 1415 referrer

Footnote 1416

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 103-104.

Return to footnote 1416 referrer

Footnote 1417

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 81-82.

Return to footnote 1417 referrer

Footnote 1418

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 39-42.

Return to footnote 1418 referrer

Footnote 1419

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 43-45.

Return to footnote 1419 referrer

Footnote 1420

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 152-153.

Return to footnote 1420 referrer

Footnote 1421

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 153-155.

Return to footnote 1421 referrer

Footnote 1422

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 156-159.

Return to footnote 1422 referrer

Footnote 1423

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 158-159.

Return to footnote 1423 referrer

Footnote 1424

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 108-109.

Return to footnote 1424 referrer

Footnote 1425

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 109-112.

Return to footnote 1425 referrer

Footnote 1426

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 48-49.

Return to footnote 1426 referrer

Footnote 1427

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 48-50.

Return to footnote 1427 referrer

Footnote 1428

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 53-55 and 74-76.

Return to footnote 1428 referrer

Footnote 1429

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 53-55 and 74-76.

Return to footnote 1429 referrer

Footnote 1430

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 145-146.

Return to footnote 1430 referrer

Footnote 1431

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 144-146.

Return to footnote 1431 referrer

Footnote 1432

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 87-88.

Return to footnote 1432 referrer

Footnote 1433

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 104-106.

Return to footnote 1433 referrer

Footnote 1434

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 105-106.

Return to footnote 1434 referrer

Footnote 1435

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 104-106.

Return to footnote 1435 referrer

Footnote 1436

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 177-178.

Return to footnote 1436 referrer

Footnote 1437

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 177-178.

Return to footnote 1437 referrer

Footnote 1438

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 206.

Return to footnote 1438 referrer

Footnote 1439

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, p. 69.

Return to footnote 1439 referrer

Footnote 1440

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 151-153.

Return to footnote 1440 referrer

Footnote 1441

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 151-153.

Return to footnote 1441 referrer

Footnote 1442

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 157-158.

Return to footnote 1442 referrer

Footnote 1443

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 119-120.

Return to footnote 1443 referrer

Footnote 1444

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 534.

Return to footnote 1444 referrer

Footnote 1445

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 50-53.

Return to footnote 1445 referrer

Footnote 1446

Testimony of MCpl Hillier, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 139-143.

Return to footnote 1446 referrer

Footnote 1447

Testimony of MCpl Hillier, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 143-144.

Return to footnote 1447 referrer

Footnote 1448

Testimony of Kirk Lackie, Transcript of Proceedings, vol. 50, 19 September 2012, p. 50-52.

Return to footnote 1448 referrer

Footnote 1449

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 59-61.

Return to footnote 1449 referrer

Footnote 1450

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 164-165.

Return to footnote 1450 referrer

Footnote 1451

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 164-165.

Return to footnote 1451 referrer

Footnote 1452

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 158-159.

Return to footnote 1452 referrer

Footnote 1453

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 617-618.

Return to footnote 1453 referrer

Footnote 1454

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 617-618.

Return to footnote 1454 referrer

Footnote 1455

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 70-72.

Return to footnote 1455 referrer

Footnote 1456

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 73-74.

Return to footnote 1456 referrer

Footnote 1457

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 106-107.

Return to footnote 1457 referrer

Footnote 1458

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 2-4.

Return to footnote 1458 referrer

Footnote 1459

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 16-24.

Return to footnote 1459 referrer

Footnote 1460

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 34-35.

Return to footnote 1460 referrer

Footnote 1461

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 34-35 and 36-37.

Return to footnote 1461 referrer

Footnote 1462

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 34-35.

Return to footnote 1462 referrer

Footnote 1463

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 75-77.

Return to footnote 1463 referrer

Footnote 1464

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 75-77.

Return to footnote 1464 referrer

Footnote 1465

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 75-77.

Return to footnote 1465 referrer

Footnote 1466

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 76-77.

Return to footnote 1466 referrer

Footnote 1467

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 41-42.

Return to footnote 1467 referrer

Footnote 1468

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 73-74.

Return to footnote 1468 referrer

Footnote 1469

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 76-77.

Return to footnote 1469 referrer

Footnote 1470

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, p. 2.

Return to footnote 1470 referrer

Footnote 1471

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 325-326.

Return to footnote 1471 referrer

Footnote 1472

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 79-80.

Return to footnote 1472 referrer

Footnote 1473

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 80-81.

Return to footnote 1473 referrer

Footnote 1474

Exhibit P-6, Collection F, vol. 2, tab 4, doc. 1295, pp. 10-12 and 33-36.

Return to footnote 1474 referrer

Footnote 1475

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 32-33.

Return to footnote 1475 referrer

Footnote 1476

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 32-33.

Return to footnote 1476 referrer

Footnote 1477

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 35-36.

Return to footnote 1477 referrer

Footnote 1478

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 59-61.

Return to footnote 1478 referrer

Footnote 1479

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 59-61.

Return to footnote 1479 referrer

Footnote 1480

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 71-75.

Return to footnote 1480 referrer

Footnote 1481

Testimony of Dr. Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 75-79.

Return to footnote 1481 referrer

Footnote 1482

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 250.

Return to footnote 1482 referrer

Footnote 1483

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 63-65.

Return to footnote 1483 referrer

Footnote 1484

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 160-161.

Return to footnote 1484 referrer

Footnote 1485

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 112-113.

Return to footnote 1485 referrer

Footnote 1486

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 265-266.

Return to footnote 1486 referrer

Footnote 1487

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 265-266.

Return to footnote 1487 referrer

Footnote 1488

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 265-266.

Return to footnote 1488 referrer

Footnote 1489

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 71.

Return to footnote 1489 referrer

Footnote 1490

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 525 [Emphasis added].

Return to footnote 1490 referrer

Footnote 1491

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 87.

Return to footnote 1491 referrer

Footnote 1492

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 87.

Return to footnote 1492 referrer

Footnote 1493

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 104-107.

Return to footnote 1493 referrer

Footnote 1494

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 104-105 and 107-108.

Return to footnote 1494 referrer

Footnote 1495

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 106-107.

Return to footnote 1495 referrer

Footnote 1496

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 568 [Emphasis added].

Return to footnote 1496 referrer

Footnote 1497

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 213.

Return to footnote 1497 referrer

Footnote 1498

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H.

Return to footnote 1498 referrer

Footnote 1499

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 222.

Return to footnote 1499 referrer

Footnote 1500

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 222.

Return to footnote 1500 referrer

Footnote 1501

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 81.

Return to footnote 1501 referrer

Footnote 1502

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 81-82.

Return to footnote 1502 referrer

Footnote 1503

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 196.

Return to footnote 1503 referrer

Footnote 1504

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 193-197.

Return to footnote 1504 referrer

Footnote 1505

Testimony of WO Hiscock, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 12-15.

Return to footnote 1505 referrer

Footnote 1506

Testimony of Mr. Bartlett, Transcript of Proceedings, vol. 35, 18 June 2012, pp. 60-62.

Return to footnote 1506 referrer

Footnote 1507

Testimony of Mr. Bartlett, Transcript of Proceedings, vol. 35, 18 June 2012, pp. 80-81.

Return to footnote 1507 referrer

Footnote 1508

Testimony of Mr. Bartlett, Transcript of Proceedings, vol. 35, 18 June 2012, pp. 80-81.

Return to footnote 1508 referrer

Footnote 1509

Testimony of Mr. Bartlett, Transcript of Proceedings, vol. 35, 18 June 2012, pp. 69-70.

Return to footnote 1509 referrer

Footnote 1510

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 8-9.

Return to footnote 1510 referrer

Footnote 1511

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 40-41.

Return to footnote 1511 referrer

Footnote 1512

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 254.

Return to footnote 1512 referrer

Footnote 1513

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 52-53.

Return to footnote 1513 referrer

Footnote 1514

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 53.

Return to footnote 1514 referrer

Footnote 1515

Exhibit P-4, Collection D, vol. 14, tab 1, doc. 1202, pp. 130-143; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 73-74.

Return to footnote 1515 referrer

Footnote 1516

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 73-74.

Return to footnote 1516 referrer

Footnote 1517

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 78.

Return to footnote 1517 referrer

Footnote 1518

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 11-12.

Return to footnote 1518 referrer

Footnote 1519

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 13-14.

Return to footnote 1519 referrer

Footnote 1520

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 14-15.

Return to footnote 1520 referrer

Footnote 1521

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 20-21.

Return to footnote 1521 referrer

Footnote 1522

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 37-38.

Return to footnote 1522 referrer

Footnote 1523

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 36.

Return to footnote 1523 referrer

Footnote 1524

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 37-38.

Return to footnote 1524 referrer

Footnote 1525

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 79-84.

Return to footnote 1525 referrer

Footnote 1526

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 83-84.

Return to footnote 1526 referrer

Footnote 1527

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 77-78.

Return to footnote 1527 referrer

Footnote 1528

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 73-74 and 76-77.

Return to footnote 1528 referrer

Footnote 1529

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 77-78.

Return to footnote 1529 referrer

Footnote 1530

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 174-176.

Return to footnote 1530 referrer

Footnote 1531

Exhibit P-5, Collection E, vol. 3, tab 1, doc. 1242.

Return to footnote 1531 referrer

Footnote 1532

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 46-47.

Return to footnote 1532 referrer

Footnote 1533

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 66-67; Testimony of MCpl (Ret’d) Fitzpatrick, Transcript of Proceedings, vol. 15, 25 April, 2012, pp. 199-201.

Return to footnote 1533 referrer

Footnote 1534

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 493-495.

Return to footnote 1534 referrer

Footnote 1535

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 26-28.

Return to footnote 1535 referrer

Footnote 1536

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 53-54.

Return to footnote 1536 referrer

Footnote 1537

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 35.

Return to footnote 1537 referrer

Footnote 1538

Testimony of Mr. Lackie, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 34-36 and 58-59.

Return to footnote 1538 referrer

Footnote 1539

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 146-148.

Return to footnote 1539 referrer

Footnote 1540

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 73-75.

Return to footnote 1540 referrer

Footnote 1541

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 73-75.

Return to footnote 1541 referrer

Footnote 1542

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 195.

Return to footnote 1542 referrer

Footnote 1543

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 107-108.

Return to footnote 1543 referrer

Footnote 1544

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 218.

Return to footnote 1544 referrer

Footnote 1545

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 22-23.

Return to footnote 1545 referrer

Footnote 1546

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 94-95.

Return to footnote 1546 referrer

Footnote 1547

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 38-39.

Return to footnote 1547 referrer

Footnote 1548

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 38-40.

Return to footnote 1548 referrer

Footnote 1549

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 202-204.

Return to footnote 1549 referrer

Footnote 1550

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 205-206.

Return to footnote 1550 referrer

Footnote 1551

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 195-196.

Return to footnote 1551 referrer

Footnote 1552

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 222-224.

Return to footnote 1552 referrer

Footnote 1553

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 12-13.

Return to footnote 1553 referrer

Footnote 1554

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 254-255 [Emphasis added].

Return to footnote 1554 referrer

Footnote 1555

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 11-13.

Return to footnote 1555 referrer

Footnote 1556

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 255.

Return to footnote 1556 referrer

Footnote 1557

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 253-257.

Return to footnote 1557 referrer

Footnote 1558

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 74-75 [Emphasis added].

Return to footnote 1558 referrer

Footnote 1559

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 36-37.

Return to footnote 1559 referrer

Footnote 1560

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 95-96.

Return to footnote 1560 referrer

Footnote 1561

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 63-64.

Return to footnote 1561 referrer

Footnote 1562

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 111-112.

Return to footnote 1562 referrer

Footnote 1563

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 82-84.

Return to footnote 1563 referrer

Footnote 1564

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 64-65.

Return to footnote 1564 referrer

Footnote 1565

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 111-112.

Return to footnote 1565 referrer

Footnote 1566

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 99-101.

Return to footnote 1566 referrer

Footnote 1567

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 85-87.

Return to footnote 1567 referrer

Footnote 1568

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 85-86.

Return to footnote 1568 referrer

Footnote 1569

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 89-90.

Return to footnote 1569 referrer

Footnote 1570

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 89-91.

Return to footnote 1570 referrer

Footnote 1571

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 90-91.

Return to footnote 1571 referrer

Footnote 1572

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 36-37.

Return to footnote 1572 referrer

Footnote 1573

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 146-148.

Return to footnote 1573 referrer

Footnote 1574

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 211.

Return to footnote 1574 referrer

Footnote 1575

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 17-18.

Return to footnote 1575 referrer

Footnote 1576

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 147-149.

Return to footnote 1576 referrer

Footnote 1577

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, p. 51.

Return to footnote 1577 referrer

Footnote 1578

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, p. 191.

Return to footnote 1578 referrer

Footnote 1579

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 84-85.

Return to footnote 1579 referrer

Footnote 1580

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 152-153.

Return to footnote 1580 referrer

Footnote 1581

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 103-104.

Return to footnote 1581 referrer

Footnote 1582

Testimony of WO Hiscock, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 36-37.

Return to footnote 1582 referrer

Footnote 1583

Testimony of Maj, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 84-85.

Return to footnote 1583 referrer

Footnote 1584

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 149-151.

Return to footnote 1584 referrer

Footnote 1585

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 65-66.

Return to footnote 1585 referrer

Footnote 1586

Testimony of WO Hiscock, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 207-208.

Return to footnote 1586 referrer

Footnote 1587

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 65-67.

Return to footnote 1587 referrer

Footnote 1588

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 209-224.

Return to footnote 1588 referrer

Footnote 1589

Testimony of Ms. Newing, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 229-230; Testimony of Dr. Yaltho, Transcript of Proceedings, vol. 5, 4 April 2012, pp. 34-36.

Return to footnote 1589 referrer

Footnote 1590

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 214-215.

Return to footnote 1590 referrer

Footnote 1591

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 55-57.

Return to footnote 1591 referrer

Footnote 1592

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 152-153.

Return to footnote 1592 referrer

Footnote 1593

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 48-50.

Return to footnote 1593 referrer

Footnote 1594

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 21-22, 44-45 and 52-54.

Return to footnote 1594 referrer

Footnote 1595

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 88-89.

Return to footnote 1595 referrer

Footnote 1596

Testimony of Maj, Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 178-180.

Return to footnote 1596 referrer

Footnote 1597

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 192-193.

Return to footnote 1597 referrer

Footnote 1598

Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 40-41; Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 22-23; Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March, 2012, pp. 222-224; Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 64-65; Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 74-75; Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 111-112; Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 99-101.

Return to footnote 1598 referrer

Footnote 1599

See Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 90-91; Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March, 2012, pp. 192-193

Return to footnote 1599 referrer

Footnote 1600

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 233-235.

Return to footnote 1600 referrer

Footnote 1601

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 195-196.

Return to footnote 1601 referrer

Footnote 1602

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 150-151; WO Hiscock, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 193-194.

Return to footnote 1602 referrer

Footnote 1603

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 191-192.

Return to footnote 1603 referrer

Footnote 1604

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 159-160.

Return to footnote 1604 referrer

Footnote 1605

Testimony of WO Hiscock, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 209-212; Testimony of WO Hiscock, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 31-33.

Return to footnote 1605 referrer

Footnote 1606

Testimony of WO Hiscock, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 210-212.

Return to footnote 1606 referrer

Footnote 1607

Testimony of WO Hiscock, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 31-33.

Return to footnote 1607 referrer

Footnote 1608

Testimony of Mr. Lackie, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 24-25.

Return to footnote 1608 referrer

Footnote 1609

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 198-200.

Return to footnote 1609 referrer

Footnote 1610

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 88-92.

Return to footnote 1610 referrer

Footnote 1611

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 141.

Return to footnote 1611 referrer

Footnote 1612

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 114-115.

Return to footnote 1612 referrer

Footnote 1613

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 114-116.

Return to footnote 1613 referrer

Footnote 1614

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 195-196.

Return to footnote 1614 referrer

Footnote 1615

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 116-117.

Return to footnote 1615 referrer

Footnote 1616

Exhibit P-147, tab 1, doc.1422, p. 155 [Emphasis added].

Return to footnote 1616 referrer

Footnote 1617

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 193-194.

Return to footnote 1617 referrer

Footnote 1618

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 52-53.

Return to footnote 1618 referrer

Footnote 1619

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 53-54.

Return to footnote 1619 referrer

Footnote 1620

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 67-69.

Return to footnote 1620 referrer

Footnote 1621

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 35-36.

Return to footnote 1621 referrer

Footnote 1622

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 176-177.

Return to footnote 1622 referrer

Footnote 1623

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 221-223.

Return to footnote 1623 referrer

Footnote 1624

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 221-223.

Return to footnote 1624 referrer

Footnote 1625

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 481.

Return to footnote 1625 referrer

Footnote 1626

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 223-224.

Return to footnote 1626 referrer

Footnote 1627

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 223-224.

Return to footnote 1627 referrer

Footnote 1628

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 223-224.

Return to footnote 1628 referrer

Footnote 1629

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 225-227.

Return to footnote 1629 referrer

Footnote 1630

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 227-228.

Return to footnote 1630 referrer

Footnote 1631

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 227-228.

Return to footnote 1631 referrer

Footnote 1632

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 140.

Return to footnote 1632 referrer

Footnote 1633

Exhibit P-147, tab 1, doc.1422, p. 155.

Return to footnote 1633 referrer

Footnote 1634

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 45-47.

Return to footnote 1634 referrer

Footnote 1635

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 71-72; Testimony of MCpl (Ret’d) Fitzpatrick, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 180-182.

Return to footnote 1635 referrer

Footnote 1636

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 26-27.

Return to footnote 1636 referrer

Footnote 1637

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 48-50.

Return to footnote 1637 referrer

Footnote 1638

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 472.

Return to footnote 1638 referrer

Footnote 1639

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 48-50 and 93.

Return to footnote 1639 referrer

Footnote 1640

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 471.

Return to footnote 1640 referrer

Footnote 1641

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 496.

Return to footnote 1641 referrer

Footnote 1642

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 236-237.

Return to footnote 1642 referrer

Footnote 1643

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 240-241.

Return to footnote 1643 referrer

Footnote 1644

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 240-243.

Return to footnote 1644 referrer

Footnote 1645

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 494-496.

Return to footnote 1645 referrer

Footnote 1646

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 494-496.

Return to footnote 1646 referrer

Footnote 1647

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 287-290.

Return to footnote 1647 referrer

Footnote 1648

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 289-290.

Return to footnote 1648 referrer

Footnote 1649

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 289-290.

Return to footnote 1649 referrer

Footnote 1650

Testimony of Maj Hannah, Transcript of Proceedings, vol. 3, 27 March 2012, pp. 289-290.

Return to footnote 1650 referrer

Footnote 1651

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 96-97.

Return to footnote 1651 referrer

Footnote 1652

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 93-96.

Return to footnote 1652 referrer

Footnote 1653

Testimony of Sgt Bowden, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 25-27 and 39-43.

Return to footnote 1653 referrer

Footnote 1654

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 35.

Return to footnote 1654 referrer

Footnote 1655

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 53-54.

Return to footnote 1655 referrer

Footnote 1656

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 245.

Return to footnote 1656 referrer

Footnote 1657

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 1657 referrer

Footnote 1658

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 28-29.

Return to footnote 1658 referrer

Footnote 1659

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 2-5.

Return to footnote 1659 referrer

Footnote 1660

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 199-200.

Return to footnote 1660 referrer

Footnote 1661

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 198-201.

Return to footnote 1661 referrer

Footnote 1662

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 250.

Return to footnote 1662 referrer

Footnote 1663

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 13.

Return to footnote 1663 referrer

Footnote 1664

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 193-196.

Return to footnote 1664 referrer

Footnote 1665

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 3-5.

Return to footnote 1665 referrer

Footnote 1666

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 196-197.

Return to footnote 1666 referrer

Footnote 1667

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 24-25.

Return to footnote 1667 referrer

Footnote 1668

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 102-104.

Return to footnote 1668 referrer

Footnote 1669

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 103-104.

Return to footnote 1669 referrer

Footnote 1670

Exhibit P-4, Collection D, vol. 13, tab 1, doc. 1128, p. 145.

Return to footnote 1670 referrer

Footnote 1671

Exhibit P-4, Collection D, vol. 13, tab 1, doc. 1128, p. 145.

Return to footnote 1671 referrer

Footnote 1672

Exhibit P-4, Collection D, vol. 13, tab 1, doc. 1128, p. 145.

Return to footnote 1672 referrer

Footnote 1673

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 31-33.

Return to footnote 1673 referrer

Footnote 1674

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 32-33.

Return to footnote 1674 referrer

Footnote 1675

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 493-495.

Return to footnote 1675 referrer

Footnote 1676

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 495.

Return to footnote 1676 referrer

Footnote 1677

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 34-35.

Return to footnote 1677 referrer

Footnote 1678

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 88-89.

Return to footnote 1678 referrer

Footnote 1679

Testimony of Lt Dunn, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 157-158.

Return to footnote 1679 referrer

Footnote 1680

Testimony of Maj Cadieu, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 151-153.

Return to footnote 1680 referrer

Footnote 1681

Testimony of Mr. Bartlett, Transcript of Proceedings, vol. 35, 18 June 2012, pp. 62-63.

Return to footnote 1681 referrer

Footnote 1682

Exhibit P-105, doc. 1382, p. 31.

Return to footnote 1682 referrer

Footnote 1683

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 202-204.

Return to footnote 1683 referrer

Footnote 1684

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 202-204.

Return to footnote 1684 referrer

Footnote 1685

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 79-80.

Return to footnote 1685 referrer

Footnote 1686

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 79-80.

Return to footnote 1686 referrer

Footnote 1687

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 146-148.

Return to footnote 1687 referrer

Footnote 1688

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 464.

Return to footnote 1688 referrer

Footnote 1689

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 170-171.

Return to footnote 1689 referrer

Footnote 1690

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 464.

Return to footnote 1690 referrer

Footnote 1691

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 73-75.

Return to footnote 1691 referrer

Footnote 1692

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 474-475; Exhibit P-4, Collection D, vol. 14, tab 1, doc. 1202, pp. 62-63.

Return to footnote 1692 referrer

Footnote 1693

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 135-136.

Return to footnote 1693 referrer

Footnote 1694

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 135-136.

Return to footnote 1694 referrer

Footnote 1695

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 479-480.

Return to footnote 1695 referrer

Footnote 1696

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 136-138.

Return to footnote 1696 referrer

Footnote 1697

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 479-480.

Return to footnote 1697 referrer

Footnote 1698

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 136-138.

Return to footnote 1698 referrer

Footnote 1699

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 138-140.

Return to footnote 1699 referrer

Footnote 1700

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 144-145.

Return to footnote 1700 referrer

Footnote 1701

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 146-148.

Return to footnote 1701 referrer

Footnote 1702

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 493-495.

Return to footnote 1702 referrer

Footnote 1703

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 796.

Return to footnote 1703 referrer

Footnote 1704

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 796.

Return to footnote 1704 referrer

Footnote 1705

Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 150-153.

Return to footnote 1705 referrer

Footnote 1706

Testimony of Maj Volstad, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 106-108.

Return to footnote 1706 referrer

Footnote 1707

Testimony of Maj Volstad, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 114-117.

Return to footnote 1707 referrer

Footnote 1708

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 796.

Return to footnote 1708 referrer

Footnote 1709

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 617-618.

Return to footnote 1709 referrer

Footnote 1710

Testimony of Maj Volstad, Transcript of Proceedings, vol. 7, 10 April 2012, pp. 118-119.

Return to footnote 1710 referrer

Footnote 1711

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 73-74.

Return to footnote 1711 referrer

Footnote 1712

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 78-87.

Return to footnote 1712 referrer

Footnote 1713

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 86-87 [Emphasis added].

Return to footnote 1713 referrer

Footnote 1714

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 107-109.

Return to footnote 1714 referrer

Footnote 1715

Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 188-191.

Return to footnote 1715 referrer

Footnote 1716

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 245-248.

Return to footnote 1716 referrer

Footnote 1717

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 249-258.

Return to footnote 1717 referrer

Footnote 1718

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 114-116.

Return to footnote 1718 referrer

Footnote 1719

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 114-116.

Return to footnote 1719 referrer

Footnote 1720

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 151.

Return to footnote 1720 referrer

Footnote 1721

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, pp. 13-14.

Return to footnote 1721 referrer

Footnote 1722

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 151-153.

Return to footnote 1722 referrer

Footnote 1723

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 76-77.

Return to footnote 1723 referrer

Footnote 1724

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 74-80.

Return to footnote 1724 referrer

Footnote 1725

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 154-155.

Return to footnote 1725 referrer

Footnote 1726

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 151-153.

Return to footnote 1726 referrer

Footnote 1727

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 199-201.

Return to footnote 1727 referrer

Footnote 1728

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 76-77.

Return to footnote 1728 referrer

Footnote 1729

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 76-79.

Return to footnote 1729 referrer

Footnote 1730

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 125-126.

Return to footnote 1730 referrer

Footnote 1731

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 78-79.

Return to footnote 1731 referrer

Footnote 1732

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 74-80.

Return to footnote 1732 referrer

Footnote 1733

See Chapter 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 1733 referrer

Footnote 1734

Exhibit P-6, Collection F, vol. 3, tab 1, doc. 1315, pp. 3-4

Return to footnote 1734 referrer

Footnote 1735

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 137-138.

Return to footnote 1735 referrer

Footnote 1736

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 94.

Return to footnote 1736 referrer

Footnote 1737

The duty of care for criminal negligence is established by the criminal negligence provisions of the Criminal Code, R.S.C. 1985,c.C-46, s. 219(1)(a): “Every one is criminally negligent who […] in doing anything […] shows wanton or reckless disregard for the lives or safety of other persons.”; and Criminal Code, R.S.C. 1985,c.C-46, s. 219(1)(b): “Every one is criminally negligent who […] in omitting to do anything that it is his duty to do, shows wanton or reckless disregard for the lives or safety of other persons.” See also Ewaschuck, E.G., Criminal Pleadings & Practice in Canada (2d ed.) (Toronto: Canada Law Book, 2013), p. 28-13: “Criminal negligence may be established by acts or omissions (where there is a legal duty) or both where the acts and omissions show a wanton or reckless disregard for the lives or safety of others.”

Return to footnote 1737 referrer

Footnote 1738

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 134-135.

Return to footnote 1738 referrer

Footnote 1739

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 183-185.

Return to footnote 1739 referrer

Footnote 1740

Testimony of Ms. A., Transcript of Proceedings, vol. 20, 10 May 2012, pp. 40-41.

Return to footnote 1740 referrer

Footnote 1741

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 188-189.

Return to footnote 1741 referrer

Footnote 1742

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 188-189.

Return to footnote 1742 referrer

Footnote 1743

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 189-190.

Return to footnote 1743 referrer

Footnote 1744

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 191-193.

Return to footnote 1744 referrer

Footnote 1745

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 193-195.

Return to footnote 1745 referrer

Footnote 1746

Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 10-12.

Return to footnote 1746 referrer

Footnote 1747

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 248.

Return to footnote 1747 referrer

Footnote 1748

Exhibit P-6, Collection F, vol. 2, tab 1, doc.1293, pp. 13 and 25-30.

Return to footnote 1748 referrer

Footnote 1749

Exhibit P-6, Collection F, vol. 2, tab 1, doc.1293, p. 37.

Return to footnote 1749 referrer

Footnote 1750

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 274-276.

Return to footnote 1750 referrer

Footnote 1751

Testimony of Capt Hubbard, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 29-32.

Return to footnote 1751 referrer

Footnote 1752

Testimony of Capt Hubbard, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 32-34.

Return to footnote 1752 referrer

Footnote 1753

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 82-84.

Return to footnote 1753 referrer

Footnote 1754

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 89-91.

Return to footnote 1754 referrer

Footnote 1755

Testimony of Capt Hubbard, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 38-39.

Return to footnote 1755 referrer

Footnote 1756

Exhibit P-132, vol. 1, tab 1, doc. 1399, pp. 4-14.

Return to footnote 1756 referrer

Footnote 1757

Testimony of Sgt Murrin, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 188-195; Testimony of Capt Ross, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 10-12.

Return to footnote 1757 referrer

Footnote 1758

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 72-75; Testimony of Ms. Ferdinand, Transcript of Proceedings, vol. 10, 16 April 2012, pp. 124-128.

Return to footnote 1758 referrer

Footnote 1759

Testimony of Capt Hubbard, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 32-34.

Return to footnote 1759 referrer

Footnote 1760

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 82-84.

Return to footnote 1760 referrer

Footnote 1761

Exhibit P-105, doc. 1382, p. 31.

Return to footnote 1761 referrer

Footnote 1762

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-H, p. 13.

Return to footnote 1762 referrer

Footnote 1763

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 111-115.

Return to footnote 1763 referrer

Footnote 1764

National Defence Act, RSC 1985, c N-5, Part III, ss. 55-249.26.

Return to footnote 1764 referrer

Footnote 1765

See Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 1765 referrer

Footnote 1766

Greenspan, Edward L., Rosenberg, Marc, and Heinein, Marie, 2013 Martin’s Annual Criminal Code, (Toronto: Canada Law Book, 2012), pp. 447-449; R. v. F. (J.), [2008] 3 S.C.R. 215 at paras. 7-11.

Return to footnote 1766 referrer

Footnote 1767

See R. v. Brocklebank, 1996 CarswellNat 1888, 134 D.L.R. (4th) 377, 106 C.C.C. (3d) 234, 30 W.C.B. (2d) 564, 5 C.M.A.R. 390, paras 18, 32 and 60; Létourneau, Gilles, and Drapeau, Michel, Canadian Military Law Annotated, (Toronto: Thomson Carswell, 2006), pp. 660-664. The text adds that QR&O 103.56 defines “negligently” in section 124 of the National Defence Act as meaning “that the accused either did something or omitted to do something in a manner which would not have been adopted by a reasonable and capable person in his position in the Service under similar circumstances.”

Return to footnote 1767 referrer

Footnote 1768

See R. v. F. (J.), [2008] 3 S.C.R. 215, paras. 7-11; R. v. Kazenelson, 2013 CarswellOnt 1765, 2013 ONCJ 63, 105 W.C.B. (2d) 132 (Ont S.C.J.); R. v. Brocklebank, 1996 CarswellNat 1888, 134 D.L.R. (4th) 377, 106 C.C.C. (3d) 234, 30 W.C.B. (2d) 564, 5 C.M.A.R. 390, para 60; R. v. Creighton, [1993] 3 S.C.R. 3, pp. 73-74.

Return to footnote 1768 referrer

Footnote 1769

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 73-74 and 85.

Return to footnote 1769 referrer

Footnote 1770

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 202.

Return to footnote 1770 referrer

Footnote 1771

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 33-34 and 55-56; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 120; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 29.

Return to footnote 1771 referrer

Footnote 1772

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 180-181; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 33-34, 55-56 and 133-134.

Return to footnote 1772 referrer

Footnote 1773

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 120.

Return to footnote 1773 referrer

Footnote 1774

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 17-19.

Return to footnote 1774 referrer

Footnote 1775

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-265.

Return to footnote 1775 referrer

Footnote 1776

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 53.

Return to footnote 1776 referrer

Footnote 1777

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 215-216.

Return to footnote 1777 referrer

Footnote 1778

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 45-47.

Return to footnote 1778 referrer

Footnote 1779

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 87-88.

Return to footnote 1779 referrer

Footnote 1780

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 88.

Return to footnote 1780 referrer

Footnote 1781

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 88-89.

Return to footnote 1781 referrer

Footnote 1782

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 86-87.

Return to footnote 1782 referrer

Footnote 1783

See Section 4.1.2, Investigating Negligence.

Return to footnote 1783 referrer

Footnote 1784

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 264 and 274-497; Testimony of Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 73-78 and 81-85; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 41-43, 50-51 and 152-154; Section 4.1.2, Investigating Negligence.

Return to footnote 1784 referrer

Footnote 1785

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-264.

Return to footnote 1785 referrer

Footnote 1786

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 65.

Return to footnote 1786 referrer

Footnote 1787

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 30-31.

Return to footnote 1787 referrer

Footnote 1788

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 208.

Return to footnote 1788 referrer

Footnote 1789

Exhibit P-1, Collection A, vol. 2, tab 1, doc. 001-C, pp. 22-25.

Return to footnote 1789 referrer

Footnote 1790

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 60-61.

Return to footnote 1790 referrer

Footnote 1791

See, generally, Section 4.1.1, Investigating the Sudden Death; Section 4.1.2, Investigating Negligence.

Return to footnote 1791 referrer

Footnote 1792

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 96-97; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 50-51.

Return to footnote 1792 referrer

Footnote 1793

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 48.

Return to footnote 1793 referrer

Footnote 1794

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 113-114.

Return to footnote 1794 referrer

Footnote 1795

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 48.

Return to footnote 1795 referrer

Footnote 1796

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 163.

Return to footnote 1796 referrer

Footnote 1797

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-265; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 16-17.

Return to footnote 1797 referrer

Footnote 1798

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 40.

Return to footnote 1798 referrer

Footnote 1799

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 67-68.

Return to footnote 1799 referrer

Footnote 1800

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 263.

Return to footnote 1800 referrer

Footnote 1801

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 188-191.

Return to footnote 1801 referrer

Footnote 1802

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 188-191.

Return to footnote 1802 referrer

Footnote 1803

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 263.

Return to footnote 1803 referrer

Footnote 1804

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 28.

Return to footnote 1804 referrer

Footnote 1805

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 28-29.

Return to footnote 1805 referrer

Footnote 1806

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 263.

Return to footnote 1806 referrer

Footnote 1807

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 276, 464, 479-480, 584-586 and 617-618.

Return to footnote 1807 referrer

Footnote 1808

See Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 54-57; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 102 and 273; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 107-108; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 71-72.

Return to footnote 1808 referrer

Footnote 1809

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 263.

Return to footnote 1809 referrer

Footnote 1810

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 263.

Return to footnote 1810 referrer

Footnote 1811

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 264.

Return to footnote 1811 referrer

Footnote 1812

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 135-137.

Return to footnote 1812 referrer

Footnote 1813

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 180-182; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 189.

Return to footnote 1813 referrer

Footnote 1814

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 258.

Return to footnote 1814 referrer

Footnote 1815

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 61.

Return to footnote 1815 referrer

Footnote 1816

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 142-143.

Return to footnote 1816 referrer

Footnote 1817

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 189-190 and 206-207.

Return to footnote 1817 referrer

Footnote 1818

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 18-19.

Return to footnote 1818 referrer

Footnote 1819

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 163-164.

Return to footnote 1819 referrer

Footnote 1820

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 1820 referrer

Footnote 1821

Exhibit P-158, tab 1, doc. 1432, p. 44; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 277-279.

Return to footnote 1821 referrer

Footnote 1822

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 113-123 and 162-163; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 42-45; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 113-114.

Return to footnote 1822 referrer

Footnote 1823

Exhibit P-158, tab 1, doc. 1432, pp. 31-38.

Return to footnote 1823 referrer

Footnote 1824

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 521.

Return to footnote 1824 referrer

Footnote 1825

See Section 4.1, Investigating Negligence.

Return to footnote 1825 referrer

Footnote 1826

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 3, p. 1.

Return to footnote 1826 referrer

Footnote 1827

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 11-13, 115-116 and 127-129; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 199.

Return to footnote 1827 referrer

Footnote 1828

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 14-15 and 116-118; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 199-200.

Return to footnote 1828 referrer

Footnote 1829

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 14 and 116-117; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 200.

Return to footnote 1829 referrer

Footnote 1830

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 11-16 and 115-118; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 39-41 and 74-75; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 198-200.

Return to footnote 1830 referrer

Footnote 1831

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 200.

Return to footnote 1831 referrer

Footnote 1832

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 13-14.

Return to footnote 1832 referrer

Footnote 1833

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 116.

Return to footnote 1833 referrer

Footnote 1834

See, generally, Section 4.1.1 Investigating the Sudden Death; Section 4.1.3 The Investigation Plan.

Return to footnote 1834 referrer

Footnote 1835

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 520-521.

Return to footnote 1835 referrer

Footnote 1836

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 274-497. See, generally, Section 3.0 Narrative.

Return to footnote 1836 referrer

Footnote 1837

See Exhibit P-1, Collection A, vol. 2, tab 7, doc. 001-I, pp. 28-29 and 36; Final Submissions of the Subjects of the Complaint, pp. 64-65.

Return to footnote 1837 referrer

Footnote 1838

See Exhibit P-1, Collection A, vol. 2, tab 7, doc. 00-I, p. 2; Section 4.1.2 Investigating Negligence.

Return to footnote 1838 referrer

Footnote 1839

See Section 4.1.2, Investigating Negligence.

Return to footnote 1839 referrer

Footnote 1840

See Section 4.1.2, Investigating Negligence.

Return to footnote 1840 referrer

Footnote 1841

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 164-166.

Return to footnote 1841 referrer

Footnote 1842

See Section 4.1.2, Investigating Negligence.

Return to footnote 1842 referrer

Footnote 1843

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 1843 referrer

Footnote 1844

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 1844 referrer

Footnote 1845

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 198-200.

Return to footnote 1845 referrer

Footnote 1846

See Section 4.6 CFNIS Independence and Impartiality.

Return to footnote 1846 referrer

Footnote 1847

See Section 4.6 CFNIS Independence and Impartiality.

Return to footnote 1847 referrer

Footnote 1848

See Section 4.1.2, Investigating Negligence.

Return to footnote 1848 referrer

Footnote 1849

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 7.

Return to footnote 1849 referrer

Footnote 1850

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 9-10.

Return to footnote 1850 referrer

Footnote 1851

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 1.

Return to footnote 1851 referrer

Footnote 1852

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 14.

Return to footnote 1852 referrer

Footnote 1853

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 113-116.

Return to footnote 1853 referrer

Footnote 1854

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 116.

Return to footnote 1854 referrer

Footnote 1855

Testimony of Mr. Beaulieu, Transcript of Proceedings, vol. 40, 26 June 2012, p. 118.

Return to footnote 1855 referrer

Footnote 1856

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 7.

Return to footnote 1856 referrer

Footnote 1857

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 5-6.

Return to footnote 1857 referrer

Footnote 1858

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 11.

Return to footnote 1858 referrer

Footnote 1859

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 136.

Return to footnote 1859 referrer

Footnote 1860

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 625.

Return to footnote 1860 referrer

Footnote 1861

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 264; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 14.

Return to footnote 1861 referrer

Footnote 1862

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 265.

Return to footnote 1862 referrer

Footnote 1863

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 15-16.

Return to footnote 1863 referrer

Footnote 1864

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 47-117.

Return to footnote 1864 referrer

Footnote 1865

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 96-97 and 113-114.

Return to footnote 1865 referrer

Footnote 1866

Exhibit P-150, tab 1, doc. 1429; Exhibit P-158, tab 1, doc. 1432.

Return to footnote 1866 referrer

Footnote 1867

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 523.

Return to footnote 1867 referrer

Footnote 1868

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 7; p. 38; pp. 191-192.

Return to footnote 1868 referrer

Footnote 1869

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 7.

Return to footnote 1869 referrer

Footnote 1870

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 7-8.

Return to footnote 1870 referrer

Footnote 1871

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 14-16.

Return to footnote 1871 referrer

Footnote 1872

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 19-21 and 27.

Return to footnote 1872 referrer

Footnote 1873

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 16-17 and 24-25.

Return to footnote 1873 referrer

Footnote 1874

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 41-42.

Return to footnote 1874 referrer

Footnote 1875

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 96.

Return to footnote 1875 referrer

Footnote 1876

Exhibit P-149, doc. 1427, pp. 11-68.

Return to footnote 1876 referrer

Footnote 1877

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 623-624; Exhibit P-158, doc. 1432, p. 37; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 157-160.

Return to footnote 1877 referrer

Footnote 1878

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 65-66.

Return to footnote 1878 referrer

Footnote 1879

Exhibit P-1, Collection A, vol. 2, tab 12, doc. 001-Q, p. 1.

Return to footnote 1879 referrer

Footnote 1880

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 117.

Return to footnote 1880 referrer

Footnote 1881

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 13-14.

Return to footnote 1881 referrer

Footnote 1882

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 13-14.

Return to footnote 1882 referrer

Footnote 1883

Testimony of CWO (Ret’d) Watson, vol. 55, 1 October 2012, pp. 11-128.

Return to footnote 1883 referrer

Footnote 1884

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 17.

Return to footnote 1884 referrer

Footnote 1885

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 19-20.

Return to footnote 1885 referrer

Footnote 1886

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 21.

Return to footnote 1886 referrer

Footnote 1887

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 84-85; pp. 99-100; pp. 156-157.

Return to footnote 1887 referrer

Footnote 1888

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 18-21.

Return to footnote 1888 referrer

Footnote 1889

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 257-258.

Return to footnote 1889 referrer

Footnote 1890

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 96-97.

Return to footnote 1890 referrer

Footnote 1891

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 115; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 107-108.

Return to footnote 1891 referrer

Footnote 1892

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 107-108.

Return to footnote 1892 referrer

Footnote 1893

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p 150-152.

Return to footnote 1893 referrer

Footnote 1894

Exhibit P-1, Collection A, vol. 1, tab 1, doc 001, pp 113-114.

Return to footnote 1894 referrer

Footnote 1895

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 113-114.

Return to footnote 1895 referrer

Footnote 1896

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 115.

Return to footnote 1896 referrer

Footnote 1897

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 52.

Return to footnote 1897 referrer

Footnote 1898

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 38-39.

Return to footnote 1898 referrer

Footnote 1899

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 106-109.

Return to footnote 1899 referrer

Footnote 1900

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 184-185; Testimony of Insp Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 204-205.

Return to footnote 1900 referrer

Footnote 1901

Exhibit P-150, tab 1, doc. 1429.

Return to footnote 1901 referrer

Footnote 1902

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 113-123.

Return to footnote 1902 referrer

Footnote 1903

Exhibit P-150, tab 1, doc. 1429; Exhibit P-158, tab 1, doc. 1432; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001.

Return to footnote 1903 referrer

Footnote 1904

Testimony of Mr. Beaulieu, Transcript of Proceedings, vol. 40, 26 June 2012, p. 118.

Return to footnote 1904 referrer

Footnote 1905

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 13.

Return to footnote 1905 referrer

Footnote 1906

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 135; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 209-210.

Return to footnote 1906 referrer

Footnote 1907

Exhibit P-1, Collection A, vol. 2, tab 12, doc. 001-Q, p. 2.

Return to footnote 1907 referrer

Footnote 1908

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 42-45; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 113-114.

Return to footnote 1908 referrer

Footnote 1909

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 113-114.

Return to footnote 1909 referrer

Footnote 1910

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 114-115; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 185-186; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 145.

Return to footnote 1910 referrer

Footnote 1911

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 140-142.

Return to footnote 1911 referrer

Footnote 1912

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 140.

Return to footnote 1912 referrer

Footnote 1913

Exhibit P-158, tab 1, doc. 1432, pp. 31 and 36.

Return to footnote 1913 referrer

Footnote 1914

Exhibit P-158, tab 1, doc. 1432, p. 30.

Return to footnote 1914 referrer

Footnote 1915

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 143.

Return to footnote 1915 referrer

Footnote 1916

See: 4.1.2, Investigating Negligence.

Return to footnote 1916 referrer

Footnote 1917

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 141-142.

Return to footnote 1917 referrer

Footnote 1918

See: 4.1.2, Investigating Negligence.

Return to footnote 1918 referrer

Footnote 1919

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 143-144.

Return to footnote 1919 referrer

Footnote 1920

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 143.

Return to footnote 1920 referrer

Footnote 1921

See: 4.1.5, Recordkeeping and Supervision.

Return to footnote 1921 referrer

Footnote 1922

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 121-122.

Return to footnote 1922 referrer

Footnote 1923

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 120-122.

Return to footnote 1923 referrer

Footnote 1924

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 186-187.

Return to footnote 1924 referrer

Footnote 1925

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 187-188.

Return to footnote 1925 referrer

Footnote 1926

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 188-189.

Return to footnote 1926 referrer

Footnote 1927

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 190-192.

Return to footnote 1927 referrer

Footnote 1928

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 192-193.

Return to footnote 1928 referrer

Footnote 1929

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 118-119.

Return to footnote 1929 referrer

Footnote 1930

See 4.1.3, The Investigation Plan.

Return to footnote 1930 referrer

Footnote 1931

See 4.1.4, The Concluding Remarks.

Return to footnote 1931 referrer

Footnote 1932

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 113-115.

Return to footnote 1932 referrer

Footnote 1933

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 114-115.

Return to footnote 1933 referrer

Footnote 1934

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 165-166.

Return to footnote 1934 referrer

Footnote 1935

See: 4.1.4, The Concluding Remarks.

Return to footnote 1935 referrer

Footnote 1936

Exhibit P-1, Collection A, vol. 2, tab 12, doc. 001-Q_r, p. 1.

Return to footnote 1936 referrer

Footnote 1937

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 65-66.

Return to footnote 1937 referrer

Footnote 1938

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 210-211.

Return to footnote 1938 referrer

Footnote 1939

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 210-211.

Return to footnote 1939 referrer

Footnote 1940

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 14.

Return to footnote 1940 referrer

Footnote 1941

See, generally, Section 4.1.4, The Concluding Remarks.

Return to footnote 1941 referrer

Footnote 1942

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 2.

Return to footnote 1942 referrer

Footnote 1943

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 2.

Return to footnote 1943 referrer

Footnote 1944

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 3.

Return to footnote 1944 referrer

Footnote 1945

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 6.

Return to footnote 1945 referrer

Footnote 1946

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 2.

Return to footnote 1946 referrer

Footnote 1947

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 14.

Return to footnote 1947 referrer

Footnote 1948

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 116; Exhibit P-147, tab 1, doc. 1422, p. 173.

Return to footnote 1948 referrer

Footnote 1949

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 280-282.

Return to footnote 1949 referrer

Footnote 1950

Exhibit P-6, Collection F, vol. 1, tab 43, doc. 1190, p. 7.

Return to footnote 1950 referrer

Footnote 1951

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 171.

Return to footnote 1951 referrer

Footnote 1952

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 157-158.

Return to footnote 1952 referrer

Footnote 1953

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 169.

Return to footnote 1953 referrer

Footnote 1954

Exhibit P-6, Collection F, vol. 1, tab 43, doc. 1190, p. 4.

Return to footnote 1954 referrer

Footnote 1955

Exhibit P-6, Collection F, vol. 1, tab 43, doc. 1190, p. 3.

Return to footnote 1955 referrer

Footnote 1956

Exhibit P-6, Collection F, vol. 1, tab 43, doc. 1190, p. 7.

Return to footnote 1956 referrer

Footnote 1957

Exhibit P-6, Collection F, vol. 1, tab 43, doc. 1190, p. 5.

Return to footnote 1957 referrer

Footnote 1958

Exhibit P-6, Collection F, vol. 1, tab 43, doc. 1190, p. 3.

Return to footnote 1958 referrer

Footnote 1959

Exhibit P-177, doc. 1457, p. 1.

Return to footnote 1959 referrer

Footnote 1960

See generally the scanned images of documents included in Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001

Return to footnote 1960 referrer

Footnote 1961

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 91.

Return to footnote 1961 referrer

Footnote 1962

Testimony of Mr. Beaulieu, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 118-120; Exhibit P-177, doc. 1457, pp. 1-2..

Return to footnote 1962 referrer

Footnote 1963

Exhibit P-6, Collection F, vol. 1, tab 37, doc. 1184, p. 2.

Return to footnote 1963 referrer

Footnote 1964

Exhibit P-150, tabs 1 to 3, docs. 1429, 1430, and 1431; Exhibit P-158, tabs 1 and 2, docs. 1432 and 1433.

Return to footnote 1964 referrer

Footnote 1965

Testimony of Mr. Beaulieu, Transcript of Proceedings, vol. 40, 26 June 2012, p. 118.

Return to footnote 1965 referrer

Footnote 1966

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 49; Exhibit P-147, tab 1, doc. 1422, p. 134.

Return to footnote 1966 referrer

Footnote 1967

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 116.

Return to footnote 1967 referrer

Footnote 1968

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 280-281.

Return to footnote 1968 referrer

Footnote 1969

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 104.

Return to footnote 1969 referrer

Footnote 1970

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 93.

Return to footnote 1970 referrer

Footnote 1971

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 96-97.

Return to footnote 1971 referrer

Footnote 1972

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 115.

Return to footnote 1972 referrer

Footnote 1973

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 1.

Return to footnote 1973 referrer

Footnote 1974

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, p. 1.

Return to footnote 1974 referrer

Footnote 1975

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, p. 1.

Return to footnote 1975 referrer

Footnote 1976

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 1.

Return to footnote 1976 referrer

Footnote 1977

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 67.

Return to footnote 1977 referrer

Footnote 1978

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 614.

Return to footnote 1978 referrer

Footnote 1979

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 620.

Return to footnote 1979 referrer

Footnote 1980

Exhibit P-1, Collection A, vol. 2, tab 6, doc. 001-D, p. 1.

Return to footnote 1980 referrer

Footnote 1981

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 115.

Return to footnote 1981 referrer

Footnote 1982

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 310-311.

Return to footnote 1982 referrer

Footnote 1983

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 85-88.

Return to footnote 1983 referrer

Footnote 1984

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 89.

Return to footnote 1984 referrer

Footnote 1985

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 104-108.

Return to footnote 1985 referrer

Footnote 1986

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, p. 107.

Return to footnote 1986 referrer

Footnote 1987

Exhibit P-1, Collection A, vol. 2, tab 2, doc. 001-D, pp. 100-103; p. 107.

Return to footnote 1987 referrer

Footnote 1988

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 568.

Return to footnote 1988 referrer

Footnote 1989

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 74-76.

Return to footnote 1989 referrer

Footnote 1990

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 590-592.

Return to footnote 1990 referrer

Footnote 1991

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 591-592.

Return to footnote 1991 referrer

Footnote 1992

Exhibit P-1, Collection A, vol. 2, tab 3, doc. 001-E, pp. 75 and 79-80.

Return to footnote 1992 referrer

Footnote 1993

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, p. 35.

Return to footnote 1993 referrer

Footnote 1994

Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 53-54.

Return to footnote 1994 referrer

Footnote 1995

See: 4.1.2, Investigating Negligence.

Return to footnote 1995 referrer

Footnote 1996

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 79-80.

Return to footnote 1996 referrer

Footnote 1997

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 621.

Return to footnote 1997 referrer

Footnote 1998

Exhibit P-1, Collection A, vol. 2, tab 7, 001-I, pp. 27-28.

Return to footnote 1998 referrer

Footnote 1999

Exhibit P-1, Collection A, vol. 2, tab 7, 001-I, pp. 4-6.

Return to footnote 1999 referrer

Footnote 2000

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 274.

Return to footnote 2000 referrer

Footnote 2001

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 141-142.

Return to footnote 2001 referrer

Footnote 2002

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 533.

Return to footnote 2002 referrer

Footnote 2003

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 566.

Return to footnote 2003 referrer

Footnote 2004

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 611.

Return to footnote 2004 referrer

Footnote 2005

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 243-244.

Return to footnote 2005 referrer

Footnote 2006

See: 4.1.1, Investigating the Sudden Death; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 527-528.

Return to footnote 2006 referrer

Footnote 2007

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 86-88.

Return to footnote 2007 referrer

Footnote 2008

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 43-45

Return to footnote 2008 referrer

Footnote 2009

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 43.

Return to footnote 2009 referrer

Footnote 2010

Exhibit P-149, doc. 1427, pp. 11-17. The first File Status Report for this file is included in a collection of CFNIS WR File Status Reports dated March 4, 2008. The explanation may be the date of the 2008 Sudden Death Investigation report was redacted. there was an error when compiling the document, or a page is missing. See Transcript of Proceedings, vol. 48, 14 September 2012, pp. 123-126.

Return to footnote 2010 referrer

Footnote 2011

Exhibit P-149, doc. 1427, p. 17.

Return to footnote 2011 referrer

Footnote 2012

Exhibit P-149, doc. 1427, pp. 18-26.

Return to footnote 2012 referrer

Footnote 2013

Exhibit P-149, doc. 1427, pp. 27-35.

Return to footnote 2013 referrer

Footnote 2014

Exhibit P-149, doc. 1427, p. 45 [Emphasis added].

Return to footnote 2014 referrer

Footnote 2015

Exhibit P-149, doc. 1427, pp. 36-46.

Return to footnote 2015 referrer

Footnote 2016

Exhibit P-149, doc. 1427, pp. 47-68.

Return to footnote 2016 referrer

Footnote 2017

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 122-123.

Return to footnote 2017 referrer

Footnote 2018

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 64-65.

Return to footnote 2018 referrer

Footnote 2019

Exhibit P-149, doc. 1427, pp. 27-68.

Return to footnote 2019 referrer

Footnote 2020

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 291-292.

Return to footnote 2020 referrer

Footnote 2021

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 295-296.

Return to footnote 2021 referrer

Footnote 2022

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 78.

Return to footnote 2022 referrer

Footnote 2023

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 295-296.

Return to footnote 2023 referrer

Footnote 2024

Exhibit P-149, doc. 1427, p. 45.

Return to footnote 2024 referrer

Footnote 2025

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p 66.

Return to footnote 2025 referrer

Footnote 2026

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 60.

Return to footnote 2026 referrer

Footnote 2027

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 128-133.

Return to footnote 2027 referrer

Footnote 2028

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 65-67.

Return to footnote 2028 referrer

Footnote 2029

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 52-55.

Return to footnote 2029 referrer

Footnote 2030

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 95-96.

Return to footnote 2030 referrer

Footnote 2031

See: Section 4.1.2, Investigating Negligence.

Return to footnote 2031 referrer

Footnote 2032

Exhibit P-1, Collection A, vol. 2, tab 4, doc. 001-F, pp. 53-59; pp. 90-93; pp. 96-101. On May 5, 2008, the CFNIS interviewed MCpl Bowden, who also discussed the abortive suicide watch in detail. See Exhibit P-1, Collection A, vol. 2, tab 5, doc. 001-G, pp. 12-15; pp. 19-38.

Return to footnote 2032 referrer

Footnote 2033

Exhibit P-149, doc. 1427, p. 45.

Return to footnote 2033 referrer

Footnote 2034

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 175.

Return to footnote 2034 referrer

Footnote 2035

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 181-182.

Return to footnote 2035 referrer

Footnote 2036

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 100.

Return to footnote 2036 referrer

Footnote 2037

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 175.

Return to footnote 2037 referrer

Footnote 2038

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 79-80.

Return to footnote 2038 referrer

Footnote 2039

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp.181-182.

Return to footnote 2039 referrer

Footnote 2040

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 181.

Return to footnote 2040 referrer

Footnote 2041

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 99-100.

Return to footnote 2041 referrer

Footnote 2042

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 99.

Return to footnote 2042 referrer

Footnote 2043

Fatality Inquiries Act, RSA 2000, c F-9.

Return to footnote 2043 referrer

Footnote 2044

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 308-309.

Return to footnote 2044 referrer

Footnote 2045

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 172-173.

Return to footnote 2045 referrer

Footnote 2046

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 212.

Return to footnote 2046 referrer

Footnote 2047

Final Submissions of the Subjects of the Complaint, pp. 53-54.

Return to footnote 2047 referrer

Footnote 2048

Submissions of Ms. McLaine, Transcript of Proceedings, vol. 62, 9 January 2013, p. 97.

Return to footnote 2048 referrer

Footnote 2049

Submissions of Ms. Richards, Transcript of Proceedings, vol. 62, 9 January 2013, pp. 98-99.

Return to footnote 2049 referrer

Footnote 2050

See, generally, Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 2050 referrer

Footnote 2051

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 178 and 181-182.

Return to footnote 2051 referrer

Footnote 2052

National Defence Act, RSC 1985, c N-5, s. 273.2 and 273.3.

Return to footnote 2052 referrer

Footnote 2053

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 170.

Return to footnote 2053 referrer

Footnote 2054

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 31.

Return to footnote 2054 referrer

Footnote 2055

Fatality Inquiries Act, RSA 2000, c F-9.

Return to footnote 2055 referrer

Footnote 2056

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 170.

Return to footnote 2056 referrer

Footnote 2057

R. v. Pugliese, 1992 CanLII 2781 (ON CA).

Return to footnote 2057 referrer

Footnote 2058

R. v. Wills, 7 OR (3d) 337 (CA).

Return to footnote 2058 referrer

Footnote 2059

R. v. Caslake, [1998] 1 SCR 51.

Return to footnote 2059 referrer

Footnote 2060

R. v. Mann, 2004 SCC 52, [2004] 3 SCR 59 at para 40.

Return to footnote 2060 referrer

Footnote 2061

Criminal Code, RSC 1985, c C-46, s. 487.11; R. v. Silveira, [1995] 2 SCR 297 at paras 101-115.

Return to footnote 2061 referrer

Footnote 2062

Criminal Code, RSC 1985, c C-46, ss. 117.02 and 529.3; R. v. Silveira, [1995] 2 SCR 297 at paras 101-115; Canada (House of Commons) v. Vaid, 2002 FCA 473, [2003] 1 FC 602 at para 39.

Return to footnote 2062 referrer

Footnote 2063

R. v. Grant, [1993] 3 SCR 223 at 242, citing R. v. Wise, [1992] 1 SCR 527.

Return to footnote 2063 referrer

Footnote 2064

Fatality Inquiries Act, RSA 2000, c F-9, s. 21.

Return to footnote 2064 referrer

Footnote 2065

Fatality Inquiries Act, RSA 2000, c F-9, s. 6(b).

Return to footnote 2065 referrer

Footnote 2066

Fatality Inquiries Act, RSA 2000, c F-9, s. 9(1).

Return to footnote 2066 referrer

Footnote 2067

Fatality Inquiries Act, RSA 2000, c F-9, s. 21(1).

Return to footnote 2067 referrer

Footnote 2068

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 98-99.

Return to footnote 2068 referrer

Footnote 2069

Final Submissions of the Subjects of the Complaint, p. 54.

Return to footnote 2069 referrer

Footnote 2070

See: Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2070 referrer

Footnote 2071

Although the term “exhibits” generally refers to items entered in evidence before courts or tribunals, and the MP policies generally use the term in this manner (see Exhibit P-6, Collection F, vol. 1, tab 41, doc. 1188, p. 5; Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, pp. 12-14), both the complainants and the CFNIS members involved in this investigation have used this term to describe the property seized during the investigation, even though the items were never used in any court proceedings (see Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 161-166; Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 28, p. 5). The CFNIS members often identified the seized items retained for the purposes of the investigation as “exhibits,” while they identified other items turned over to Cpl Langridge’s Regiment as “personal effects” or “personal property” (see Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 161-166, 178-179, 208 and 227). Because the documents and testimony at the hearings generally use the term “exhibits” to describe the property seized by the CFNIS and retained for the purposes of the investigation, this Report also uses the term “exhibits” in this manner.

Return to footnote 2071 referrer

Footnote 2072

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 28, p. 5.

Return to footnote 2072 referrer

Footnote 2073

See: Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2073 referrer

Footnote 2074

See: Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2074 referrer

Footnote 2075

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 181-182.

Return to footnote 2075 referrer

Footnote 2076

See: Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2076 referrer

Footnote 2077

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-714; Testimony of MCpl Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 152-153.

Return to footnote 2077 referrer

Footnote 2078

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189.

Return to footnote 2078 referrer

Footnote 2079

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 2.

Return to footnote 2079 referrer

Footnote 2080

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 12.

Return to footnote 2080 referrer

Footnote 2081

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 14.

Return to footnote 2081 referrer

Footnote 2082

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 13.

Return to footnote 2082 referrer

Footnote 2083

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 47-52.

Return to footnote 2083 referrer

Footnote 2084

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, pp. 12-13.

Return to footnote 2084 referrer

Footnote 2085

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 13.

Return to footnote 2085 referrer

Footnote 2086

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 14.

Return to footnote 2086 referrer

Footnote 2087

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, pp. 12-14.

Return to footnote 2087 referrer

Footnote 2088

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 43-45 and 52-54 [Translation]; Testimony of LCol Delaney, Transcript of Proceedings, vol. 16, 25 April 2012, pp. 53-54.

Return to footnote 2088 referrer

Footnote 2089

See: Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2089 referrer

Footnote 2090

See: Section 4.1.1, Investigating the Sudden Death; Section 4.1.2, Investigating Negligence; Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2090 referrer

Footnote 2091

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 2091 referrer

Footnote 2092

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 523.

Return to footnote 2092 referrer

Footnote 2093

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 1 and 630.

Return to footnote 2093 referrer

Footnote 2094

Exhibit P-1, Collection A, vol. 2, tab 10, doc. 001-Q.

Return to footnote 2094 referrer

Footnote 2095

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 524.

Return to footnote 2095 referrer

Footnote 2096

See: Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2096 referrer

Footnote 2097

See: Section 4.1.2, Investigating Negligence.

Return to footnote 2097 referrer

Footnote 2098

See: Section 4.1.1, Investigating the Sudden Death and Section 4.1.2, Investigating Negligence.

Return to footnote 2098 referrer

Footnote 2099

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 89-90.

Return to footnote 2099 referrer

Footnote 2100

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 1 and 630.

Return to footnote 2100 referrer

Footnote 2101

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 1 and 630.

Return to footnote 2101 referrer

Footnote 2102

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 513-515.

Return to footnote 2102 referrer

Footnote 2103

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 512-513.

Return to footnote 2103 referrer

Footnote 2104

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 512.

Return to footnote 2104 referrer

Footnote 2105

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 151-152.

Return to footnote 2105 referrer

Footnote 2106

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2106 referrer

Footnote 2107

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 218.

Return to footnote 2107 referrer

Footnote 2108

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 134-135 and 152; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 36-37.

Return to footnote 2108 referrer

Footnote 2109

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 152.

Return to footnote 2109 referrer

Footnote 2110

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2110 referrer

Footnote 2111

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2111 referrer

Footnote 2112

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2112 referrer

Footnote 2113

See: Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2113 referrer

Footnote 2114

See Exhibit P-4, Collection D, vol. 1, tab 89, doc. 086.

Return to footnote 2114 referrer

Footnote 2115

Exhibit P-1, Collection A, vol. 2, tab 11, doc. 001-P.

Return to footnote 2115 referrer

Footnote 2116

Exhibit P-1, Collection A, vol. 2, tab 11, doc. 001-P.

Return to footnote 2116 referrer

Footnote 2117

Exhibit P-1, Collection A, vol. 2, tab 11, doc. 001-P.

Return to footnote 2117 referrer

Footnote 2118

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 634-714.

Return to footnote 2118 referrer

Footnote 2119

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 109.

Return to footnote 2119 referrer

Footnote 2120

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 109-110.

Return to footnote 2120 referrer

Footnote 2121

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 110.

Return to footnote 2121 referrer

Footnote 2122

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 215.

Return to footnote 2122 referrer

Footnote 2123

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 214-216. See, generally, Section 4.2,The Suicide Note Left by Cpl Langridge.

Return to footnote 2123 referrer

Footnote 2124

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 220-221.

Return to footnote 2124 referrer

Footnote 2125

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 217.

Return to footnote 2125 referrer

Footnote 2126

See Section 4.2,The Suicide Note Left by Cpl Langridge.

Return to footnote 2126 referrer

Footnote 2127

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 12; Exhibit P-147, tab 1, doc. 1422, p. 22; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 85-86 [Translation]. See, generally, Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2127 referrer

Footnote 2128

This individual is not the same person as CWO Douglas Ross, the RSM for the LDSH Regiment.

Return to footnote 2128 referrer

Footnote 2129

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 7.

Return to footnote 2129 referrer

Footnote 2130

Exhibit P-5, Collection E, vol. 6, tab 37, doc. 1270, p. 1.

Return to footnote 2130 referrer

Footnote 2131

Exhibit P-5, Collection E, vol. 6, tab 37, doc. 1270, p. 2.

Return to footnote 2131 referrer

Footnote 2132

Exhibit P-5, Collection E, vol. 6, tab 37, doc. 1270, p. 1.

Return to footnote 2132 referrer

Footnote 2133

Exhibit P-5, Collection E, vol. 6, tab 37, doc. 1270, pp. 2-3.

Return to footnote 2133 referrer

Footnote 2134

Exhibit P-5, Collection E, vol. 6, tab 37, doc. 1270, p. 3.

Return to footnote 2134 referrer

Footnote 2135

Exhibit P-5, Collection E, vol. 6, tab 37, doc. 1270, p. 3.

Return to footnote 2135 referrer

Footnote 2136

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261.

Return to footnote 2136 referrer

Footnote 2137

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2137 referrer

Footnote 2138

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261.

Return to footnote 2138 referrer

Footnote 2139

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2139 referrer

Footnote 2140

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2140 referrer

Footnote 2141

See Section 4.1.1, Investigating the Sudden Death; Section 4.1.2, Investigating Negligence; Section 4.1.3, The Investigation Plan; Section 4.1.4, The Concluding Remarks; Section 4.1.5 Recordkeeping and Supervision; Section 4.1.6, Search Warrants.

Return to footnote 2141 referrer

Footnote 2142

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2142 referrer

Footnote 2143

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 2.

Return to footnote 2143 referrer

Footnote 2144

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 1-2.

Return to footnote 2144 referrer

Footnote 2145

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 2.

Return to footnote 2145 referrer

Footnote 2146

See Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2146 referrer

Footnote 2147

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 2-6.

Return to footnote 2147 referrer

Footnote 2148

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 6-7.

Return to footnote 2148 referrer

Footnote 2149

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 6-7.

Return to footnote 2149 referrer

Footnote 2150

See Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 3-4. See, generally, Section 4.1.4, The Concluding Remarks; Section 4.1.5, Recordkeeping and Supervision.

Return to footnote 2150 referrer

Footnote 2151

See Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2151 referrer

Footnote 2152

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 7.

Return to footnote 2152 referrer

Footnote 2153

Exhibit P-148, tab 3, doc. 1428.

Return to footnote 2153 referrer

Footnote 2154

See Section 4.1.1, Investigating the Sudden Death.

Return to footnote 2154 referrer

Footnote 2155

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 3.

Return to footnote 2155 referrer

Footnote 2156

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 2-3.

Return to footnote 2156 referrer

Footnote 2157

See, generally, Section 4.1.2, Investigating Negligence; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 2157 referrer

Footnote 2158

See Section 4.1.2, Investigating Negligence.

Return to footnote 2158 referrer

Footnote 2159

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2159 referrer

Footnote 2160

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 4-5.

Return to footnote 2160 referrer

Footnote 2161

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2161 referrer

Footnote 2162

Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2162 referrer

Footnote 2163

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 5.

Return to footnote 2163 referrer

Footnote 2164

See Section 4.2, The Suicide Note Left by Cpl Langridge; Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2164 referrer

Footnote 2165

See Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 6-7.

Return to footnote 2165 referrer

Footnote 2166

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 6.

Return to footnote 2166 referrer

Footnote 2167

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 6.

Return to footnote 2167 referrer

Footnote 2168

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 2168 referrer

Footnote 2169

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 161; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 157.

Return to footnote 2169 referrer

Footnote 2170

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 157.

Return to footnote 2170 referrer

Footnote 2171

Testimony of MWO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 184-185.

Return to footnote 2171 referrer

Footnote 2172

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 149-150.

Return to footnote 2172 referrer

Footnote 2173

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 135-136 and 138-139.

Return to footnote 2173 referrer

Footnote 2174

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2174 referrer

Footnote 2175

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2175 referrer

Footnote 2176

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2176 referrer

Footnote 2177

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2177 referrer

Footnote 2178

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2178 referrer

Footnote 2179

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2179 referrer

Footnote 2180

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2180 referrer

Footnote 2181

See: 4.1.5, Supervision and Recordkeeping.

Return to footnote 2181 referrer

Footnote 2182

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background.

Return to footnote 2182 referrer

Footnote 2183

See: 4.1.1, Investigating the Sudden Death; 4.1.2 Investigating Negligence.

Return to footnote 2183 referrer

Footnote 2184

See: 4.1.1, Investigating the Sudden Death.

Return to footnote 2184 referrer

Footnote 2185

See: 4.1.1, Investigating the Sudden Death; 4.2 The Suicide Note Left by Cpl Langridge.

Return to footnote 2185 referrer

Footnote 2186

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 70-72 [Translation]; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 106-109; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 20.

Return to footnote 2186 referrer

Footnote 2187

See: 4.1.1, Investigating the Sudden Death.

Return to footnote 2187 referrer

Footnote 2188

See: 4.0, The Subjects of the Complaint: Role, Involvement and Background; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 356-357.

Return to footnote 2188 referrer

Footnote 2189

Exhibit P-6, Collection F, vol. 3, tab 8, doc. 1327; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 287.

Return to footnote 2189 referrer

Footnote 2190

See Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 175 and 306.

Return to footnote 2190 referrer

Footnote 2191

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2191 referrer

Footnote 2192

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 139; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 149-151; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 156-158. See also, Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 76.

Return to footnote 2192 referrer

Footnote 2193

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 197 and 209; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 18-21 and 256-258.

Return to footnote 2193 referrer

Footnote 2194

Final Submissions of the Subjects of the Complaint, pp. 1, 51 and 107.

Return to footnote 2194 referrer

Footnote 2195

Final Submissions of the Subjects of the Complaint, p. 49.

Return to footnote 2195 referrer

Footnote 2196

Final Submissions of the Subjects of the Complaint, pp. 48-49.

Return to footnote 2196 referrer

Footnote 2197

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 139; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 18-21, 149-151 and 256-258; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 197 and 209; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 156-158. See also, Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 76.

Return to footnote 2197 referrer

Footnote 2198

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 163.

Return to footnote 2198 referrer

Footnote 2199

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2199 referrer

Footnote 2200

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 2; Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 390.

Return to footnote 2200 referrer

Footnote 2201

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 2.

Return to footnote 2201 referrer

Footnote 2202

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 387.

Return to footnote 2202 referrer

Footnote 2203

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 2.

Return to footnote 2203 referrer

Footnote 2204

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 2.

Return to footnote 2204 referrer

Footnote 2205

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 2.

Return to footnote 2205 referrer

Footnote 2206

Exhibit P-4, Collection D, vol. 12, tab 70, doc. 1097.

Return to footnote 2206 referrer

Footnote 2207

Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012, pp. 37 & 86-87.

Return to footnote 2207 referrer

Footnote 2208

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 390.

Return to footnote 2208 referrer

Footnote 2209

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, pp. 229-230.

Return to footnote 2209 referrer

Footnote 2210

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, pp. 229-230.

Return to footnote 2210 referrer

Footnote 2211

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 230.

Return to footnote 2211 referrer

Footnote 2212

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 89-90.

Return to footnote 2212 referrer

Footnote 2213

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 89; Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012, p. 87; Closing Submission of the Complainants, p. 10. For a discussion of the authority over the planning of the funeral, see Section 4.3, The 2009 PNOK Investigation.

Return to footnote 2213 referrer

Footnote 2214

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 5.

Return to footnote 2214 referrer

Footnote 2215

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 2-3.

Return to footnote 2215 referrer

Footnote 2216

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 631-633.

Return to footnote 2216 referrer

Footnote 2217

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 521 & 523.

Return to footnote 2217 referrer

Footnote 2218

Exhibit P-147, tab 1, doc. 1422, p. 9.

Return to footnote 2218 referrer

Footnote 2219

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 21-22; Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 226.

Return to footnote 2219 referrer

Footnote 2220

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 115.

Return to footnote 2220 referrer

Footnote 2221

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 115.

Return to footnote 2221 referrer

Footnote 2222

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 115.

Return to footnote 2222 referrer

Footnote 2223

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 151, 163, 164 & 631.

Return to footnote 2223 referrer

Footnote 2224

Reply Submissions of the Subjects of the complaint, p. 8.

Return to footnote 2224 referrer

Footnote 2225

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 259-261.

Return to footnote 2225 referrer

Footnote 2226

Exhibit P-147, tab 2, doc. 1423, p. 22.

Return to footnote 2226 referrer

Footnote 2227

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 104.

Return to footnote 2227 referrer

Footnote 2228

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 103.

Return to footnote 2228 referrer

Footnote 2229

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 103.

Return to footnote 2229 referrer

Footnote 2230

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 227.

Return to footnote 2230 referrer

Footnote 2231

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 227.

Return to footnote 2231 referrer

Footnote 2232

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, pp. 116-117.

Return to footnote 2232 referrer

Footnote 2233

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 117.

Return to footnote 2233 referrer

Footnote 2234

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 117.

Return to footnote 2234 referrer

Footnote 2235

Exhibit P-147, tab 2, doc. 1423, p. 16.

Return to footnote 2235 referrer

Footnote 2236

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 103.

Return to footnote 2236 referrer

Footnote 2237

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 102.

Return to footnote 2237 referrer

Footnote 2238

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 102.

Return to footnote 2238 referrer

Footnote 2239

Exhibit P-147, tab 2, doc. 1423, p. 22.

Return to footnote 2239 referrer

Footnote 2240

Exhibit P-147, tab 2, doc. 1423, p. 22.

Return to footnote 2240 referrer

Footnote 2241

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 125.

Return to footnote 2241 referrer

Footnote 2242

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 125.

Return to footnote 2242 referrer

Footnote 2243

Exhibit P-147, tab 2, doc. 1423, p. 20.

Return to footnote 2243 referrer

Footnote 2244

Exhibit P-147, tab 2, doc. 1423, p. 26.

Return to footnote 2244 referrer

Footnote 2245

Exhibit P-147, tab 1, doc. 1422, p. 11.

Return to footnote 2245 referrer

Footnote 2246

Exhibit P-147, tab 1, doc. 1422, p. 11.

Return to footnote 2246 referrer

Footnote 2247

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 27.

Return to footnote 2247 referrer

Footnote 2248

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 28 & 29.

Return to footnote 2248 referrer

Footnote 2249

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 30.

Return to footnote 2249 referrer

Footnote 2250

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 28-29.

Return to footnote 2250 referrer

Footnote 2251

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 28.

Return to footnote 2251 referrer

Footnote 2252

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 27-29.

Return to footnote 2252 referrer

Footnote 2253

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 29.

Return to footnote 2253 referrer

Footnote 2254

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 63-64 [Translation]. See also Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 19-20.

Return to footnote 2254 referrer

Footnote 2255

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 20.

Return to footnote 2255 referrer

Footnote 2256

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 64-65 [Translation].

Return to footnote 2256 referrer

Footnote 2257

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 65 [Translation].

Return to footnote 2257 referrer

Footnote 2258

Exhibit P-147, tab 2, doc. 1423, p. 26.

Return to footnote 2258 referrer

Footnote 2259

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 32.

Return to footnote 2259 referrer

Footnote 2260

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 27; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 115.

Return to footnote 2260 referrer

Footnote 2261

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 18.

Return to footnote 2261 referrer

Footnote 2262

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 115.

Return to footnote 2262 referrer

Footnote 2263

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 115-116.

Return to footnote 2263 referrer

Footnote 2264

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 116.

Return to footnote 2264 referrer

Footnote 2265

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 116-117.

Return to footnote 2265 referrer

Footnote 2266

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 116-117.

Return to footnote 2266 referrer

Footnote 2267

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 62-64 [Translation].

Return to footnote 2267 referrer

Footnote 2268

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 51.

Return to footnote 2268 referrer

Footnote 2269

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 14-15 & 50-52.

Return to footnote 2269 referrer

Footnote 2270

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 392.

Return to footnote 2270 referrer

Footnote 2271

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 391.

Return to footnote 2271 referrer

Footnote 2272

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, pp. 124-125.

Return to footnote 2272 referrer

Footnote 2273

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 391.

Return to footnote 2273 referrer

Footnote 2274

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 391.

Return to footnote 2274 referrer

Footnote 2275

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 391.

Return to footnote 2275 referrer

Footnote 2276

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 92-94; Closing Submissions of the Complainants, p. 78 & Prologue, p. 5.

Return to footnote 2276 referrer

Footnote 2277

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 390.

Return to footnote 2277 referrer

Footnote 2278

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 390.

Return to footnote 2278 referrer

Footnote 2279

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 389.

Return to footnote 2279 referrer

Footnote 2280

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 389.

Return to footnote 2280 referrer

Footnote 2281

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 389.

Return to footnote 2281 referrer

Footnote 2282

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 389.

Return to footnote 2282 referrer

Footnote 2283

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, pp. 128-129.

Return to footnote 2283 referrer

Footnote 2284

Exhibit P-5, Collection E, vol. 5, tab 11, doc. 1233, p. 616.

Return to footnote 2284 referrer

Footnote 2285

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 15.

Return to footnote 2285 referrer

Footnote 2286

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 18.

Return to footnote 2286 referrer

Footnote 2287

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 15.

Return to footnote 2287 referrer

Footnote 2288

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 15.

Return to footnote 2288 referrer

Footnote 2289

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 49-50; Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 7.

Return to footnote 2289 referrer

Footnote 2290

Closing Submission of the Complainants, p. 10.

Return to footnote 2290 referrer

Footnote 2291

Exhibit P-147, tab 1, doc. 1422, pp. 13-14.

Return to footnote 2291 referrer

Footnote 2292

Exhibit P-147, tab 1, doc. 1422, p. 13.

Return to footnote 2292 referrer

Footnote 2293

Exhibit P-147, tab 1, doc. 1422, p. 13.

Return to footnote 2293 referrer

Footnote 2294

Exhibit P-147, tab 1, doc. 1422, p. 13.

Return to footnote 2294 referrer

Footnote 2295

Exhibit P-147, tab 1, doc. 1422, p. 13.

Return to footnote 2295 referrer

Footnote 2296

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 2296 referrer

Footnote 2297

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 2297 referrer

Footnote 2298

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 2298 referrer

Footnote 2299

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 96.

Return to footnote 2299 referrer

Footnote 2300

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 96.

Return to footnote 2300 referrer

Footnote 2301

Exhibit P-147, tab 1, doc. 1422, p. 18.

Return to footnote 2301 referrer

Footnote 2302

Exhibit P-147, tab 1, doc. 1422, p. 18.

Return to footnote 2302 referrer

Footnote 2303

Exhibit P-5, Collection E, vol. 5, tab 8, doc. 1230, p. 770.

Return to footnote 2303 referrer

Footnote 2304

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 225.

Return to footnote 2304 referrer

Footnote 2305

Exhibit P-1, Collection A, vol. 1, tab 1, pp. 631-633.

Return to footnote 2305 referrer

Footnote 2306

Exhibit P-1, Collection A, vol. 1, tab 1, p. 633.

Return to footnote 2306 referrer

Footnote 2307

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 227.

Return to footnote 2307 referrer

Footnote 2308

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 18.

Return to footnote 2308 referrer

Footnote 2309

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 15.

Return to footnote 2309 referrer

Footnote 2310

Exhibit P-5, Collection E, vol. 5, tab 11, doc. 1233, pp. 616-617.

Return to footnote 2310 referrer

Footnote 2311

Exhibit P-5, Collection E, vol. 5, tab 11, doc. 1233, p. 616.

Return to footnote 2311 referrer

Footnote 2312

Exhibit P-5, Collection E, vol. 5, tab 11, doc. 1233, p. 616.

Return to footnote 2312 referrer

Footnote 2313

Exhibit P-5, Collection E, vol. 4, tab 14, doc. 1221, p. 32.

Return to footnote 2313 referrer

Footnote 2314

Exhibit P-4, Collection D, vol. 12, tab 98, doc. 1125.

Return to footnote 2314 referrer

Footnote 2315

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 14.

Return to footnote 2315 referrer

Footnote 2316

Exhibit P-5, Collection E, vol. 5, tab 8, doc. 1230, pp. 766-767.

Return to footnote 2316 referrer

Footnote 2317

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 13.

Return to footnote 2317 referrer

Footnote 2318

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, pp. 12-13.

Return to footnote 2318 referrer

Footnote 2319

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 13.

Return to footnote 2319 referrer

Footnote 2320

Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, pp. 35-36.

Return to footnote 2320 referrer

Footnote 2321

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 11.

Return to footnote 2321 referrer

Footnote 2322

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 246-247.

Return to footnote 2322 referrer

Footnote 2323

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 63.

Return to footnote 2323 referrer

Footnote 2324

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 246.

Return to footnote 2324 referrer

Footnote 2325

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 246.

Return to footnote 2325 referrer

Footnote 2326

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 245-246.

Return to footnote 2326 referrer

Footnote 2327

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 245-246.

Return to footnote 2327 referrer

Footnote 2328

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 65.

Return to footnote 2328 referrer

Footnote 2329

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 123-124.

Return to footnote 2329 referrer

Footnote 2330

Exhibit P-147, tab 1, doc. 1422, p. 16.

Return to footnote 2330 referrer

Footnote 2331

See Exhibit P-147, tab 1, doc. 1422, p. 16; Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 244-245; Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, p. 36; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 60.

Return to footnote 2331 referrer

Footnote 2332

Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, p. 36.

Return to footnote 2332 referrer

Footnote 2333

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 48.

Return to footnote 2333 referrer

Footnote 2334

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, p. 137.

Return to footnote 2334 referrer

Footnote 2335

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 48; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 11; Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, pp. 40-44.

Return to footnote 2335 referrer

Footnote 2336

See Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, p. 126; Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, p. 138.

Return to footnote 2336 referrer

Footnote 2337

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 48; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 11; Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, pp. 38 & 40-41.

Return to footnote 2337 referrer

Footnote 2338

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 1-144, 147-163, 171-245, 394-441 & 783-788; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, pp. 3-5 & 11; Exhibit P-5, Collection E, vol. 5, tab 8, doc. 1230, p. 766; Exhibit P-147, tab 1, doc. 1422, pp. 111-113; Exhibit P-92, doc. 1377.

Return to footnote 2338 referrer

Footnote 2339

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 78-80, 107-111, 133 & 198; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 3; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, p. 146.

Return to footnote 2339 referrer

Footnote 2340

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 176-177 & 402; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 166-169.

Return to footnote 2340 referrer

Footnote 2341

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 78-79 & 83-84 [Translation].

Return to footnote 2341 referrer

Footnote 2342

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 176-177; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 166-169.

Return to footnote 2342 referrer

Footnote 2343

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, pp. 3 & 11; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 1, 38, 79, 107-111 & 133; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 137-138 & 146; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 74 & 81.

Return to footnote 2343 referrer

Footnote 2344

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 137-138, 144-147 & 162-163; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 38, 59-60, 63-67, 106-107, 236-238 & 402.

Return to footnote 2344 referrer

Footnote 2345

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 63; Exhibit P-147, tab 1, doc. 1422, pp. 111-113.

Return to footnote 2345 referrer

Footnote 2346

See Exhibit P-147, tab 1, doc. 1422, pp. 111-113.

Return to footnote 2346 referrer

Footnote 2347

Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, pp. 40 & 51.

Return to footnote 2347 referrer

Footnote 2348

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 133-134.

Return to footnote 2348 referrer

Footnote 2349

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 133-134.

Return to footnote 2349 referrer

Footnote 2350

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 133.

Return to footnote 2350 referrer

Footnote 2351

Exhibit P-92, doc. 1377; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 402-403.

Return to footnote 2351 referrer

Footnote 2352

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 398; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 162-163.

Return to footnote 2352 referrer

Footnote 2353

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 78-79.

Return to footnote 2353 referrer

Footnote 2354

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 78-79.

Return to footnote 2354 referrer

Footnote 2355

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 59-60.

Return to footnote 2355 referrer

Footnote 2356

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 227.

Return to footnote 2356 referrer

Footnote 2357

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 203.

Return to footnote 2357 referrer

Footnote 2358

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 203.

Return to footnote 2358 referrer

Footnote 2359

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 203.

Return to footnote 2359 referrer

Footnote 2360

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 203.

Return to footnote 2360 referrer

Footnote 2361

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 2361 referrer

Footnote 2362

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 415, 416, 419-420 & 426-430.

Return to footnote 2362 referrer

Footnote 2363

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 426-427.

Return to footnote 2363 referrer

Footnote 2364

See Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2364 referrer

Footnote 2365

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 182-184, 198-201 & 701.

Return to footnote 2365 referrer

Footnote 2366

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 193 & 181.

Return to footnote 2366 referrer

Footnote 2367

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 171-173.

Return to footnote 2367 referrer

Footnote 2368

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 206-207.

Return to footnote 2368 referrer

Footnote 2369

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 205-207.

Return to footnote 2369 referrer

Footnote 2370

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 246-351, 442-659, 668-672, 680-688, 697-701, 726-732, 735-744, 768-775, 779-781, 796-798 & 808-810; Exhibit P-93, doc. 1378.

Return to footnote 2370 referrer

Footnote 2371

Exhibit P-93, doc. 1378; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 170-171; 174; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 704-712.

Return to footnote 2371 referrer

Footnote 2372

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 256-257, 262, 453-454, 535, 542-543 & 737-738.

Return to footnote 2372 referrer

Footnote 2373

Closing Submissions of the Complainants, p. 9.

Return to footnote 2373 referrer

Footnote 2374

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 26 & 33.

Return to footnote 2374 referrer

Footnote 2375

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 2375 referrer

Footnote 2376

Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, pp. 35-36.

Return to footnote 2376 referrer

Footnote 2377

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 354-355.

Return to footnote 2377 referrer

Footnote 2378

Exhibit P-147, tab 1, doc. 1422, p. 20.

Return to footnote 2378 referrer

Footnote 2379

Exhibit P-147, tab 1, doc. 1422, p. 20.

Return to footnote 2379 referrer

Footnote 2380

Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, p. 35.

Return to footnote 2380 referrer

Footnote 2381

Exhibit P-147, tab 1, doc. 1422, p. 112.

Return to footnote 2381 referrer

Footnote 2382

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 2382 referrer

Footnote 2383

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76-77.

Return to footnote 2383 referrer

Footnote 2384

Exhibit P-4, Collection D, vol. 1, tab 35, doc. 032, p. 6.

Return to footnote 2384 referrer

Footnote 2385

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 48; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 13.

Return to footnote 2385 referrer

Footnote 2386

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 43.

Return to footnote 2386 referrer

Footnote 2387

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 12. See Exhibit P-147, tab 1, doc. 1422, p. 22; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 85-86 [Translation].

Return to footnote 2387 referrer

Footnote 2388

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 28.

Return to footnote 2388 referrer

Footnote 2389

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 60 [Translation].

Return to footnote 2389 referrer

Footnote 2390

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 68-69 [Translation].

Return to footnote 2390 referrer

Footnote 2391

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 133 [Translation].

Return to footnote 2391 referrer

Footnote 2392

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 132-133 [Translation].

Return to footnote 2392 referrer

Footnote 2393

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 55-56 [Translation].

Return to footnote 2393 referrer

Footnote 2394

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 51-52.

Return to footnote 2394 referrer

Footnote 2395

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 50.

Return to footnote 2395 referrer

Footnote 2396

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 49.

Return to footnote 2396 referrer

Footnote 2397

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 71-72 & 78-79 [Translation].

Return to footnote 2397 referrer

Footnote 2398

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 71-72 [Translation].

Return to footnote 2398 referrer

Footnote 2399

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 71-72 & 78-79 [Translation].

Return to footnote 2399 referrer

Footnote 2400

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 70. See Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2400 referrer

Footnote 2401

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 201 & Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2401 referrer

Footnote 2402

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 71.

Return to footnote 2402 referrer

Footnote 2403

Exhibit P-147, tab 1, doc. 1422, p. 16.

Return to footnote 2403 referrer

Footnote 2404

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 61.

Return to footnote 2404 referrer

Footnote 2405

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 64-66 & 71.

Return to footnote 2405 referrer

Footnote 2406

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 61-62.

Return to footnote 2406 referrer

Footnote 2407

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 62.

Return to footnote 2407 referrer

Footnote 2408

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 62.

Return to footnote 2408 referrer

Footnote 2409

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 7; Exhibit P-147, tab 1, doc. 1422, pp. 13-14 & 22.

Return to footnote 2409 referrer

Footnote 2410

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 51.

Return to footnote 2410 referrer

Footnote 2411

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 12-13; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 48, 201 & 699; Exhibit P-147, tab 1, doc. 1422, p. 22; Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1.

Return to footnote 2411 referrer

Footnote 2412

Exhibit P-147, tab 1, doc. 1422, p. 22.

Return to footnote 2412 referrer

Footnote 2413

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 1. See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 29-30.

Return to footnote 2413 referrer

Footnote 2414

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261.

Return to footnote 2414 referrer

Footnote 2415

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 2.

Return to footnote 2415 referrer

Footnote 2416

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 2.

Return to footnote 2416 referrer

Footnote 2417

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 4.

Return to footnote 2417 referrer

Footnote 2418

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 4-5.

Return to footnote 2418 referrer

Footnote 2419

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 5.

Return to footnote 2419 referrer

Footnote 2420

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 5.

Return to footnote 2420 referrer

Footnote 2421

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 7.

Return to footnote 2421 referrer

Footnote 2422

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 48.

Return to footnote 2422 referrer

Footnote 2423

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 76.

Return to footnote 2423 referrer

Footnote 2424

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 125-126.

Return to footnote 2424 referrer

Footnote 2425

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 125-126 [Translation].

Return to footnote 2425 referrer

Footnote 2426

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 47.

Return to footnote 2426 referrer

Footnote 2427

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 47.

Return to footnote 2427 referrer

Footnote 2428

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 161; Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 5; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 264; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 149; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 156-157.

Return to footnote 2428 referrer

Footnote 2429

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 161.

Return to footnote 2429 referrer

Footnote 2430

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 5.

Return to footnote 2430 referrer

Footnote 2431

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 264; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 149.

Return to footnote 2431 referrer

Footnote 2432

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 156-157.

Return to footnote 2432 referrer

Footnote 2433

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 156-157.

Return to footnote 2433 referrer

Footnote 2434

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 20-21 & 56-57.

Return to footnote 2434 referrer

Footnote 2435

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 264; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 149; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 213 & 241.

Return to footnote 2435 referrer

Footnote 2436

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 20-21, 116 & 132-133.

Return to footnote 2436 referrer

Footnote 2437

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 21, 116 & 132-133.

Return to footnote 2437 referrer

Footnote 2438

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 131-132.

Return to footnote 2438 referrer

Footnote 2439

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 131-132 & 176-177.

Return to footnote 2439 referrer

Footnote 2440

Exhibit P-147, tab 1, doc. 1422, pp. 134-135.

Return to footnote 2440 referrer

Footnote 2441

Exhibit P-147, tab 1, doc. 1422, p. 135.

Return to footnote 2441 referrer

Footnote 2442

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 161; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 101; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 69-70.

Return to footnote 2442 referrer

Footnote 2443

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 101.

Return to footnote 2443 referrer

Footnote 2444

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 70.

Return to footnote 2444 referrer

Footnote 2445

Testimony of Dennis Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 41-43

Return to footnote 2445 referrer

Footnote 2446

See Testimony of Dennis Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, p. 42.

Return to footnote 2446 referrer

Footnote 2447

Testimony of Dennis Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 40-43.

Return to footnote 2447 referrer

Footnote 2448

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 161 & Exhibit P-147, tab 1, doc. 1422, p. 136.

Return to footnote 2448 referrer

Footnote 2449

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 632.

Return to footnote 2449 referrer

Footnote 2450

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 164.

Return to footnote 2450 referrer

Footnote 2451

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 7, 37 & 136.

Return to footnote 2451 referrer

Footnote 2452

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 143.

Return to footnote 2452 referrer

Footnote 2453

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 110 & 115-116.

Return to footnote 2453 referrer

Footnote 2454

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 110.

Return to footnote 2454 referrer

Footnote 2455

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 115-116.

Return to footnote 2455 referrer

Footnote 2456

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 111.

Return to footnote 2456 referrer

Footnote 2457

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 111.

Return to footnote 2457 referrer

Footnote 2458

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 116.

Return to footnote 2458 referrer

Footnote 2459

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 117.

Return to footnote 2459 referrer

Footnote 2460

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 117.

Return to footnote 2460 referrer

Footnote 2461

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001.

Return to footnote 2461 referrer

Footnote 2462

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 84, 85, 88, 94, 96, 97, 104, 113 & 115.

Return to footnote 2462 referrer

Footnote 2463

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 115-116.

Return to footnote 2463 referrer

Footnote 2464

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 143-144.

Return to footnote 2464 referrer

Footnote 2465

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 37-38 & 212.

Return to footnote 2465 referrer

Footnote 2466

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 37-38 & 212.

Return to footnote 2466 referrer

Footnote 2467

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 250-251.

Return to footnote 2467 referrer

Footnote 2468

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 39.

Return to footnote 2468 referrer

Footnote 2469

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 265.

Return to footnote 2469 referrer

Footnote 2470

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 265-266.

Return to footnote 2470 referrer

Footnote 2471

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 10-11 & 24-25.

Return to footnote 2471 referrer

Footnote 2472

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 24-25.

Return to footnote 2472 referrer

Footnote 2473

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 25-26.

Return to footnote 2473 referrer

Footnote 2474

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 87.

Return to footnote 2474 referrer

Footnote 2475

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 118-119.

Return to footnote 2475 referrer

Footnote 2476

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 119 & Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 87.

Return to footnote 2476 referrer

Footnote 2477

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 119 & Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 88.

Return to footnote 2477 referrer

Footnote 2478

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 119.

Return to footnote 2478 referrer

Footnote 2479

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 146.

Return to footnote 2479 referrer

Footnote 2480

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 146-147.

Return to footnote 2480 referrer

Footnote 2481

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 230-231.

Return to footnote 2481 referrer

Footnote 2482

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 230-231.

Return to footnote 2482 referrer

Footnote 2483

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 149 & 211.

Return to footnote 2483 referrer

Footnote 2484

Exhibit P-75, tab 1, doc. 1087-J, p. 21.

Return to footnote 2484 referrer

Footnote 2485

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 208; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 121.

Return to footnote 2485 referrer

Footnote 2486

Exhibit P-75, tab 1, doc. 1087-J, p. 21.

Return to footnote 2486 referrer

Footnote 2487

Exhibit P-75, tab 1, doc. 1087-J, p. 21.

Return to footnote 2487 referrer

Footnote 2488

Exhibit P-75, tab 1, doc. 1087-J, p. 21.

Return to footnote 2488 referrer

Footnote 2489

Exhibit P-75, tab 1, doc. 1087-J, p. 21.

Return to footnote 2489 referrer

Footnote 2490

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 123-124.

Return to footnote 2490 referrer

Footnote 2491

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 232.

Return to footnote 2491 referrer

Footnote 2492

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 163; Exhibit P-150, tab 1, doc. 1429, p. 3; Exhibit P-158, tab 1, doc. 1432, p. 60.

Return to footnote 2492 referrer

Footnote 2493

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 632.

Return to footnote 2493 referrer

Footnote 2494

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 105.

Return to footnote 2494 referrer

Footnote 2495

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 632-633; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 105-106; Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 104.

Return to footnote 2495 referrer

Footnote 2496

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001; Exhibit P-147, tab 1, doc. 1422, pp. 132-173; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 145-146.

Return to footnote 2496 referrer

Footnote 2497

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-265, 140-144 & 520-521.

Return to footnote 2497 referrer

Footnote 2498

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 184.

Return to footnote 2498 referrer

Footnote 2499

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 328.

Return to footnote 2499 referrer

Footnote 2500

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 96-97.

Return to footnote 2500 referrer

Footnote 2501

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 115.

Return to footnote 2501 referrer

Footnote 2502

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 254 & 256.

Return to footnote 2502 referrer

Footnote 2503

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 521.

Return to footnote 2503 referrer

Footnote 2504

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 523.

Return to footnote 2504 referrer

Footnote 2505

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 1.

Return to footnote 2505 referrer

Footnote 2506

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 524.

Return to footnote 2506 referrer

Footnote 2507

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 73-74.

Return to footnote 2507 referrer

Footnote 2508

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 160-161.

Return to footnote 2508 referrer

Footnote 2509

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 219.

Return to footnote 2509 referrer

Footnote 2510

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 161.

Return to footnote 2510 referrer

Footnote 2511

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 524.

Return to footnote 2511 referrer

Footnote 2512

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 3, 69 & 110.

Return to footnote 2512 referrer

Footnote 2513

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 110.

Return to footnote 2513 referrer

Footnote 2514

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 512-513.

Return to footnote 2514 referrer

Footnote 2515

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 512-513.

Return to footnote 2515 referrer

Footnote 2516

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 512-513.

Return to footnote 2516 referrer

Footnote 2517

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 512-513.

Return to footnote 2517 referrer

Footnote 2518

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 512.

Return to footnote 2518 referrer

Footnote 2519

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 151-152.

Return to footnote 2519 referrer

Footnote 2520

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 154-155.

Return to footnote 2520 referrer

Footnote 2521

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 152; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 511.

Return to footnote 2521 referrer

Footnote 2522

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2522 referrer

Footnote 2523

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2523 referrer

Footnote 2524

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 217.

Return to footnote 2524 referrer

Footnote 2525

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 217.

Return to footnote 2525 referrer

Footnote 2526

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2526 referrer

Footnote 2527

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2527 referrer

Footnote 2528

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 2528 referrer

Footnote 2529

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 220-221.

Return to footnote 2529 referrer

Footnote 2530

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 218.

Return to footnote 2530 referrer

Footnote 2531

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 218.

Return to footnote 2531 referrer

Footnote 2532

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 134-135 & 152; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 36-37.

Return to footnote 2532 referrer

Footnote 2533

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 152.

Return to footnote 2533 referrer

Footnote 2534

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 511.

Return to footnote 2534 referrer

Footnote 2535

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 511.

Return to footnote 2535 referrer

Footnote 2536

Exhibit P-1, Collection A, vol. 2, tab 11, doc. 001-P.

Return to footnote 2536 referrer

Footnote 2537

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 633-642, 644-645, 647-648, 657-658 & 660-662.

Return to footnote 2537 referrer

Footnote 2538

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 631-633; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 223.

Return to footnote 2538 referrer

Footnote 2539

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 90-92; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 140-141; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 119.

Return to footnote 2539 referrer

Footnote 2540

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 70-71; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 142; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 95 & 142; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 186. See also, Investigation Plan: Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-265.

Return to footnote 2540 referrer

Footnote 2541

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 91-92, 95, 102-103 & 141-142; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 70 & 183; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 142 & 144-145; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 38 & 121.

Return to footnote 2541 referrer

Footnote 2542

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 328; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 124.

Return to footnote 2542 referrer

Footnote 2543

See Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 251; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001.

Return to footnote 2543 referrer

Footnote 2544

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 195-196.

Return to footnote 2544 referrer

Footnote 2545

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 207.

Return to footnote 2545 referrer

Footnote 2546

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 145 & 207.

Return to footnote 2546 referrer

Footnote 2547

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 146-147.

Return to footnote 2547 referrer

Footnote 2548

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 208.

Return to footnote 2548 referrer

Footnote 2549

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 632.

Return to footnote 2549 referrer

Footnote 2550

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 49; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 161-162. See also Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 140 & 205; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 134-135.

Return to footnote 2550 referrer

Footnote 2551

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 120.

Return to footnote 2551 referrer

Footnote 2552

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 38 & 233-234; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 93-95 & 141-142; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 142 & 144-145.

Return to footnote 2552 referrer

Footnote 2553

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 38-39, 231-232 & 295; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 107.

Return to footnote 2553 referrer

Footnote 2554

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 252-255, 257-262, 274-275 & 321-323; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 142-144, 149 & 211; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 89, 108-110, 113-114, 142, 174 & 176-178; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 177-178.

Return to footnote 2554 referrer

Footnote 2555

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 111-114 & 163.

Return to footnote 2555 referrer

Footnote 2556

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 112-114.

Return to footnote 2556 referrer

Footnote 2557

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 216-217.

Return to footnote 2557 referrer

Footnote 2558

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 113 & 163.

Return to footnote 2558 referrer

Footnote 2559

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 113.

Return to footnote 2559 referrer

Footnote 2560

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 117. See also Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 196-197.

Return to footnote 2560 referrer

Footnote 2561

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 251-252; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 39-40.

Return to footnote 2561 referrer

Footnote 2562

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 39-40.

Return to footnote 2562 referrer

Footnote 2563

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 103-104.

Return to footnote 2563 referrer

Footnote 2564

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 103-104, 128, 133-135, 152 & 155-156; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 36-37.

Return to footnote 2564 referrer

Footnote 2565

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 154.

Return to footnote 2565 referrer

Footnote 2566

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 215-216.

Return to footnote 2566 referrer

Footnote 2567

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 214.

Return to footnote 2567 referrer

Footnote 2568

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 214.

Return to footnote 2568 referrer

Footnote 2569

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 214-215.

Return to footnote 2569 referrer

Footnote 2570

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 109-110.

Return to footnote 2570 referrer

Footnote 2571

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 215.

Return to footnote 2571 referrer

Footnote 2572

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 215.

Return to footnote 2572 referrer

Footnote 2573

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 41 [Translation].

Return to footnote 2573 referrer

Footnote 2574

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 46-47 [Translation].

Return to footnote 2574 referrer

Footnote 2575

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 50-51.

Return to footnote 2575 referrer

Footnote 2576

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 36-37; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 134-135 & 152. See also Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 217.

Return to footnote 2576 referrer

Footnote 2577

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 219-220.

Return to footnote 2577 referrer

Footnote 2578

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 2578 referrer

Footnote 2579

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 103-104, 128, 134-135, 152 & 155-156; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 36-37; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 321; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 217; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 144.

Return to footnote 2579 referrer

Footnote 2580

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 236.

Return to footnote 2580 referrer

Footnote 2581

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 31.

Return to footnote 2581 referrer

Footnote 2582

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 31.

Return to footnote 2582 referrer

Footnote 2583

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 39.

Return to footnote 2583 referrer

Footnote 2584

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 42.

Return to footnote 2584 referrer

Footnote 2585

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 43.

Return to footnote 2585 referrer

Footnote 2586

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 38.

Return to footnote 2586 referrer

Footnote 2587

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 73 & 109-110.

Return to footnote 2587 referrer

Footnote 2588

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 109-110.

Return to footnote 2588 referrer

Footnote 2589

Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, p. 35.

Return to footnote 2589 referrer

Footnote 2590

See Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2590 referrer

Footnote 2591

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 198-199.

Return to footnote 2591 referrer

Footnote 2592

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 197-198.

Return to footnote 2592 referrer

Footnote 2593

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 265-266.

Return to footnote 2593 referrer

Footnote 2594

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 238-240.

Return to footnote 2594 referrer

Footnote 2595

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 357-358.

Return to footnote 2595 referrer

Footnote 2596

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, p. 324.

Return to footnote 2596 referrer

Footnote 2597

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 25-26; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 48-49.

Return to footnote 2597 referrer

Footnote 2598

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 25-26.

Return to footnote 2598 referrer

Footnote 2599

Exhibit P-147, tab 1, doc. 1422, p. 112.

Return to footnote 2599 referrer

Footnote 2600

Exhibit P-147, tab 1, doc. 1422, p. 112.

Return to footnote 2600 referrer

Footnote 2601

See Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 5.

Return to footnote 2601 referrer

Footnote 2602

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 120.

Return to footnote 2602 referrer

Footnote 2603

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 198-199; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 88-89.

Return to footnote 2603 referrer

Footnote 2604

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 88-89; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 36-37.

Return to footnote 2604 referrer

Footnote 2605

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 2605 referrer

Footnote 2606

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 2606 referrer

Footnote 2607

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 2607 referrer

Footnote 2608

See Section 4.0, The Subjects of the Complaint: Role Involvement and Background.

Return to footnote 2608 referrer

Footnote 2609

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 118.

Return to footnote 2609 referrer

Footnote 2610

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 116.

Return to footnote 2610 referrer

Footnote 2611

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 117.

Return to footnote 2611 referrer

Footnote 2612

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 119-122 & 125-126.

Return to footnote 2612 referrer

Footnote 2613

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76-77.

Return to footnote 2613 referrer

Footnote 2614

See below, The Change of Policies and Procedures.

Return to footnote 2614 referrer

Footnote 2615

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 39-40.

Return to footnote 2615 referrer

Footnote 2616

Exhibit P-4, Collection D, vol. 1 tab 35, doc. 032, p. 6.

Return to footnote 2616 referrer

Footnote 2617

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 292-293. See, generally, Section 4.5.6, CFNIS Interactions with the Fynes – CFNIS Answers to the Col Blais Questions.

Return to footnote 2617 referrer

Footnote 2618

See, for example, Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 125-126 [Translation]; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 117.

Return to footnote 2618 referrer

Footnote 2619

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 117 & 282; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 84, 179 & 289 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 39, 73 & 107-111; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 69-71 & 73.

Return to footnote 2619 referrer

Footnote 2620

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 131-132.

Return to footnote 2620 referrer

Footnote 2621

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 46-47.

Return to footnote 2621 referrer

Footnote 2622

See Exhibit P-147, tab 1, doc. 1422, p. 111; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 73-74; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 72-73, 81, 84 & 92-94 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 76.

Return to footnote 2622 referrer

Footnote 2623

See Section 4.5.3, CFNIS Interactions with the Fynes, The November 2009 Briefing; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 56.

Return to footnote 2623 referrer

Footnote 2624

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 14.

Return to footnote 2624 referrer

Footnote 2625

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 13.

Return to footnote 2625 referrer

Footnote 2626

See Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 195-196; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 134-135; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 192; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 235.

Return to footnote 2626 referrer

Footnote 2627

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 103-104.

Return to footnote 2627 referrer

Footnote 2628

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 73.

Return to footnote 2628 referrer

Footnote 2629

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 198, 201 & 230-231. of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 17. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 196 & Exhibit P-4, Collection D, vol. 1 tab 35, doc. 032, p. 6.

Return to footnote 2629 referrer

Footnote 2630

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 198, 201 & 230-231.

Return to footnote 2630 referrer

Footnote 2631

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 17.

Return to footnote 2631 referrer

Footnote 2632

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 199-200. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 231-232.

Return to footnote 2632 referrer

Footnote 2633

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 230.

Return to footnote 2633 referrer

Footnote 2634

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 257.

Return to footnote 2634 referrer

Footnote 2635

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 99-100.

Return to footnote 2635 referrer

Footnote 2636

Exhibit P-4, Collection D, vol. 1, tab 35, doc. 032, p. 6.

Return to footnote 2636 referrer

Footnote 2637

Final Submissions of the Subjects of the complaint, p. 65.

Return to footnote 2637 referrer

Footnote 2638

Final Submissions of the Subjects of the complaint, p. 66.

Return to footnote 2638 referrer

Footnote 2639

Final Submissions of the Subjects of the complaint, p. 67.

Return to footnote 2639 referrer

Footnote 2640

See Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2640 referrer

Footnote 2641

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 70-71.

Return to footnote 2641 referrer

Footnote 2642

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 89 & 94.

Return to footnote 2642 referrer

Footnote 2643

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 162.

Return to footnote 2643 referrer

Footnote 2644

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 171.

Return to footnote 2644 referrer

Footnote 2645

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 163.

Return to footnote 2645 referrer

Footnote 2646

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 165.

Return to footnote 2646 referrer

Footnote 2647

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 60, 203, 429 & 737-739; Exhibit P-147, tab 1, doc. 1422, pp. 111-113.

Return to footnote 2647 referrer

Footnote 2648

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 257.

Return to footnote 2648 referrer

Footnote 2649

See Exhibit P-119, doc. 1396, pp. 85-86; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 444 & 446.

Return to footnote 2649 referrer

Footnote 2650

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 557.

Return to footnote 2650 referrer

Footnote 2651

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 63 & 66-68; Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2651 referrer

Footnote 2652

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 120-122 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 69.

Return to footnote 2652 referrer

Footnote 2653

generally, Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2653 referrer

Footnote 2654

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 63 & 66-68.

Return to footnote 2654 referrer

Footnote 2655

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 73-74.

Return to footnote 2655 referrer

Footnote 2656

See Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 2656 referrer

Footnote 2657

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 200.

Return to footnote 2657 referrer

Footnote 2658

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 203.

Return to footnote 2658 referrer

Footnote 2659

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 203.

Return to footnote 2659 referrer

Footnote 2660

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 203 & 429.

Return to footnote 2660 referrer

Footnote 2661

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 161-163; Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76-77 & 93-94.

Return to footnote 2661 referrer

Footnote 2662

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 77 & 93-94.

Return to footnote 2662 referrer

Footnote 2663

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 94.

Return to footnote 2663 referrer

Footnote 2664

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 44-47.

Return to footnote 2664 referrer

Footnote 2665

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 4 & 12-13; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 67-68.

Return to footnote 2665 referrer

Footnote 2666

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 73.

Return to footnote 2666 referrer

Footnote 2667

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 13.

Return to footnote 2667 referrer

Footnote 2668

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 67-68.

Return to footnote 2668 referrer

Footnote 2669

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 12 & 230; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 68.

Return to footnote 2669 referrer

Footnote 2670

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 72-73.

Return to footnote 2670 referrer

Footnote 2671

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 34.

Return to footnote 2671 referrer

Footnote 2672

See Section 4.6, CFNIS Independence and Impartiality; Section 4.5.6, CFNIS Interactions with the Fynes – CFNIS Answers to the Col Blais Questions.

Return to footnote 2672 referrer

Footnote 2673

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 68; Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33(a).

Return to footnote 2673 referrer

Footnote 2674

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33(a).

Return to footnote 2674 referrer

Footnote 2675

See Exhibit P-2, Collection B, vol. 2, tabs 1 & 2, docs 1087-B & 1087-C; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B.

Return to footnote 2675 referrer

Footnote 2676

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 2676 referrer

Footnote 2677

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 62-63.

Return to footnote 2677 referrer

Footnote 2678

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 192-193.

Return to footnote 2678 referrer

Footnote 2679

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 160.

Return to footnote 2679 referrer

Footnote 2680

See Exhibit P-4, Collection D, vol. 1, tab 35, doc. 032, pp. 4-6.

Return to footnote 2680 referrer

Footnote 2681

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 4.

Return to footnote 2681 referrer

Footnote 2682

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 91-95. See also Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, p. 55.

Return to footnote 2682 referrer

Footnote 2683

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 92.

Return to footnote 2683 referrer

Footnote 2684

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 5.

Return to footnote 2684 referrer

Footnote 2685

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 59-60.

Return to footnote 2685 referrer

Footnote 2686

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 59-60.

Return to footnote 2686 referrer

Footnote 2687

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 59-60.

Return to footnote 2687 referrer

Footnote 2688

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 60.

Return to footnote 2688 referrer

Footnote 2689

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 236-237. See Exhibit P-147, tab 1, doc. 1422, pp. 111-113.

Return to footnote 2689 referrer

Footnote 2690

Exhibit P-147, tab 1, doc. 1422, p. 111.

Return to footnote 2690 referrer

Footnote 2691

Exhibit P-147, tab 1, doc. 1422, p. 112.

Return to footnote 2691 referrer

Footnote 2692

See Exhibit P-92, doc. 1377; Exhibit P-93, doc. 1378; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 508-509 & 699-701; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 170-171.

Return to footnote 2692 referrer

Footnote 2693

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 426-430; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 170-171 & 174.

Return to footnote 2693 referrer

Footnote 2694

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 256-257, 262, 453-454, 488 & 738.

Return to footnote 2694 referrer

Footnote 2695

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 542. See also Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 256-257, 262 & 535.

Return to footnote 2695 referrer

Footnote 2696

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 704-712.

Return to footnote 2696 referrer

Footnote 2697

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 76. See also pp. 90, 93 & 96.

Return to footnote 2697 referrer

Footnote 2698

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 166.

Return to footnote 2698 referrer

Footnote 2699

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 166-167.

Return to footnote 2699 referrer

Footnote 2700

Exhibit P-4, Collection D, vol. 1 tab 35, doc. 032, p. 5-6.

Return to footnote 2700 referrer

Footnote 2701

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 5-6, 12 & 43.

Return to footnote 2701 referrer

Footnote 2702

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 12.

Return to footnote 2702 referrer

Footnote 2703

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 45.

Return to footnote 2703 referrer

Footnote 2704

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 12-13 & 16; Exhibit P-59, doc. 1356, p. 4.

Return to footnote 2704 referrer

Footnote 2705

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 12-13, 16 & 22; Exhibit P-59, doc. 1356, p. 4.

Return to footnote 2705 referrer

Footnote 2706

Exhibit P-57, doc. 1354.

Return to footnote 2706 referrer

Footnote 2707

Exhibit P-58, doc. 1355, p. 1.

Return to footnote 2707 referrer

Footnote 2708

Exhibit P-119, doc. 1396, pp. 2-3.

Return to footnote 2708 referrer

Footnote 2709

See Exhibit P-119, doc. 1396, pp. 167-168 & 143-150; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 76-77.

Return to footnote 2709 referrer

Footnote 2710

Exhibit P-119, p. 159.

Return to footnote 2710 referrer

Footnote 2711

Exhibit P-5, Collection E, vol. 6, tab 48, doc. 1281. See also, Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B.

Return to footnote 2711 referrer

Footnote 2712

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 23-25.

Return to footnote 2712 referrer

Footnote 2713

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 39-41.

Return to footnote 2713 referrer

Footnote 2714

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 4.

Return to footnote 2714 referrer

Footnote 2715

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 40-41.

Return to footnote 2715 referrer

Footnote 2716

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 144-146 [Translation].

Return to footnote 2716 referrer

Footnote 2717

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B.

Return to footnote 2717 referrer

Footnote 2718

Exhibit P-5, Collection E, vol. 6, tab 48, doc. 1281, pp. 6-7, s. 20-21; Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, pp. 46-51. LCol Sansterre testified the Annex was already included in the October 2010 version of the SOP: Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 25-26.

Return to footnote 2718 referrer

Footnote 2719

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, pp. 48 & 50.

Return to footnote 2719 referrer

Footnote 2720

Exhibit P-5, Collection E, vol. 6, tab 48, doc. 1281, p. 7, s. 21; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 150 [Translation].

Return to footnote 2720 referrer

Footnote 2721

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 83; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 151-152 [Translation]; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 78.

Return to footnote 2721 referrer

Footnote 2722

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15, s. 21.

Return to footnote 2722 referrer

Footnote 2723

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 153 [Translation]; Exhibit P-119, p. 193.

Return to footnote 2723 referrer

Footnote 2724

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 153-155 [Translation].

Return to footnote 2724 referrer

Footnote 2725

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 155-156 [Translation]; Exhibit P-119, doc. 1396, pp. 191-193; Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15, s. 21.

Return to footnote 2725 referrer

Footnote 2726

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15, s. 21.

Return to footnote 2726 referrer

Footnote 2727

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 37-38 & 41-43; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 7-8.

Return to footnote 2727 referrer

Footnote 2728

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 8-9 & 11.

Return to footnote 2728 referrer

Footnote 2729

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 41-43.

Return to footnote 2729 referrer

Footnote 2730

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 34-39.

Return to footnote 2730 referrer

Footnote 2731

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 8, 39, 42 & 88-89.

Return to footnote 2731 referrer

Footnote 2732

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 62-65.

Return to footnote 2732 referrer

Footnote 2733

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 37-38, 43-44, 49 & 73; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 14, 71-73, 81-85, 87, 89-91 & 95-96 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 97-98.

Return to footnote 2733 referrer

Footnote 2734

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 12-13, 15-17 & 43-44; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 14 [Translation]. See also Exhibit P-59, doc. 1356, p. 3.

Return to footnote 2734 referrer

Footnote 2735

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 16-17.

Return to footnote 2735 referrer

Footnote 2736

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 44. See also pp. 37, 43 & 49.

Return to footnote 2736 referrer

Footnote 2737

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 17.

Return to footnote 2737 referrer

Footnote 2738

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 17.

Return to footnote 2738 referrer

Footnote 2739

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 44-45 & 83-84.

Return to footnote 2739 referrer

Footnote 2740

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 44-45.

Return to footnote 2740 referrer

Footnote 2741

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 14, 71-73, 81-84, 87, 90-91 & 94-95 [Translation].

Return to footnote 2741 referrer

Footnote 2742

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 88-89 [Translation].

Return to footnote 2742 referrer

Footnote 2743

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 82 [Translation].

Return to footnote 2743 referrer

Footnote 2744

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 71-73, 81, 87 & 89 [Translation].

Return to footnote 2744 referrer

Footnote 2745

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 35-36 & 69.

Return to footnote 2745 referrer

Footnote 2746

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 20, 50 & 61-62.

Return to footnote 2746 referrer

Footnote 2747

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 40, 52-54 & 56-57.

Return to footnote 2747 referrer

Footnote 2748

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 42 & 52-55.

Return to footnote 2748 referrer

Footnote 2749

See Exhibit P-59, doc. 1356, pp. 3-10; Exhibit P-58, doc. 1355; Exhibit P-119, doc. 1396, pp. 1-6; Exhibit P-119, doc. 1396, pp. 7-16; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 19, 21-22, & 55-56.

Return to footnote 2749 referrer

Footnote 2750

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 87-88, 151-152 & 155 [Translation].

Return to footnote 2750 referrer

Footnote 2751

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 164 [Translation].

Return to footnote 2751 referrer

Footnote 2752

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 27.

Return to footnote 2752 referrer

Footnote 2753

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 70.

Return to footnote 2753 referrer

Footnote 2754

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 26-27.

Return to footnote 2754 referrer

Footnote 2755

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 97-98; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 72-73 & 81-83 [Translation].

Return to footnote 2755 referrer

Footnote 2756

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 84 & 90-94 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 97-98.

Return to footnote 2756 referrer

Footnote 2757

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 84, 179 & 289 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 69-71 & 73.

Return to footnote 2757 referrer

Footnote 2758

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 37, 39-40, 54, 69; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 81, 97-98 & 151 [Translation].

Return to footnote 2758 referrer

Footnote 2759

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 69.

Return to footnote 2759 referrer

Footnote 2760

See Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 2760 referrer

Footnote 2761

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 31, 42, 73 & 109-110.

Return to footnote 2761 referrer

Footnote 2762

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 126-128; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 2762 referrer

Footnote 2763

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 39, 73 & 107-111.

Return to footnote 2763 referrer

Footnote 2764

Exhibit P-147, tab 1, doc. 1422, p. 16.

Return to footnote 2764 referrer

Footnote 2765

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 52-53 & 89-90; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 136-137.

Return to footnote 2765 referrer

Footnote 2766

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 25, 36-37, 40-41, 50, 56, 74 & 79; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 87, 89 & 117-119 [Translation].

Return to footnote 2766 referrer

Footnote 2767

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 3-4 & 89-90 [Translation].

Return to footnote 2767 referrer

Footnote 2768

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 56.

Return to footnote 2768 referrer

Footnote 2769

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 112-113 & 163; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 253; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 140-141; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 235; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 65-66; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 49-50; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 109; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 54; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 66-67; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 55-56; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 97-98 [Translation].

Return to footnote 2769 referrer

Footnote 2770

Exhibit P-6, Collection F, vol. 1, tab 41, doc. 1188, p. 5, s. 13.

Return to footnote 2770 referrer

Footnote 2771

Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189, p. 12-14, s. 28, 29(a) & 31. See also Exhibit P-53, doc. 1350, p. 6.

Return to footnote 2771 referrer

Footnote 2772

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 163; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 55-56; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 31, 39, 42, 73 & 109-113.

Return to footnote 2772 referrer

Footnote 2773

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 40-41, 98 & 100-101 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 40-42; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 50-52.

Return to footnote 2773 referrer

Footnote 2774

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 237.

Return to footnote 2774 referrer

Footnote 2775

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 48-50 & 55-56; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 235-237; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 163-164 & 175; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 40-41 & 101-102 [Translation].

Return to footnote 2775 referrer

Footnote 2776

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 42.

Return to footnote 2776 referrer

Footnote 2777

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 50-52; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 101 & 105 [Translation].

Return to footnote 2777 referrer

Footnote 2778

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 165-166 & 172-173; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 101 & 105 [Translation].

Return to footnote 2778 referrer

Footnote 2779

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 31, 39, 42, 73 & 109-113; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 252-255 & 257-260.

Return to footnote 2779 referrer

Footnote 2780

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 252-255 & 257-260.

Return to footnote 2780 referrer

Footnote 2781

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 52-54.

Return to footnote 2781 referrer

Footnote 2782

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 52-53.

Return to footnote 2782 referrer

Footnote 2783

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 53.

Return to footnote 2783 referrer

Footnote 2784

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 39-40, 233 & 295.

Return to footnote 2784 referrer

Footnote 2785

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 101 & 105 [Translation].

Return to footnote 2785 referrer

Footnote 2786

Return to footnote 2786 referrer

Footnote 2787

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 141-142 & 146.

Return to footnote 2787 referrer

Footnote 2788

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 66-67; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 97-98 & 101 [Translation].

Return to footnote 2788 referrer

Footnote 2789

Final Submissions of the Subjects of the complaint, pp. 65-66.

Return to footnote 2789 referrer

Footnote 2790

See, generally, Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2790 referrer

Footnote 2791

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15, s. 21.

Return to footnote 2791 referrer

Footnote 2792

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 44-45 & 83-84.

Return to footnote 2792 referrer

Footnote 2793

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 164 [Translation].

Return to footnote 2793 referrer

Footnote 2794

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 81-82, 103-105, 107-108 & 162-163 [Translation].

Return to footnote 2794 referrer

Footnote 2795

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 182 [Translation].

Return to footnote 2795 referrer

Footnote 2796

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 107-108 [Translation].

Return to footnote 2796 referrer

Footnote 2797

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 251 [Translation].

Return to footnote 2797 referrer

Footnote 2798

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 105-106 [Translation].

Return to footnote 2798 referrer

Footnote 2799

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 107-109 & 162 [Translation].

Return to footnote 2799 referrer

Footnote 2800

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 96-97.

Return to footnote 2800 referrer

Footnote 2801

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 102-103.

Return to footnote 2801 referrer

Footnote 2802

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 67-69.

Return to footnote 2802 referrer

Footnote 2803

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 70.

Return to footnote 2803 referrer

Footnote 2804

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 69.

Return to footnote 2804 referrer

Footnote 2805

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 175 & 177-178.

Return to footnote 2805 referrer

Footnote 2806

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 177-178.

Return to footnote 2806 referrer

Footnote 2807

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 31-32.

Return to footnote 2807 referrer

Footnote 2808

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 33-35.

Return to footnote 2808 referrer

Footnote 2809

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 35-36.

Return to footnote 2809 referrer

Footnote 2810

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 58 & 60.

Return to footnote 2810 referrer

Footnote 2811

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 59-60.

Return to footnote 2811 referrer

Footnote 2812

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 59.

Return to footnote 2812 referrer

Footnote 2813

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 173-175 & 183-184.

Return to footnote 2813 referrer

Footnote 2814

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 174-177.

Return to footnote 2814 referrer

Footnote 2815

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 173-174.

Return to footnote 2815 referrer

Footnote 2816

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 46; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 31-32; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 95-96 & 103-104 [Translation].

Return to footnote 2816 referrer

Footnote 2817

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 45-46; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 32-33; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 104 & 165 [Translation].

Return to footnote 2817 referrer

Footnote 2818

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 111-112 [Translation].

Return to footnote 2818 referrer

Footnote 2819

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 95-96 & 111-112 [Translation].

Return to footnote 2819 referrer

Footnote 2820

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 173. See also Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 70-71.

Return to footnote 2820 referrer

Footnote 2821

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 178.

Return to footnote 2821 referrer

Footnote 2822

See Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 176.

Return to footnote 2822 referrer

Footnote 2823

See Closing Submissions of the Complainants, p. 11.

Return to footnote 2823 referrer

Footnote 2824

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 105 [Translation].

Return to footnote 2824 referrer

Footnote 2825

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 112-113.

Return to footnote 2825 referrer

Footnote 2826

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 111-112.

Return to footnote 2826 referrer

Footnote 2827

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 55.

Return to footnote 2827 referrer

Footnote 2828

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 65.

Return to footnote 2828 referrer

Footnote 2829

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 65. See also Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 25.

Return to footnote 2829 referrer

Footnote 2830

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 113.

Return to footnote 2830 referrer

Footnote 2831

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 112-113.

Return to footnote 2831 referrer

Footnote 2832

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 105-106 [Translation].

Return to footnote 2832 referrer

Footnote 2833

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 105-106 [Translation].

Return to footnote 2833 referrer

Footnote 2834

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 59-60, 218, 256-257, 262, 426-430, 535 & 542.

Return to footnote 2834 referrer

Footnote 2835

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 35-37.

Return to footnote 2835 referrer

Footnote 2836

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 41.

Return to footnote 2836 referrer

Footnote 2837

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 37 & 41; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 178-181 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 76, 94-97 & 100.

Return to footnote 2837 referrer

Footnote 2838

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 36-37.

Return to footnote 2838 referrer

Footnote 2839

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 71-72.

Return to footnote 2839 referrer

Footnote 2840

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 59-61.

Return to footnote 2840 referrer

Footnote 2841

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 218; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 157-158; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 429.

Return to footnote 2841 referrer

Footnote 2842

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 4; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, pp. 3-4.

Return to footnote 2842 referrer

Footnote 2843

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 62-64; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 171-173 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 72-75, 81-83 & 85. See also Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, p. 192.

Return to footnote 2843 referrer

Footnote 2844

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 106; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 176-177 [Translation].

Return to footnote 2844 referrer

Footnote 2845

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 63.

Return to footnote 2845 referrer

Footnote 2846

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 63.

Return to footnote 2846 referrer

Footnote 2847

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 429.

Return to footnote 2847 referrer

Footnote 2848

See Exhibit P-147, tab 1, doc. 1422, p. 113: the members consulted were LCol Sansterre, Maj Bolduc and Maj Dandurand.

Return to footnote 2848 referrer

Footnote 2849

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 28-29.

Return to footnote 2849 referrer

Footnote 2850

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 30.

Return to footnote 2850 referrer

Footnote 2851

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 102-103.

Return to footnote 2851 referrer

Footnote 2852

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 102-103.

Return to footnote 2852 referrer

Footnote 2853

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 183 [Translation].

Return to footnote 2853 referrer

Footnote 2854

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 182 [Translation].

Return to footnote 2854 referrer

Footnote 2855

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 182-183 [Translation].

Return to footnote 2855 referrer

Footnote 2856

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76-77.

Return to footnote 2856 referrer

Footnote 2857

See, generally, Section 4.5.3, The November 2009 Briefing.

Return to footnote 2857 referrer

Footnote 2858

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 4-5.

Return to footnote 2858 referrer

Footnote 2859

See Exhibit P-4, Collection D, vol. 1 tab 35, doc. 032, p. 5.

Return to footnote 2859 referrer

Footnote 2860

Exhibit P-4, Collection D, vol. 1 tab 35, doc. 032, p. 6.

Return to footnote 2860 referrer

Footnote 2861

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 6-7.

Return to footnote 2861 referrer

Footnote 2862

Return to footnote 2862 referrer

Footnote 2863

See Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 21; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 104; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 213.

Return to footnote 2863 referrer

Footnote 2864

See Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 164-165; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 266-267; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 112 & 170.

Return to footnote 2864 referrer

Footnote 2865

See Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 267 & 269-270; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 88; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 112 & 170-171; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 26; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 240-241.

Return to footnote 2865 referrer

Footnote 2866

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 26, 28, 30-31 & 67.

Return to footnote 2866 referrer

Footnote 2867

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 78 & 86-88.

Return to footnote 2867 referrer

Footnote 2868

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 4-5 & 7.

Return to footnote 2868 referrer

Footnote 2869

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 28-29; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 71-72, 83 & 140-141 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 134-136.

Return to footnote 2869 referrer

Footnote 2870

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 76; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 129-131 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 134-136.

Return to footnote 2870 referrer

Footnote 2871

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 48; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 135-136 [Translation].

Return to footnote 2871 referrer

Footnote 2872

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 184-185, 272-274 & 315; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 149-150. However, see Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 33-34.

Return to footnote 2872 referrer

Footnote 2873

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 130-131 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 76-77.

Return to footnote 2873 referrer

Footnote 2874

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 137-138.

Return to footnote 2874 referrer

Footnote 2875

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, p. 6.

Return to footnote 2875 referrer

Footnote 2876

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 32-33.

Return to footnote 2876 referrer

Footnote 2877

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 135-136 & 138-139.

Return to footnote 2877 referrer

Footnote 2878

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 62-65.

Return to footnote 2878 referrer

Footnote 2879

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 84-85 & 165-168 [Translation]; Exhibit P-119, pp. 35-45.

Return to footnote 2879 referrer

Footnote 2880

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 85 & 167 [Translation].

Return to footnote 2880 referrer

Footnote 2881

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 167 [Translation].

Return to footnote 2881 referrer

Footnote 2882

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 113 [Translation].

Return to footnote 2882 referrer

Footnote 2883

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 47-48 & 87.

Return to footnote 2883 referrer

Footnote 2884

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 103 [Translation].

Return to footnote 2884 referrer

Footnote 2885

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 103, 113-114 & 162-164 [Translation].

Return to footnote 2885 referrer

Footnote 2886

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 113 [Translation]; Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15, s. 21.

Return to footnote 2886 referrer

Footnote 2887

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 167-168.

Return to footnote 2887 referrer

Footnote 2888

Exhibit P-183, tab 1, doc. 1461, p. 2.

Return to footnote 2888 referrer

Footnote 2889

Final Submissions of the Subjects of the complaint, p. 66.

Return to footnote 2889 referrer

Footnote 2890

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 107.

Return to footnote 2890 referrer

Footnote 2891

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 38-39, 125, 213 & 295.

Return to footnote 2891 referrer

Footnote 2892

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 33-35. See also p. 48.

Return to footnote 2892 referrer

Footnote 2893

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 34-35.

Return to footnote 2893 referrer

Footnote 2894

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 88-89, 113-114 & 142; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 177-178.

Return to footnote 2894 referrer

Footnote 2895

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 109-110.

Return to footnote 2895 referrer

Footnote 2896

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 108.

Return to footnote 2896 referrer

Footnote 2897

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 111-112.

Return to footnote 2897 referrer

Footnote 2898

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 174, 176 & 178.

Return to footnote 2898 referrer

Footnote 2899

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 177-178.

Return to footnote 2899 referrer

Footnote 2900

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 274-275 & 322-323; Exhibit P-1, Collection A, doc. 001, pp. 235 & 258.

Return to footnote 2900 referrer

Footnote 2901

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 323-324.

Return to footnote 2901 referrer

Footnote 2902

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 274-275 & 323-324.

Return to footnote 2902 referrer

Footnote 2903

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 157-159.

Return to footnote 2903 referrer

Footnote 2904

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 107-108, 159 & 167.

Return to footnote 2904 referrer

Footnote 2905

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 168.

Return to footnote 2905 referrer

Footnote 2906

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 168.

Return to footnote 2906 referrer

Footnote 2907

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 168-173.

Return to footnote 2907 referrer

Footnote 2908

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 168-173. See, generally, Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2908 referrer

Footnote 2909

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 170.

Return to footnote 2909 referrer

Footnote 2910

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 136-137 [Translation].

Return to footnote 2910 referrer

Footnote 2911

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 4-5.

Return to footnote 2911 referrer

Footnote 2912

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 142 & 144.

Return to footnote 2912 referrer

Footnote 2913

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 18 & 48.

Return to footnote 2913 referrer

Footnote 2914

Final Submissions of the Subjects of the complaint, p. 66.

Return to footnote 2914 referrer

Footnote 2915

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2915 referrer

Footnote 2916

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2916 referrer

Footnote 2917

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2917 referrer

Footnote 2918

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 12-13. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 4.

Return to footnote 2918 referrer

Footnote 2919

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2919 referrer

Footnote 2920

See Closing Submission of the Complainants, pp. 9-10.

Return to footnote 2920 referrer

Footnote 2921

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2921 referrer

Footnote 2922

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death. Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 2922 referrer

Footnote 2923

See Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15, s. 21.

Return to footnote 2923 referrer

Footnote 2924

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 89; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 5; Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012, p. 87; Closing Submission of the Complainants, p. 10.

Return to footnote 2924 referrer

Footnote 2925

Final Submissions of the Subjects of the complaint, p. 68 [Emphasis added].

Return to footnote 2925 referrer

Footnote 2926

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 137-138 [Translation].

Return to footnote 2926 referrer

Footnote 2927

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 251-252 [Translation].

Return to footnote 2927 referrer

Footnote 2928

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 138.

Return to footnote 2928 referrer

Footnote 2929

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 138 [Translation].

Return to footnote 2929 referrer

Footnote 2930

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 109-111 [Translation].

Return to footnote 2930 referrer

Footnote 2931

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 109 [Translation].

Return to footnote 2931 referrer

Footnote 2932

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 110-111 [Translation].

Return to footnote 2932 referrer

Footnote 2933

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 109 [Translation].

Return to footnote 2933 referrer

Footnote 2934

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 157-161, 164 & 167.

Return to footnote 2934 referrer

Footnote 2935

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 93-94.

Return to footnote 2935 referrer

Footnote 2936

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 164.

Return to footnote 2936 referrer

Footnote 2937

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 44-47.

Return to footnote 2937 referrer

Footnote 2938

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 161 & 167.

Return to footnote 2938 referrer

Footnote 2939

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 161.

Return to footnote 2939 referrer

Footnote 2940

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 157-159, 162 & 167.

Return to footnote 2940 referrer

Footnote 2941

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 271.

Return to footnote 2941 referrer

Footnote 2942

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 274-275 & 323-324.

Return to footnote 2942 referrer

Footnote 2943

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 176.

Return to footnote 2943 referrer

Footnote 2944

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 143-144.

Return to footnote 2944 referrer

Footnote 2945

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 144.

Return to footnote 2945 referrer

Footnote 2946

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 295.

Return to footnote 2946 referrer

Footnote 2947

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 295.

Return to footnote 2947 referrer

Footnote 2948

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 52-54.

Return to footnote 2948 referrer

Footnote 2949

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 33-34.

Return to footnote 2949 referrer

Footnote 2950

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 34-35.

Return to footnote 2950 referrer

Footnote 2951

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, p. 177.

Return to footnote 2951 referrer

Footnote 2952

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 2952 referrer

Footnote 2953

See, generally, Testimony of Det Insp Olinyk, Insp Fitzpatrick and S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 178-181, 184-186, 191-208 & 255-264.

Return to footnote 2953 referrer

Footnote 2954

See Testimony of Insp Fitzpatrick, Transcript of Proceedings, vol. 44, 10 September 2012, p. 264; Testimony of Dennis Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 40-43.

Return to footnote 2954 referrer

Footnote 2955

Although the concepts “next-of-kin” and “primary next-of-kin” are legally distinct, the documents and testimony at the hearings sometimes refer to next-of-kin (NOK) interchangeably with primary next-of-kin (PNOK). Strictly speaking, the term PNOK refers to someone from amongst persons with next-of-kin status who is given primacy for a specific purpose. In this chapter, the correct term PNOK is used, except where the source refers specifically to NOK. For purposes of the present discussion, there is no practical difference in the way the two terms are used.

Return to footnote 2955 referrer

Footnote 2956

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518.

Return to footnote 2956 referrer

Footnote 2957

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518.

Return to footnote 2957 referrer

Footnote 2958

Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 5-6.

Return to footnote 2958 referrer

Footnote 2959

Exhibit P-6, Collection F, vol. 1, tab 55, doc. 1292, pp. 1-2.

Return to footnote 2959 referrer

Footnote 2960

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518.

Return to footnote 2960 referrer

Footnote 2961

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 231-232.

Return to footnote 2961 referrer

Footnote 2962

Exhibit P-6, Collection F, vol. 1, tab 55, doc. 1292, pp. 2 and 7.

Return to footnote 2962 referrer

Footnote 2963

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 221; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 239-241.

Return to footnote 2963 referrer

Footnote 2964

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1369.

Return to footnote 2964 referrer

Footnote 2965

Exhibit P-147, tab 2, doc. 1423, pp. 72-75.

Return to footnote 2965 referrer

Footnote 2966

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 2966 referrer

Footnote 2967

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 294.

Return to footnote 2967 referrer

Footnote 2968

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 1-2.

Return to footnote 2968 referrer

Footnote 2969

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518.

Return to footnote 2969 referrer

Footnote 2970

Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 34-39.

Return to footnote 2970 referrer

Footnote 2971

Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 38-39.

Return to footnote 2971 referrer

Footnote 2972

Mr. Martel did contact the CFNIS twice to get updates on the investigation: Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 39-42.

Return to footnote 2972 referrer

Footnote 2973

Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 39-42.

Return to footnote 2973 referrer

Footnote 2974

Testimony of Sheila Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 49-50; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 182-183; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 142; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 36.

Return to footnote 2974 referrer

Footnote 2975

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 144-145.

Return to footnote 2975 referrer

Footnote 2976

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 39-40.

Return to footnote 2976 referrer

Footnote 2977

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 119-121.

Return to footnote 2977 referrer

Footnote 2978

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 97-98.

Return to footnote 2978 referrer

Footnote 2979

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 39-42, 88 and 118-121.

Return to footnote 2979 referrer

Footnote 2980

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 27.

Return to footnote 2980 referrer

Footnote 2981

Exhibit P-177, doc. 1457, p. 3.

Return to footnote 2981 referrer

Footnote 2982

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1261.

Return to footnote 2982 referrer

Footnote 2983

Exhibit P-4, Collection D, vol. 9, tab 80, doc. 804; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 294. There is a short email exchange on December 1-2, 2009 between Maj Dandurand and Mr. Fynes concerning issues raised about the 2008 investigation: see Exhibit P-147, tab 1, doc. 1422, pp. 63-64.

Return to footnote 2983 referrer

Footnote 2984

See Section 4.5.4, CFNIS Interactions with the Fynes, 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 2984 referrer

Footnote 2985

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 166-167; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 259; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 114-115.

Return to footnote 2985 referrer

Footnote 2986

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 133.

Return to footnote 2986 referrer

Footnote 2987

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 259.

Return to footnote 2987 referrer

Footnote 2988

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 259.

Return to footnote 2988 referrer

Footnote 2989

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 186-187.

Return to footnote 2989 referrer

Footnote 2990

Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, p. 9, 31; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 186.

Return to footnote 2990 referrer

Footnote 2991

See, generally, Section 4.5, CFNIS Interactions with the Fynes.

Return to footnote 2991 referrer

Footnote 2992

Exhibit P-147, tab 1, doc. 1422, pp. 115-116.

Return to footnote 2992 referrer

Footnote 2993

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 199-200; Exhibit P-147, tab 1, doc. 1422, p. 115.

Return to footnote 2993 referrer

Footnote 2994

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 189-190.

Return to footnote 2994 referrer

Footnote 2995

Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 199-200.

Return to footnote 2995 referrer

Footnote 2996

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp.27; Exhibit P-177, doc. 1457, p. 3.

Return to footnote 2996 referrer

Footnote 2997

Exhibit P-161, doc. 1087-O.

Return to footnote 2997 referrer

Footnote 2998

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1263-1265.

Return to footnote 2998 referrer

Footnote 2999

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1369.

Return to footnote 2999 referrer

Footnote 3000

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 141-142 and 203-205.

Return to footnote 3000 referrer

Footnote 3001

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 3001 referrer

Footnote 3002

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518; Exhibit P-2, Collection B, vol. 1, tab 1, doc.1087, pp. 31-32.

Return to footnote 3002 referrer

Footnote 3003

Exhibit P-6, Collection F, vol. 1,tab 55, doc. 1292, pp. 2 and 7; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p.87.

Return to footnote 3003 referrer

Footnote 3004

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 221.

Return to footnote 3004 referrer

Footnote 3005

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 31-32, 87 and 221; Testimony of PO2 McLaughlin, vol. 49, 18 September 2012, pp. 241-242.

Return to footnote 3005 referrer

Footnote 3006

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 31-221.

Return to footnote 3006 referrer

Footnote 3007

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 219.

Return to footnote 3007 referrer

Footnote 3008

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 41-42, 89-113, 122-148 and 157-181.

Return to footnote 3008 referrer

Footnote 3009

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 39-40.

Return to footnote 3009 referrer

Footnote 3010

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1263.

Return to footnote 3010 referrer

Footnote 3011

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1263-1265.

Return to footnote 3011 referrer

Footnote 3012

Exhibit P-6, Collection F, vol. 1,tab 55, doc. 1292, p. 2.

Return to footnote 3012 referrer

Footnote 3013

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 212-213; Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, p. 15.

Return to footnote 3013 referrer

Footnote 3014

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 264.

Return to footnote 3014 referrer

Footnote 3015

Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 16-17.

Return to footnote 3015 referrer

Footnote 3016

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 136 and 201-202.

Return to footnote 3016 referrer

Footnote 3017

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 135-138, 186-191 and 268-269.

Return to footnote 3017 referrer

Footnote 3018

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 186-19.

Return to footnote 3018 referrer

Footnote 3019

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 113-114.

Return to footnote 3019 referrer

Footnote 3020

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 31-32 and 87.

Return to footnote 3020 referrer

Footnote 3021

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 236-241.

Return to footnote 3021 referrer

Footnote 3022

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 241-242.

Return to footnote 3022 referrer

Footnote 3023

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 251-252.

Return to footnote 3023 referrer

Footnote 3024

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 193.

Return to footnote 3024 referrer

Footnote 3025

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 27 and 221.

Return to footnote 3025 referrer

Footnote 3026

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 191.

Return to footnote 3026 referrer

Footnote 3027

Exhibit P-150, tab 2, doc. 1430, p. 2.

Return to footnote 3027 referrer

Footnote 3028

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 3028 referrer

Footnote 3029

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 3029 referrer

Footnote 3030

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 294.

Return to footnote 3030 referrer

Footnote 3031

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 122.

Return to footnote 3031 referrer

Footnote 3032

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1105.

Return to footnote 3032 referrer

Footnote 3033

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1105.

Return to footnote 3033 referrer

Footnote 3034

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 231-232.

Return to footnote 3034 referrer

Footnote 3035

See below: “The Shannon Investigation”.

Return to footnote 3035 referrer

Footnote 3036

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 224-228.

Return to footnote 3036 referrer

Footnote 3037

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 294 and 1369.

Return to footnote 3037 referrer

Footnote 3038

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 55; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 2.

Return to footnote 3038 referrer

Footnote 3039

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 13-14 and 101.

Return to footnote 3039 referrer

Footnote 3040

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 55.

Return to footnote 3040 referrer

Footnote 3041

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 13-14.

Return to footnote 3041 referrer

Footnote 3042

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 2 and 5-6.

Return to footnote 3042 referrer

Footnote 3043

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 27; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 44-51 and 54-55.

Return to footnote 3043 referrer

Footnote 3044

See Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 48-49; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 526, 575 and 634.

Return to footnote 3044 referrer

Footnote 3045

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 48-49.

Return to footnote 3045 referrer

Footnote 3046

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 61-62.

Return to footnote 3046 referrer

Footnote 3047

See Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 133-134.

Return to footnote 3047 referrer

Footnote 3048

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 33-34; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 284-285.

Return to footnote 3048 referrer

Footnote 3049

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 284-285.

Return to footnote 3049 referrer

Footnote 3050

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 284-285.

Return to footnote 3050 referrer

Footnote 3051

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 40.

Return to footnote 3051 referrer

Footnote 3052

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 40.

Return to footnote 3052 referrer

Footnote 3053

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 41.

Return to footnote 3053 referrer

Footnote 3054

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 40-42.

Return to footnote 3054 referrer

Footnote 3055

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 40-41.

Return to footnote 3055 referrer

Footnote 3056

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 91-99 and 102.

Return to footnote 3056 referrer

Footnote 3057

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 284-285.

Return to footnote 3057 referrer

Footnote 3058

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 284-285.

Return to footnote 3058 referrer

Footnote 3059

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F.

Return to footnote 3059 referrer

Footnote 3060

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 14-16.

Return to footnote 3060 referrer

Footnote 3061

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 22-24 and 26-29.

Return to footnote 3061 referrer

Footnote 3062

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 25-26.

Return to footnote 3062 referrer

Footnote 3063

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 29 and 38-39.

Return to footnote 3063 referrer

Footnote 3064

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 43.

Return to footnote 3064 referrer

Footnote 3065

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 59-60.

Return to footnote 3065 referrer

Footnote 3066

Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012, p. 15.

Return to footnote 3066 referrer

Footnote 3067

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 27-29, 37-39, 40, 42, 51 and 60.

Return to footnote 3067 referrer

Footnote 3068

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, p. 1.

Return to footnote 3068 referrer

Footnote 3069

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 24-25.

Return to footnote 3069 referrer

Footnote 3070

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 50, 64, 81 and 87.

Return to footnote 3070 referrer

Footnote 3071

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 59-60.

Return to footnote 3071 referrer

Footnote 3072

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 55 and 59-60.

Return to footnote 3072 referrer

Footnote 3073

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 60 and 85-87; Testimony of Capt Brown, Transcript of Proceedings, vol. 18, 8 May 2012, p. 149.

Return to footnote 3073 referrer

Footnote 3074

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 25 and 55-56.

Return to footnote 3074 referrer

Footnote 3075

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 52-55, 61 and 117-118.

Return to footnote 3075 referrer

Footnote 3076

Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H, pp. 25-26 and 30.

Return to footnote 3076 referrer

Footnote 3077

Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H, p. 14-16.

Return to footnote 3077 referrer

Footnote 3078

Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H, pp. 27-28.

Return to footnote 3078 referrer

Footnote 3079

It had been provided by the Ombudsman’s investigator and was part of the GO file: Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 217.

Return to footnote 3079 referrer

Footnote 3080

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 83-84.

Return to footnote 3080 referrer

Footnote 3081

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 16.

Return to footnote 3081 referrer

Footnote 3082

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 284.

Return to footnote 3082 referrer

Footnote 3083

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 301-406 and 1105.

Return to footnote 3083 referrer

Footnote 3084

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 31.

Return to footnote 3084 referrer

Footnote 3085

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 37-38.

Return to footnote 3085 referrer

Footnote 3086

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 426-428.

Return to footnote 3086 referrer

Footnote 3087

Exhibit P-70, doc. 1358, p. 3.

Return to footnote 3087 referrer

Footnote 3088

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 426-427 and 1143.

Return to footnote 3088 referrer

Footnote 3089

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 426-428 and 1143. See also Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1037-1040; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 120-121 and 184.

Return to footnote 3089 referrer

Footnote 3090

Exhibit P-70, doc. 1358, pp. 1-2.

Return to footnote 3090 referrer

Footnote 3091

Exhibit P-22, doc. 1318, p. 1.

Return to footnote 3091 referrer

Footnote 3092

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 108-109.

Return to footnote 3092 referrer

Footnote 3093

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 19-20.

Return to footnote 3093 referrer

Footnote 3094

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 201.

Return to footnote 3094 referrer

Footnote 3095

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 525.

Return to footnote 3095 referrer

Footnote 3096

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 122.

Return to footnote 3096 referrer

Footnote 3097

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 99.

Return to footnote 3097 referrer

Footnote 3098

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 547.

Return to footnote 3098 referrer

Footnote 3099

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 550.

Return to footnote 3099 referrer

Footnote 3100

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 526, 573, 575 and 831.

Return to footnote 3100 referrer

Footnote 3101

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1032.

Return to footnote 3101 referrer

Footnote 3102

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 110.

Return to footnote 3102 referrer

Footnote 3103

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 112-114.

Return to footnote 3103 referrer

Footnote 3104

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 79-80.

Return to footnote 3104 referrer

Footnote 3105

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 133-134.

Return to footnote 3105 referrer

Footnote 3106

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 49-52 and 64.

Return to footnote 3106 referrer

Footnote 3107

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 52-55, 61 and 117-118.

Return to footnote 3107 referrer

Footnote 3108

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 38-39.

Return to footnote 3108 referrer

Footnote 3109

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 38-39; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 32.

Return to footnote 3109 referrer

Footnote 3110

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 84 and 120-121.

Return to footnote 3110 referrer

Footnote 3111

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 84-85.

Return to footnote 3111 referrer

Footnote 3112

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 1; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 1.

Return to footnote 3112 referrer

Footnote 3113

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, p. 1.

Return to footnote 3113 referrer

Footnote 3114

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1105; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 9-10.

Return to footnote 3114 referrer

Footnote 3115

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 122-123.

Return to footnote 3115 referrer

Footnote 3116

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 101.

Return to footnote 3116 referrer

Footnote 3117

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 285.

Return to footnote 3117 referrer

Footnote 3118

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1145.

Return to footnote 3118 referrer

Footnote 3119

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 170-171; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 26-27 and 142-143.

Return to footnote 3119 referrer

Footnote 3120

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 122.

Return to footnote 3120 referrer

Footnote 3121

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1370.

Return to footnote 3121 referrer

Footnote 3122

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 98-100.

Return to footnote 3122 referrer

Footnote 3123

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 97-98.

Return to footnote 3123 referrer

Footnote 3124

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 97-98.

Return to footnote 3124 referrer

Footnote 3125

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 47-48.

Return to footnote 3125 referrer

Footnote 3126

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 286.

Return to footnote 3126 referrer

Footnote 3127

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 6-7.

Return to footnote 3127 referrer

Footnote 3128

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 219.

Return to footnote 3128 referrer

Footnote 3129

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 235.

Return to footnote 3129 referrer

Footnote 3130

Exhibit P-3, Collection C, vol. 1, tab 3, doc. 1088-C, p. 27.

Return to footnote 3130 referrer

Footnote 3131

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 226; Exhibit P-75, tab 2, doc 1087-K, pp. 50-53.

Return to footnote 3131 referrer

Footnote 3132

Exhibit P-75, tab 2, doc 1087-K, p. 50.

Return to footnote 3132 referrer

Footnote 3133

Exhibit P-75, tab 2, doc 1087-K, p. 50; Exhibit P-3, Collection C, vol. 1, tab 3, doc. 1088-C, p. 26.

Return to footnote 3133 referrer

Footnote 3134

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 146-147; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 274.

Return to footnote 3134 referrer

Footnote 3135

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 210.

Return to footnote 3135 referrer

Footnote 3136

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 210; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p.92; Exhibit P-75, tab 3, doc. 1087-L, pp. 5-130.

Return to footnote 3136 referrer

Footnote 3137

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 210.

Return to footnote 3137 referrer

Footnote 3138

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 210.

Return to footnote 3138 referrer

Footnote 3139

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 225 [Emphasis added].

Return to footnote 3139 referrer

Footnote 3140

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 149-150.

Return to footnote 3140 referrer

Footnote 3141

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 132.

Return to footnote 3141 referrer

Footnote 3142

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 132-133.

Return to footnote 3142 referrer

Footnote 3143

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 133.

Return to footnote 3143 referrer

Footnote 3144

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 133.

Return to footnote 3144 referrer

Footnote 3145

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 133 and 135.

Return to footnote 3145 referrer

Footnote 3146

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 137.

Return to footnote 3146 referrer

Footnote 3147

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 133-134.

Return to footnote 3147 referrer

Footnote 3148

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 207.

Return to footnote 3148 referrer

Footnote 3149

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 137.

Return to footnote 3149 referrer

Footnote 3150

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 245.

Return to footnote 3150 referrer

Footnote 3151

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 150-151.

Return to footnote 3151 referrer

Footnote 3152

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 151.

Return to footnote 3152 referrer

Footnote 3153

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 151-152.

Return to footnote 3153 referrer

Footnote 3154

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 225-226.

Return to footnote 3154 referrer

Footnote 3155

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 227.

Return to footnote 3155 referrer

Footnote 3156

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 221-222.

Return to footnote 3156 referrer

Footnote 3157

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 217-218.

Return to footnote 3157 referrer

Footnote 3158

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 177-179.

Return to footnote 3158 referrer

Footnote 3159

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 5-6 and 26.

Return to footnote 3159 referrer

Footnote 3160

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 224-228.

Return to footnote 3160 referrer

Footnote 3161

Exhibit P-75, tab 5, doc. 1087-N, p. 42.

Return to footnote 3161 referrer

Footnote 3162

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 227-228; Exhibit P-75, tab 4, doc. 1087-M, pp. 111-114.

Return to footnote 3162 referrer

Footnote 3163

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 71-75.

Return to footnote 3163 referrer

Footnote 3164

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 76.

Return to footnote 3164 referrer

Footnote 3165

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 76.

Return to footnote 3165 referrer

Footnote 3166

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 76-77; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 54.

Return to footnote 3166 referrer

Footnote 3167

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 78.

Return to footnote 3167 referrer

Footnote 3168

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 77.

Return to footnote 3168 referrer

Footnote 3169

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 78-79.

Return to footnote 3169 referrer

Footnote 3170

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 84

Return to footnote 3170 referrer

Footnote 3171

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 175.

Return to footnote 3171 referrer

Footnote 3172

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 238-239.

Return to footnote 3172 referrer

Footnote 3173

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 7.

Return to footnote 3173 referrer

Footnote 3174

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 286-289.

Return to footnote 3174 referrer

Footnote 3175

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 224-228.

Return to footnote 3175 referrer

Footnote 3176

Exhibit P-3, Collection C, vol. 1, tab 3, doc. 1088-C.

Return to footnote 3176 referrer

Footnote 3177

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 214.

Return to footnote 3177 referrer

Footnote 3178

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 196.

Return to footnote 3178 referrer

Footnote 3179

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 197-198.

Return to footnote 3179 referrer

Footnote 3180

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 201-202.

Return to footnote 3180 referrer

Footnote 3181

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 33-34.

Return to footnote 3181 referrer

Footnote 3182

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 35.

Return to footnote 3182 referrer

Footnote 3183

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 261.

Return to footnote 3183 referrer

Footnote 3184

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 3184 referrer

Footnote 3185

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 27; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 160-161, 192-193 and 252-253; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 118-119; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 156-157.

Return to footnote 3185 referrer

Footnote 3186

See Exhibit P-2, Collection B, vol. 2, tab 1, doc 1087-B, p. 40.

Return to footnote 3186 referrer

Footnote 3187

Exhibit P-2, Collection B, vol. 2, tab 2, doc 1087-C, p. 50.

Return to footnote 3187 referrer

Footnote 3188

Exhibit P-6, Collection F, vol. 1, tab 55, doc 1292, p. 2; Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 5-6; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 3 October 2012, p. 269.

Return to footnote 3188 referrer

Footnote 3189

Testimony of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 138-139.

Return to footnote 3189 referrer

Footnote 3190

Testimony of LCol Cadieu, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 169-170.

Return to footnote 3190 referrer

Footnote 3191

Exhibit P-6, Collection F, vol. 1, tab 24, doc. 1171, p. 2.

Return to footnote 3191 referrer

Footnote 3192

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, p. 139-140; Testimony of LCol Cadieu, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 182-183; Testimony of Maj Jared, Transcript of Proceedings, vol. 9, 12 April 2012, pp. 128-129.

Return to footnote 3192 referrer

Footnote 3193

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 27; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 160-161.

Return to footnote 3193 referrer

Footnote 3194

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 118-119.

Return to footnote 3194 referrer

Footnote 3195

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 252-253.

Return to footnote 3195 referrer

Footnote 3196

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 94-95, 160-161 and 192-193.

Return to footnote 3196 referrer

Footnote 3197

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 156-157.

Return to footnote 3197 referrer

Footnote 3198

estimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 156-157.

Return to footnote 3198 referrer

Footnote 3199

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 160-161.

Return to footnote 3199 referrer

Footnote 3200

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 28.

Return to footnote 3200 referrer

Footnote 3201

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 221.

Return to footnote 3201 referrer

Footnote 3202

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 3202 referrer

Footnote 3203

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 284.

Return to footnote 3203 referrer

Footnote 3204

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 120-121.

Return to footnote 3204 referrer

Footnote 3205

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 120.

Return to footnote 3205 referrer

Footnote 3206

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 122 and 139.

Return to footnote 3206 referrer

Footnote 3207

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 122.

Return to footnote 3207 referrer

Footnote 3208

Exhibit P-2, Collection B, vol. 2, tab 2, doc 1087-C; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B.

Return to footnote 3208 referrer

Footnote 3209

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1346-1347; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, pp. 69-70.

Return to footnote 3209 referrer

Footnote 3210

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 98-100.

Return to footnote 3210 referrer

Footnote 3211

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 101.

Return to footnote 3211 referrer

Footnote 3212

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 101.

Return to footnote 3212 referrer

Footnote 3213

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 286.

Return to footnote 3213 referrer

Footnote 3214

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 161.

Return to footnote 3214 referrer

Footnote 3215

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 275-276.

Return to footnote 3215 referrer

Footnote 3216

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 235.

Return to footnote 3216 referrer

Footnote 3217

Exhibit P-75, tab 2, doc. 1087-K, p. 50 [Emphasis added].

Return to footnote 3217 referrer

Footnote 3218

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 147.

Return to footnote 3218 referrer

Footnote 3219

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 124-125.

Return to footnote 3219 referrer

Footnote 3220

Exhibit P-6, Collection F, vol. 1, tab 52, doc. 1199.

Return to footnote 3220 referrer

Footnote 3221

Exhibit P-75, tab 2, doc. 1087-K, pp.68-70; Exhibit P-96, doc. 1379.

Return to footnote 3221 referrer

Footnote 3222

Fasken v. Fasken, [1953] 2 SCR 10, [1953] 3 DLR 431 at para 12 (SCC).

Return to footnote 3222 referrer

Footnote 3223

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 112-113.

Return to footnote 3223 referrer

Footnote 3224

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 229.

Return to footnote 3224 referrer

Footnote 3225

Exhibit P-75, tab 2, doc 1087-K, pp. 72-80 [Emphasis added].

Return to footnote 3225 referrer

Footnote 3226

Exhibit P-75, tab 3, doc. 1087-L, pp. 33 [Emphasis added].

Return to footnote 3226 referrer

Footnote 3227

Exhibit P-6, Collection F, vol. 1, tab 24, doc. 1171, pp. 2-3; Exhibit P-6, Collection F, vol. 1, tab 52, doc 1199; Exhibit P-75, tab 3, doc 1087-L, pp. 31, 35, 76 and 148-156.

Return to footnote 3227 referrer

Footnote 3228

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 288.

Return to footnote 3228 referrer

Footnote 3229

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-D, pp. 34-35; Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E, p. 25.

Return to footnote 3229 referrer

Footnote 3230

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-D, pp. 52-53; Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E, pp. 25 and 32.

Return to footnote 3230 referrer

Footnote 3231

Exhibit P-162, doc. 1444, p. 1.

Return to footnote 3231 referrer

Footnote 3232

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 227.

Return to footnote 3232 referrer

Footnote 3233

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 27.

Return to footnote 3233 referrer

Footnote 3234

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 39-40.

Return to footnote 3234 referrer

Footnote 3235

Constitution Act, 1867 (UK), 30 &31 Vict, c 3, reprinted in RSC 1985, App II, No.5, s. 91 and 92.

Return to footnote 3235 referrer

Footnote 3236

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 1.

Return to footnote 3236 referrer

Footnote 3237

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 120-122; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 154-155.

Return to footnote 3237 referrer

Footnote 3238

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 34-36 and 38.

Return to footnote 3238 referrer

Footnote 3239

Funeral Services Act, RSA 2000, c F-29.

Return to footnote 3239 referrer

Footnote 3240

Adult Interdependent Relationships Act, SA 2002, c A-4.5.

Return to footnote 3240 referrer

Footnote 3241

Funeral Services Act, General Regulation, Alta Reg 226/1998, s.36(2).

Return to footnote 3241 referrer

Footnote 3242

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 869-870.

Return to footnote 3242 referrer

Footnote 3243

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 38.

Return to footnote 3243 referrer

Footnote 3244

Adult Interdependent Relationships Act, SA 2002, c A-4.5.

Return to footnote 3244 referrer

Footnote 3245

Adult Interdependent Relationships Act, SA 2002, c A-4.5, s. 3(1).

Return to footnote 3245 referrer

Footnote 3246

Testimony of Sheila Fynes, Transcript of Proceedings, vol.17, 7 May 2012, pp. 179-180; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 161-162.

Return to footnote 3246 referrer

Footnote 3247

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 32.

Return to footnote 3247 referrer

Footnote 3248

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 220-221.

Return to footnote 3248 referrer

Footnote 3249

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 142-143.

Return to footnote 3249 referrer

Footnote 3250

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 146.

Return to footnote 3250 referrer

Footnote 3251

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 831.

Return to footnote 3251 referrer

Footnote 3252

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 25.

Return to footnote 3252 referrer

Footnote 3253

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 287. He also identified a fifth interview with LCol King but noted later in the Plan that the interview was “not required.”

Return to footnote 3253 referrer

Footnote 3254

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 135-136.

Return to footnote 3254 referrer

Footnote 3255

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 152-153.

Return to footnote 3255 referrer

Footnote 3256

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 152-153.

Return to footnote 3256 referrer

Footnote 3257

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 40-42.

Return to footnote 3257 referrer

Footnote 3258

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 16-24.

Return to footnote 3258 referrer

Footnote 3259

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 158-159.

Return to footnote 3259 referrer

Footnote 3260

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 283-284.

Return to footnote 3260 referrer

Footnote 3261

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 284.

Return to footnote 3261 referrer

Footnote 3262

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 283-285.

Return to footnote 3262 referrer

Footnote 3263

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 82-84.

Return to footnote 3263 referrer

Footnote 3264

Testimony of Capt Hubbard, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 54-55.

Return to footnote 3264 referrer

Footnote 3265

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 122 and 139.

Return to footnote 3265 referrer

Footnote 3266

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 6.

Return to footnote 3266 referrer

Footnote 3267

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 7.

Return to footnote 3267 referrer

Footnote 3268

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 38 and 119-121.

Return to footnote 3268 referrer

Footnote 3269

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 61-63.

Return to footnote 3269 referrer

Footnote 3270

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 188-190 and 213; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 97.

Return to footnote 3270 referrer

Footnote 3271

Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H, pp. 33-36; Testimony of Sgt Weir, Transcript of Proceedings, 15 May 2012, vol. 22, pp. 37-38.

Return to footnote 3271 referrer

Footnote 3272

Testimony of MCpl (Ret’d) Fitzpatrick, Transcript of Proceedings, 25 April 2012, vol. 15, pp. 191-193.

Return to footnote 3272 referrer

Footnote 3273

Testimony of Sgt Weir, Transcript of Proceedings, 15 May 2012, vol. 22, pp. 37-38.

Return to footnote 3273 referrer

Footnote 3274

Testimony of MCpl (Ret’d) Fitzpatrick, Transcript of Proceedings, 25 April 2012, vol. 15, p. 193

Return to footnote 3274 referrer

Footnote 3275

Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H.

Return to footnote 3275 referrer

Footnote 3276

Testimony of LCol Cadieu, Transcript of Proceedings, vol. 8, 11 April 2012, p. 171; Exhibit P-70, doc. 1358, p. 26.

Return to footnote 3276 referrer

Footnote 3277

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 49-50; Testimony of Sheila Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, p. 171; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 91, 127; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 79.

Return to footnote 3277 referrer

Footnote 3278

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 47; Testimony of Mrs. Fynes, Transcript of Proceedings, 26 April 2012, vol. 16, pp. 172-173.

Return to footnote 3278 referrer

Footnote 3279

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 196.

Return to footnote 3279 referrer

Footnote 3280

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 210.

Return to footnote 3280 referrer

Footnote 3281

Testimony of Sheila Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, p. 172.

Return to footnote 3281 referrer

Footnote 3282

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 195.

Return to footnote 3282 referrer

Footnote 3283

Exhibit P-2, Collection B, vol.2, tab 1, doc. 1087-B, p. 40; Exhibit P-2, Collection B, vol.2, tab 2, doc. 1087-C, p. 54; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 30.

Return to footnote 3283 referrer

Footnote 3284

Exhibit P-2, Collection B, vol.2, tab 1, doc. 1087-B, p. 40; Exhibit P-2, Collection B, vol.2, tab 2, doc. 1087-C, p. 54; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 30.

Return to footnote 3284 referrer

Footnote 3285

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 50.

Return to footnote 3285 referrer

Footnote 3286

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 50.

Return to footnote 3286 referrer

Footnote 3287

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 271.

Return to footnote 3287 referrer

Footnote 3288

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 173; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 96.

Return to footnote 3288 referrer

Footnote 3289

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 153-154.

Return to footnote 3289 referrer

Footnote 3290

See Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 246 and 287.

Return to footnote 3290 referrer

Footnote 3291

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 113-114.

Return to footnote 3291 referrer

Footnote 3292

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 287.

Return to footnote 3292 referrer

Footnote 3293

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, pp. 71-72.

Return to footnote 3293 referrer

Footnote 3294

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 172; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 21.

Return to footnote 3294 referrer

Footnote 3295

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 172.

Return to footnote 3295 referrer

Footnote 3296

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 4.

Return to footnote 3296 referrer

Footnote 3297

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 4.

Return to footnote 3297 referrer

Footnote 3298

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 28.

Return to footnote 3298 referrer

Footnote 3299

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 3.

Return to footnote 3299 referrer

Footnote 3300

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 77-78, 81-85, 213-216, 1346-1347 and PDF pp. 82-84; Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 119 and 121-122; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 1-2, 13-14, 27-32, 117 and 155.

Return to footnote 3300 referrer

Footnote 3301

Testimony of Sheila Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 184-185 and 188; Testimony of Dirk Velthuizen, Transcript of Proceedings, vol. 19, 9 May 2012, pp. 110-111.

Return to footnote 3301 referrer

Footnote 3302

Testimony of Dirk Velthuizen, Transcript of Proceedings, vol. 19, 9 May 2012, p. 109.

Return to footnote 3302 referrer

Footnote 3303

Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 114-115; Testimony of Sheila Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, pp. 205-206.

Return to footnote 3303 referrer

Footnote 3304

Testimony of Sheila Fynes, Transcript of Proceedings, vol. 16, 26 April 2012, p. 185; Testimony of Sheila Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 172.

Return to footnote 3304 referrer

Footnote 3305

Exhibit P-4, Collection D, vol. 6, tab 12, doc. 511.

Return to footnote 3305 referrer

Footnote 3306

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp.27-32, 117 and 155; Exhibit P-2, Collection B, vol. 2, tab 1, 1087-B, pp. 40, 119 and 121-122.

Return to footnote 3306 referrer

Footnote 3307

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 155.

Return to footnote 3307 referrer

Footnote 3308

Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 161-164.

Return to footnote 3308 referrer

Footnote 3309

Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 165.

Return to footnote 3309 referrer

Footnote 3310

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 120; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 119-129; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp.152-153; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 168-170; Testimony of Sheila Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 172.

Return to footnote 3310 referrer

Footnote 3311

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1347.

Return to footnote 3311 referrer

Footnote 3312

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 67.

Return to footnote 3312 referrer

Footnote 3313

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 69.

Return to footnote 3313 referrer

Footnote 3314

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 68.

Return to footnote 3314 referrer

Footnote 3315

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 70.

Return to footnote 3315 referrer

Footnote 3316

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 578.

Return to footnote 3316 referrer

Footnote 3317

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 869-870.

Return to footnote 3317 referrer

Footnote 3318

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 119; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 104.

Return to footnote 3318 referrer

Footnote 3319

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 104-106.

Return to footnote 3319 referrer

Footnote 3320

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1107-1109.

Return to footnote 3320 referrer

Footnote 3321

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 34-37, 56-57, 59-60, 77-78 and 81-85.

Return to footnote 3321 referrer

Footnote 3322

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1346-1347.

Return to footnote 3322 referrer

Footnote 3323

Exhibit P-2, Collection B, vol. 2, tab 1, doc 1087-B, pp. 118-119 and 121-122; Exhibit P-2, Collection B, vol.2, tab 2, doc. 1087-C, pp. 9-11 and 105; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 1-2, 8-9, 13-14, 27-32, 117 and 155.

Return to footnote 3323 referrer

Footnote 3324

Exhibit P-6, Collection F, vol. 1,tab 55, doc. 1292, p. 2; Testimony of Patrick Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 7, 17 and 34-39.

Return to footnote 3324 referrer

Footnote 3325

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 43 and 48-51.

Return to footnote 3325 referrer

Footnote 3326

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 4.

Return to footnote 3326 referrer

Footnote 3327

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 245.

Return to footnote 3327 referrer

Footnote 3328

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 65-66.

Return to footnote 3328 referrer

Footnote 3329

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 20-21.

Return to footnote 3329 referrer

Footnote 3330

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 65-66.

Return to footnote 3330 referrer

Footnote 3331

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 65-66.

Return to footnote 3331 referrer

Footnote 3332

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 155.

Return to footnote 3332 referrer

Footnote 3333

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p.175.

Return to footnote 3333 referrer

Footnote 3334

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 188-189.

Return to footnote 3334 referrer

Footnote 3335

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F; Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G; Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H.

Return to footnote 3335 referrer

Footnote 3336

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 154; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 166-167.

Return to footnote 3336 referrer

Footnote 3337

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 20-21.

Return to footnote 3337 referrer

Footnote 3338

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 154.

Return to footnote 3338 referrer

Footnote 3339

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 156.

Return to footnote 3339 referrer

Footnote 3340

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 28.

Return to footnote 3340 referrer

Footnote 3341

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p.140; Testimony of LCol King, Transcript of Proceedings, vol. 25, 22 May 2012, p. 139.

Return to footnote 3341 referrer

Footnote 3342

Exhibit P-4, Collection D, vol. 5, tab 7, doc. 405.

Return to footnote 3342 referrer

Footnote 3343

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 28.

Return to footnote 3343 referrer

Footnote 3344

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 221.

Return to footnote 3344 referrer

Footnote 3345

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 92-95.

Return to footnote 3345 referrer

Footnote 3346

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 281.

Return to footnote 3346 referrer

Footnote 3347

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 275-276 and 278-279.

Return to footnote 3347 referrer

Footnote 3348

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 276-277; Transcript of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 136-137; Testimony of LCol Cadieu, Transcript of Proceedings, vol.8, 11 April 2012, p. 168.

Return to footnote 3348 referrer

Footnote 3349

Transcript of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 136-137; Testimony of LCol Cadieu, Transcript of Proceedings, vol.8, 11 April 2012, p. 172.

Return to footnote 3349 referrer

Footnote 3350

Transcript of Maj Lubiniecki, Transcript of Proceedings, vol. 6, 5 April 2012, pp. 136-137; Testimony of LCol Cadieu, Transcript of Proceedings, vol.8, 11 April 2012, pp. 172-173; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 526 and 573.

Return to footnote 3350 referrer

Footnote 3351

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 217.

Return to footnote 3351 referrer

Footnote 3352

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 281; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 227.

Return to footnote 3352 referrer

Footnote 3353

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 115-117.

Return to footnote 3353 referrer

Footnote 3354

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 116; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 71 and 110-111; Exhibit P-3, Collection C, vol. 1, tab 3, doc. 1088-C, p. 33.

Return to footnote 3354 referrer

Footnote 3355

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 4.

Return to footnote 3355 referrer

Footnote 3356

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 9; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 6.

Return to footnote 3356 referrer

Footnote 3357

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 11-12.

Return to footnote 3357 referrer

Footnote 3358

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 5.

Return to footnote 3358 referrer

Footnote 3359

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 26-27; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 170-171.

Return to footnote 3359 referrer

Footnote 3360

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 146.

Return to footnote 3360 referrer

Footnote 3361

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 143; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 58-59.

Return to footnote 3361 referrer

Footnote 3362

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 26-27; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 121-122.

Return to footnote 3362 referrer

Footnote 3363

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 16-17 and 23-25.

Return to footnote 3363 referrer

Footnote 3364

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 21-22.

Return to footnote 3364 referrer

Footnote 3365

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 11-12.

Return to footnote 3365 referrer

Footnote 3366

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 11-12.

Return to footnote 3366 referrer

Footnote 3367

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 57, 62; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 115.

Return to footnote 3367 referrer

Footnote 3368

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 11-12.

Return to footnote 3368 referrer

Footnote 3369

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 12-13.

Return to footnote 3369 referrer

Footnote 3370

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 129.

Return to footnote 3370 referrer

Footnote 3371

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 52-53; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 129; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 57.

Return to footnote 3371 referrer

Footnote 3372

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 233.

Return to footnote 3372 referrer

Footnote 3373

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 272-273.

Return to footnote 3373 referrer

Footnote 3374

Testimony of MCpl Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 53-54.

Return to footnote 3374 referrer

Footnote 3375

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 58.

Return to footnote 3375 referrer

Footnote 3376

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 7.

Return to footnote 3376 referrer

Footnote 3377

See Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 13-14; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 5-6.

Return to footnote 3377 referrer

Footnote 3378

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 5-6.

Return to footnote 3378 referrer

Footnote 3379

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 7.

Return to footnote 3379 referrer

Footnote 3380

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 69-70.

Return to footnote 3380 referrer

Footnote 3381

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 69-70.

Return to footnote 3381 referrer

Footnote 3382

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 11.

Return to footnote 3382 referrer

Footnote 3383

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 3-4.

Return to footnote 3383 referrer

Footnote 3384

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 71-72; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 31, 95 and 105-106; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 27-28 and 89-90.

Return to footnote 3384 referrer

Footnote 3385

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 83.

Return to footnote 3385 referrer

Footnote 3386

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 33.

Return to footnote 3386 referrer

Footnote 3387

Exhibit P-147, tab 1, doc. 1422, pp. 115-116 and 119.

Return to footnote 3387 referrer

Footnote 3388

Testimony of MCpl Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 39-41, 65 and 88-92.

Return to footnote 3388 referrer

Footnote 3389

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 84, 126 and 131-132.

Return to footnote 3389 referrer

Footnote 3390

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 84 and 203.

Return to footnote 3390 referrer

Footnote 3391

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 81-88; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 145-147.

Return to footnote 3391 referrer

Footnote 3392

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 143.

Return to footnote 3392 referrer

Footnote 3393

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 94 and 99; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 116-117; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 62-63.

Return to footnote 3393 referrer

Footnote 3394

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 100; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 64-65 and 89; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 120.

Return to footnote 3394 referrer

Footnote 3395

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 101-102.

Return to footnote 3395 referrer

Footnote 3396

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 139-140.

Return to footnote 3396 referrer

Footnote 3397

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 133-134.

Return to footnote 3397 referrer

Footnote 3398

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 65-66.

Return to footnote 3398 referrer

Footnote 3399

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 66 and 89-90.

Return to footnote 3399 referrer

Footnote 3400

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 99.

Return to footnote 3400 referrer

Footnote 3401

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 288.

Return to footnote 3401 referrer

Footnote 3402

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-D, pp. 49-52; Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E, pp. 27-32.

Return to footnote 3402 referrer

Footnote 3403

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p.136; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 135.

Return to footnote 3403 referrer

Footnote 3404

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 69-70.

Return to footnote 3404 referrer

Footnote 3405

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 162.

Return to footnote 3405 referrer

Footnote 3406

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 104-108; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 133 and 171-172.

Return to footnote 3406 referrer

Footnote 3407

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 35-36.

Return to footnote 3407 referrer

Footnote 3408

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 172.

Return to footnote 3408 referrer

Footnote 3409

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 34-36 and 106; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 171-172.

Return to footnote 3409 referrer

Footnote 3410

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 7-8; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 6.

Return to footnote 3410 referrer

Footnote 3411

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 16, 26 April 2012, p. 6.

Return to footnote 3411 referrer

Footnote 3412

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 6.

Return to footnote 3412 referrer

Footnote 3413

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 108.

Return to footnote 3413 referrer

Footnote 3414

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 108-109.

Return to footnote 3414 referrer

Footnote 3415

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 118-122.

Return to footnote 3415 referrer

Footnote 3416

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 123.

Return to footnote 3416 referrer

Footnote 3417

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 225.

Return to footnote 3417 referrer

Footnote 3418

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 225-226.

Return to footnote 3418 referrer

Footnote 3419

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 249-250.

Return to footnote 3419 referrer

Footnote 3420

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 109-110.

Return to footnote 3420 referrer

Footnote 3421

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 110.

Return to footnote 3421 referrer

Footnote 3422

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 110-111; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 284; Exhibit P-70, doc. 1358, pp. 3-4; Exhibit P-147, tab 1, doc. 1422, pp. 53 and 55-56.

Return to footnote 3422 referrer

Footnote 3423

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 111.

Return to footnote 3423 referrer

Footnote 3424

Testimony of Shaun Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 183; Testimony of Shaun Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 241-242; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332; Testimony of MS McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 96-97 and 288.

Return to footnote 3424 referrer

Footnote 3425

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 196.

Return to footnote 3425 referrer

Footnote 3426

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 93.

Return to footnote 3426 referrer

Footnote 3427

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332.

Return to footnote 3427 referrer

Footnote 3428

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 93-95; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 196.

Return to footnote 3428 referrer

Footnote 3429

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 206-207.

Return to footnote 3429 referrer

Footnote 3430

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1263.

Return to footnote 3430 referrer

Footnote 3431

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 209-210.

Return to footnote 3431 referrer

Footnote 3432

Exhibit P-6, Collection F, vol. 1,tab 55, doc. 1292, pp. 2-3.

Return to footnote 3432 referrer

Footnote 3433

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 9 and 12; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 6, 167 and 174.

Return to footnote 3433 referrer

Footnote 3434

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 219-221; Exhibit P-2, Collection B, vol. 2, tab 2, doc.1087-C, pp. 55 and 57-58; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 282-283; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 13-14; Testimony of MCpl Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 39; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 255-256.

Return to footnote 3434 referrer

Footnote 3435

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 29, 221, 224 and 286-287.

Return to footnote 3435 referrer

Footnote 3436

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 43-44.

Return to footnote 3436 referrer

Footnote 3437

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 135-136 and 272.

Return to footnote 3437 referrer

Footnote 3438

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 29, 224 and 286-287.

Return to footnote 3438 referrer

Footnote 3439

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 269-270; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 298-299; Testimony of MCpl Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 75-76; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 86

Return to footnote 3439 referrer

Footnote 3440

Exhibit P-183, tab 26, doc. 1486, p. 1.

Return to footnote 3440 referrer

Footnote 3441

Exhibit P-183, tab 26, doc. 1486, pp. 1-2.

Return to footnote 3441 referrer

Footnote 3442

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 107.

Return to footnote 3442 referrer

Footnote 3443

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 127-128.

Return to footnote 3443 referrer

Footnote 3444

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 129.

Return to footnote 3444 referrer

Footnote 3445

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 134-135.

Return to footnote 3445 referrer

Footnote 3446

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1196.

Return to footnote 3446 referrer

Footnote 3447

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 136-137; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 138.

Return to footnote 3447 referrer

Footnote 3448

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 136 and 138.

Return to footnote 3448 referrer

Footnote 3449

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1351-1353.

Return to footnote 3449 referrer

Footnote 3450

Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G, pp. 76-78.

Return to footnote 3450 referrer

Footnote 3451

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1359-1361.

Return to footnote 3451 referrer

Footnote 3452

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-D, pp. 49-52.

Return to footnote 3452 referrer

Footnote 3453

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-D, pp. 56-57.

Return to footnote 3453 referrer

Footnote 3454

Testimony of LCdr Gendron, Transcript of Proceedings, vol. 21, 14 May 2012, p. 44.

Return to footnote 3454 referrer

Footnote 3455

Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E, pp. 27-31.

Return to footnote 3455 referrer

Footnote 3456

Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E, pp. 27-32.

Return to footnote 3456 referrer

Footnote 3457

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 136; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 172; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 104.

Return to footnote 3457 referrer

Footnote 3458

Exhibit P-183, tab 26, doc. 1486, p. 1.

Return to footnote 3458 referrer

Footnote 3459

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 56.

Return to footnote 3459 referrer

Footnote 3460

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518.

Return to footnote 3460 referrer

Footnote 3461

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1100.

Return to footnote 3461 referrer

Footnote 3462

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 4-5.

Return to footnote 3462 referrer

Footnote 3463

Exhibit P-6, Collection F, vol. 1,tab 55, doc. 1292, p. 2.

Return to footnote 3463 referrer

Footnote 3464

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 295.

Return to footnote 3464 referrer

Footnote 3465

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp.112-114.

Return to footnote 3465 referrer

Footnote 3466

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F; Exhibit P-2, Collection B, vol. 2, tab 6, doc. 1087-G; Exhibit P-2, Collection B, vol. 2, tab 7, doc. 1087-H.

Return to footnote 3466 referrer

Footnote 3467

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 426-428, 1023 and 1143.

Return to footnote 3467 referrer

Footnote 3468

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 19, 27, 29, 31 and 39-40.

Return to footnote 3468 referrer

Footnote 3469

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 52-53.

Return to footnote 3469 referrer

Footnote 3470

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 99.

Return to footnote 3470 referrer

Footnote 3471

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 134; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1024.

Return to footnote 3471 referrer

Footnote 3472

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 132-134.

Return to footnote 3472 referrer

Footnote 3473

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 79-80.

Return to footnote 3473 referrer

Footnote 3474

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 175.

Return to footnote 3474 referrer

Footnote 3475

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 52.

Return to footnote 3475 referrer

Footnote 3476

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 98.

Return to footnote 3476 referrer

Footnote 3477

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 79-81.

Return to footnote 3477 referrer

Footnote 3478

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 98.

Return to footnote 3478 referrer

Footnote 3479

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1196.

Return to footnote 3479 referrer

Footnote 3480

Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E.

Return to footnote 3480 referrer

Footnote 3481

Exhibit P-6, Collection F, vol. 1,tab 55, doc. 1292, p. 4.

Return to footnote 3481 referrer

Footnote 3482

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p.1100.

Return to footnote 3482 referrer

Footnote 3483

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 114-115, 172 and 221.

Return to footnote 3483 referrer

Footnote 3484

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1196.

Return to footnote 3484 referrer

Footnote 3485

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 172.

Return to footnote 3485 referrer

Footnote 3486

See Section 4.5.4, CFNIS Interactions with the Fynes, 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3486 referrer

Footnote 3487

Exhibit P-4, Collection D, vol. 12, tab 68, doc. 1095.

Return to footnote 3487 referrer

Footnote 3488

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1198; Exhibit P-147, tab 3, doc.1424, pp. 64-68.

Return to footnote 3488 referrer

Footnote 3489

See Section 4.5.4, CFNIS Interactions with the Fynes, 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3489 referrer

Footnote 3490

Exhibit P-147, tab 2, doc. 1423, pp. 45-46.

Return to footnote 3490 referrer

Footnote 3491

Exhibit P-147, tab 2, doc. 1423, pp. 45-46.

Return to footnote 3491 referrer

Footnote 3492

Exhibit P-147, tab 2, doc. 1423, p. 60.

Return to footnote 3492 referrer

Footnote 3493

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1058.

Return to footnote 3493 referrer

Footnote 3494

Exhibit P-147, tab 2, doc. 1423, p. 70.

Return to footnote 3494 referrer

Footnote 3495

Exhibit P-147, tab 1, doc. 1422, p. 102.

Return to footnote 3495 referrer

Footnote 3496

Exhibit P-147, tab 1, doc. 1422, p. 105.

Return to footnote 3496 referrer

Footnote 3497

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1096.

Return to footnote 3497 referrer

Footnote 3498

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1100.

Return to footnote 3498 referrer

Footnote 3499

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 184.

Return to footnote 3499 referrer

Footnote 3500

Exhibit P-147, tab 2, doc. 1423, pp. 202-205.

Return to footnote 3500 referrer

Footnote 3501

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 268; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 27-28.

Return to footnote 3501 referrer

Footnote 3502

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 63.

Return to footnote 3502 referrer

Footnote 3503

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 237.

Return to footnote 3503 referrer

Footnote 3504

Exhibit P-147, tab 1, doc. 1422, pp. 118-120.

Return to footnote 3504 referrer

Footnote 3505

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, pp. 3-4.

Return to footnote 3505 referrer

Footnote 3506

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, pp. 3-4.

Return to footnote 3506 referrer

Footnote 3507

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 1.

Return to footnote 3507 referrer

Footnote 3508

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 5.

Return to footnote 3508 referrer

Footnote 3509

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, p. 5.

Return to footnote 3509 referrer

Footnote 3510

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 47, 49-54, 92-93 and 124.

Return to footnote 3510 referrer

Footnote 3511

Exhibit P-147, doc. 1422, p. 73.

Return to footnote 3511 referrer

Footnote 3512

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B.

Return to footnote 3512 referrer

Footnote 3513

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 474-475; Exhibit P-4, Collection D, vol. 14, tab 1, doc. 1202, pp. 62-63.

Return to footnote 3513 referrer

Footnote 3514

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 474-477.

Return to footnote 3514 referrer

Footnote 3515

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 48-49.

Return to footnote 3515 referrer

Footnote 3516

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 48-49 and 119-120; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 475-478.

Return to footnote 3516 referrer

Footnote 3517

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 49 and 145-146; Exhibit P-6, Collection F, vol. 2, tab 4, doc. 1296, pp. 43-45.

Return to footnote 3517 referrer

Footnote 3518

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 144-146.

Return to footnote 3518 referrer

Footnote 3519

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 144.

Return to footnote 3519 referrer

Footnote 3520

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 50.

Return to footnote 3520 referrer

Footnote 3521

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 51-52.

Return to footnote 3521 referrer

Footnote 3522

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 49-52.

Return to footnote 3522 referrer

Footnote 3523

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 124.

Return to footnote 3523 referrer

Footnote 3524

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 57-58.

Return to footnote 3524 referrer

Footnote 3525

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 57.

Return to footnote 3525 referrer

Footnote 3526

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 124.

Return to footnote 3526 referrer

Footnote 3527

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 53.

Return to footnote 3527 referrer

Footnote 3528

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 59-61.

Return to footnote 3528 referrer

Footnote 3529

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 64.

Return to footnote 3529 referrer

Footnote 3530

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 66-68.

Return to footnote 3530 referrer

Footnote 3531

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 55.

Return to footnote 3531 referrer

Footnote 3532

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 64-66 and 83.

Return to footnote 3532 referrer

Footnote 3533

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 62-63.

Return to footnote 3533 referrer

Footnote 3534

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 192-193.

Return to footnote 3534 referrer

Footnote 3535

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 63.

Return to footnote 3535 referrer

Footnote 3536

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 64.

Return to footnote 3536 referrer

Footnote 3537

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 53-55.

Return to footnote 3537 referrer

Footnote 3538

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 92-93.

Return to footnote 3538 referrer

Footnote 3539

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 53-54.

Return to footnote 3539 referrer

Footnote 3540

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 56.

Return to footnote 3540 referrer

Footnote 3541

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 91.

Return to footnote 3541 referrer

Footnote 3542

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 46-47.

Return to footnote 3542 referrer

Footnote 3543

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 55.

Return to footnote 3543 referrer

Footnote 3544

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 47.

Return to footnote 3544 referrer

Footnote 3545

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 55.

Return to footnote 3545 referrer

Footnote 3546

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 46-47.

Return to footnote 3546 referrer

Footnote 3547

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 117.

Return to footnote 3547 referrer

Footnote 3548

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 117.

Return to footnote 3548 referrer

Footnote 3549

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 82-83.

Return to footnote 3549 referrer

Footnote 3550

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 95.

Return to footnote 3550 referrer

Footnote 3551

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 94.

Return to footnote 3551 referrer

Footnote 3552

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 115.

Return to footnote 3552 referrer

Footnote 3553

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 115-116.

Return to footnote 3553 referrer

Footnote 3554

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 116.

Return to footnote 3554 referrer

Footnote 3555

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 45-46.

Return to footnote 3555 referrer

Footnote 3556

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 130-131.

Return to footnote 3556 referrer

Footnote 3557

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 118-119.

Return to footnote 3557 referrer

Footnote 3558

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 108-110.

Return to footnote 3558 referrer

Footnote 3559

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 125-126.

Return to footnote 3559 referrer

Footnote 3560

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 14-16.

Return to footnote 3560 referrer

Footnote 3561

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 16.

Return to footnote 3561 referrer

Footnote 3562

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, pp. 127-128.

Return to footnote 3562 referrer

Footnote 3563

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 117.

Return to footnote 3563 referrer

Footnote 3564

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 127.

Return to footnote 3564 referrer

Footnote 3565

Criminal Code, R.S.C. 1985, c. C-46, s. 215(1)(c); s. 217; s. 219; and s. 220.

Return to footnote 3565 referrer

Footnote 3566

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, pp. 127-128.

Return to footnote 3566 referrer

Footnote 3567

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 128.

Return to footnote 3567 referrer

Footnote 3568

Section 4.5.4, CFNIS Interactions with the Fynes – 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3568 referrer

Footnote 3569

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42.

Return to footnote 3569 referrer

Footnote 3570

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42.

Return to footnote 3570 referrer

Footnote 3571

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42.

Return to footnote 3571 referrer

Footnote 3572

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42.

Return to footnote 3572 referrer

Footnote 3573

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42.

Return to footnote 3573 referrer

Footnote 3574

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 42-43.

Return to footnote 3574 referrer

Footnote 3575

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 130.

Return to footnote 3575 referrer

Footnote 3576

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 160.

Return to footnote 3576 referrer

Footnote 3577

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 163-164.

Return to footnote 3577 referrer

Footnote 3578

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 164-165.

Return to footnote 3578 referrer

Footnote 3579

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 165.

Return to footnote 3579 referrer

Footnote 3580

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 39-40, 114, 143-144 and 167-168.

Return to footnote 3580 referrer

Footnote 3581

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 167-168.

Return to footnote 3581 referrer

Footnote 3582

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 143-144 (Maj Dandurand) and 176 (MCpl Mitchell).

Return to footnote 3582 referrer

Footnote 3583

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 131-132.

Return to footnote 3583 referrer

Footnote 3584

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 133-134.

Return to footnote 3584 referrer

Footnote 3585

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 77.

Return to footnote 3585 referrer

Footnote 3586

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 142.

Return to footnote 3586 referrer

Footnote 3587

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 178.

Return to footnote 3587 referrer

Footnote 3588

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 170-171.

Return to footnote 3588 referrer

Footnote 3589

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 132-134, 158-160, 163-166, 170-171 and 173-174.

Return to footnote 3589 referrer

Footnote 3590

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 128-129.

Return to footnote 3590 referrer

Footnote 3591

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 42-43, 130-131 and 133-134.

Return to footnote 3591 referrer

Footnote 3592

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 83-85 and 92-94.

Return to footnote 3592 referrer

Footnote 3593

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 83-85.

Return to footnote 3593 referrer

Footnote 3594

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 42-43 and 130-134.

Return to footnote 3594 referrer

Footnote 3595

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 231-232.

Return to footnote 3595 referrer

Footnote 3596

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 15-16 and 43-45.

Return to footnote 3596 referrer

Footnote 3597

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 43.

Return to footnote 3597 referrer

Footnote 3598

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 43-45.

Return to footnote 3598 referrer

Footnote 3599

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 5.

Return to footnote 3599 referrer

Footnote 3600

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 69.

Return to footnote 3600 referrer

Footnote 3601

Section 4.5.4, CFNIS Interactions with the Fynes – 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3601 referrer

Footnote 3602

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 142-144.

Return to footnote 3602 referrer

Footnote 3603

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 157-158.

Return to footnote 3603 referrer

Footnote 3604

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 144-145.

Return to footnote 3604 referrer

Footnote 3605

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 71.

Return to footnote 3605 referrer

Footnote 3606

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1024.

Return to footnote 3606 referrer

Footnote 3607

Exhibit P-147, tab 2, doc. 1423, pp. 142-143.

Return to footnote 3607 referrer

Footnote 3608

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 108-110.

Return to footnote 3608 referrer

Footnote 3609

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 113-114.

Return to footnote 3609 referrer

Footnote 3610

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 113-114.

Return to footnote 3610 referrer

Footnote 3611

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 108-111 and 113-114.

Return to footnote 3611 referrer

Footnote 3612

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 108-110 and 117-118.

Return to footnote 3612 referrer

Footnote 3613

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 108-109.

Return to footnote 3613 referrer

Footnote 3614

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 224-231.

Return to footnote 3614 referrer

Footnote 3615

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 230-231.

Return to footnote 3615 referrer

Footnote 3616

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 230-231.

Return to footnote 3616 referrer

Footnote 3617

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 232-233.

Return to footnote 3617 referrer

Footnote 3618

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 234-235.

Return to footnote 3618 referrer

Footnote 3619

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 145.

Return to footnote 3619 referrer

Footnote 3620

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 2-3.

Return to footnote 3620 referrer

Footnote 3621

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 45.

Return to footnote 3621 referrer

Footnote 3622

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 48-49.

Return to footnote 3622 referrer

Footnote 3623

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 50-52.

Return to footnote 3623 referrer

Footnote 3624

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 302-406.

Return to footnote 3624 referrer

Footnote 3625

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 591-593.

Return to footnote 3625 referrer

Footnote 3626

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 3-4.

Return to footnote 3626 referrer

Footnote 3627

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 19.

Return to footnote 3627 referrer

Footnote 3628

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 19-20.

Return to footnote 3628 referrer

Footnote 3629

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 95-97.

Return to footnote 3629 referrer

Footnote 3630

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 95-100.

Return to footnote 3630 referrer

Footnote 3631

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 166-168.

Return to footnote 3631 referrer

Footnote 3632

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 168-169.

Return to footnote 3632 referrer

Footnote 3633

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 169.

Return to footnote 3633 referrer

Footnote 3634

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 169-170.

Return to footnote 3634 referrer

Footnote 3635

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 170.

Return to footnote 3635 referrer

Footnote 3636

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 170-171.

Return to footnote 3636 referrer

Footnote 3637

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 204-210.

Return to footnote 3637 referrer

Footnote 3638

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 145-146; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 8-9 and 12-13.

Return to footnote 3638 referrer

Footnote 3639

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 22-23.

Return to footnote 3639 referrer

Footnote 3640

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 184.

Return to footnote 3640 referrer

Footnote 3641

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 10-11.

Return to footnote 3641 referrer

Footnote 3642

National Defence Act, RSC 1985, c N-5, s. 2, “Code of Service Discipline”; Part III, ss. 55 to 249.26.

Return to footnote 3642 referrer

Footnote 3643

National Defence Act, RSC 1985, c N-5, s. 124.

Return to footnote 3643 referrer

Footnote 3644

National Defence Act, RSC 1985, c N-5, s. 129(1).

Return to footnote 3644 referrer

Footnote 3645

Exhibit P-163, doc. 1445, pp. 4-5.

Return to footnote 3645 referrer

Footnote 3646

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 71; Testimony of Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 97-98.

Return to footnote 3646 referrer

Footnote 3647

Section 2.0, The Hearing Process.

Return to footnote 3647 referrer

Footnote 3648

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 118-119.

Return to footnote 3648 referrer

Footnote 3649

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 118-119.

Return to footnote 3649 referrer

Footnote 3650

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 129-130.

Return to footnote 3650 referrer

Footnote 3651

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 231-232.

Return to footnote 3651 referrer

Footnote 3652

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 231.

Return to footnote 3652 referrer

Footnote 3653

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 231-232.

Return to footnote 3653 referrer

Footnote 3654

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 183-185; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 1-4.

Return to footnote 3654 referrer

Footnote 3655

Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death; Section 4.1.2, The 2008 Investigation – Investigating Negligence; Section 4.1.3, The 2008 Investigation –The Investigation Plan; Section 4.1.4, The 2008 Investigation – The Concluding Remarks; Section 4.1.5, The 2008 Investigation – Supervision and Recordkeeping; Section 4.1.9, The 2008 Investigation – The Consequences of Inexperience.

Return to footnote 3655 referrer

Footnote 3656

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 46-47 and 55.

Return to footnote 3656 referrer

Footnote 3657

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 182-184; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 42-43; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 125-126.

Return to footnote 3657 referrer

Footnote 3658

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 125-126.

Return to footnote 3658 referrer

Footnote 3659

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 125-126.

Return to footnote 3659 referrer

Footnote 3660

Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 3660 referrer

Footnote 3661

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 249.

Return to footnote 3661 referrer

Footnote 3662

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 124-126.

Return to footnote 3662 referrer

Footnote 3663

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 42-43 and 171.

Return to footnote 3663 referrer

Footnote 3664

Exhibit P-119, doc. 1396, p. 88.

Return to footnote 3664 referrer

Footnote 3665

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 200.

Return to footnote 3665 referrer

Footnote 3666

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 69.

Return to footnote 3666 referrer

Footnote 3667

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 200.

Return to footnote 3667 referrer

Footnote 3668

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 54.

Return to footnote 3668 referrer

Footnote 3669

Exhibit P-147, tab 2, doc. 1423, pp. 202-208.

Return to footnote 3669 referrer

Footnote 3670

Exhibit P-147, tab 2, doc. 1423, p. 205.

Return to footnote 3670 referrer

Footnote 3671

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 133-134 and 201.

Return to footnote 3671 referrer

Footnote 3672

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 192-193.

Return to footnote 3672 referrer

Footnote 3673

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 248.

Return to footnote 3673 referrer

Footnote 3674

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 233.

Return to footnote 3674 referrer

Footnote 3675

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 224.

Return to footnote 3675 referrer

Footnote 3676

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 97.

Return to footnote 3676 referrer

Footnote 3677

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1196; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 104-105.

Return to footnote 3677 referrer

Footnote 3678

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 104-105.

Return to footnote 3678 referrer

Footnote 3679

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1196; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 104-105.

Return to footnote 3679 referrer

Footnote 3680

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 105.

Return to footnote 3680 referrer

Footnote 3681

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 188-189.

Return to footnote 3681 referrer

Footnote 3682

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 97-98; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 171-172 and 269-270.

Return to footnote 3682 referrer

Footnote 3683

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 115-116.

Return to footnote 3683 referrer

Footnote 3684

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 138; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 127-128.

Return to footnote 3684 referrer

Footnote 3685

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 140-146.

Return to footnote 3685 referrer

Footnote 3686

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 147-151.

Return to footnote 3686 referrer

Footnote 3687

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 151.

Return to footnote 3687 referrer

Footnote 3688

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 115-116.

Return to footnote 3688 referrer

Footnote 3689

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 117-118.

Return to footnote 3689 referrer

Footnote 3690

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 117-118.

Return to footnote 3690 referrer

Footnote 3691

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 118.

Return to footnote 3691 referrer

Footnote 3692

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 76 and PDF pp. 117-152.

Return to footnote 3692 referrer

Footnote 3693

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 118.

Return to footnote 3693 referrer

Footnote 3694

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 119.

Return to footnote 3694 referrer

Footnote 3695

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 102-103.

Return to footnote 3695 referrer

Footnote 3696

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 115-117.

Return to footnote 3696 referrer

Footnote 3697

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 291-292.

Return to footnote 3697 referrer

Footnote 3698

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 119-121.

Return to footnote 3698 referrer

Footnote 3699

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1038-1039; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 119-121.

Return to footnote 3699 referrer

Footnote 3700

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 120.

Return to footnote 3700 referrer

Footnote 3701

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 120.

Return to footnote 3701 referrer

Footnote 3702

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 124.

Return to footnote 3702 referrer

Footnote 3703

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 187-189.

Return to footnote 3703 referrer

Footnote 3704

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 191-192.

Return to footnote 3704 referrer

Footnote 3705

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 189-190.

Return to footnote 3705 referrer

Footnote 3706

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 189-190.

Return to footnote 3706 referrer

Footnote 3707

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 192-194.

Return to footnote 3707 referrer

Footnote 3708

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 194.

Return to footnote 3708 referrer

Footnote 3709

R. v. Peterson, 2005 CanLII 37972 (ON CA), 201 CCC (3d) 220; 34 CR (6^th) 120; 203 OAC 364 (leave to appeal dismissed, 2006 CanLII 6167 (SCC)) at para. 34: “The phrase “necessaries of life” includes not only food, shelter, care, and medical attention necessary to sustain life but also appears to include protection of the person from harm: R. v. Popen, (1981), 60 C.C.C. (2d) 232 (Ont. C.A.) at 240. Thus, s. 215(1)(c) obligations are driven by the facts and the context of each case.”

Return to footnote 3709 referrer

Footnote 3710

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 128.

Return to footnote 3710 referrer

Footnote 3711

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 125.

Return to footnote 3711 referrer

Footnote 3712

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 127.

Return to footnote 3712 referrer

Footnote 3713

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 202.

Return to footnote 3713 referrer

Footnote 3714

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 202.

Return to footnote 3714 referrer

Footnote 3715

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 175-176.

Return to footnote 3715 referrer

Footnote 3716

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 202-203.

Return to footnote 3716 referrer

Footnote 3717

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 204.

Return to footnote 3717 referrer

Footnote 3718

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 204-205.

Return to footnote 3718 referrer

Footnote 3719

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 305 and 355-356.

Return to footnote 3719 referrer

Footnote 3720

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 205-206.

Return to footnote 3720 referrer

Footnote 3721

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 132.

Return to footnote 3721 referrer

Footnote 3722

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 129.

Return to footnote 3722 referrer

Footnote 3723

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 131.

Return to footnote 3723 referrer

Footnote 3724

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF p. 134.

Return to footnote 3724 referrer

Footnote 3725

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 210.

Return to footnote 3725 referrer

Footnote 3726

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 212-213.

Return to footnote 3726 referrer

Footnote 3727

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 212-213.

Return to footnote 3727 referrer

Footnote 3728

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 160-161.

Return to footnote 3728 referrer

Footnote 3729

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 162-163.

Return to footnote 3729 referrer

Footnote 3730

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 169.

Return to footnote 3730 referrer

Footnote 3731

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 173.

Return to footnote 3731 referrer

Footnote 3732

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 181.

Return to footnote 3732 referrer

Footnote 3733

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 102-103.

Return to footnote 3733 referrer

Footnote 3734

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 119-121.

Return to footnote 3734 referrer

Footnote 3735

Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 3735 referrer

Footnote 3736

Exhibit P-6, Collection F, vol. 1, tab 39, doc. 1186, p. 1.

Return to footnote 3736 referrer

Footnote 3737

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 183-186.

Return to footnote 3737 referrer

Footnote 3738

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 122 and 139.

Return to footnote 3738 referrer

Footnote 3739

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 122.

Return to footnote 3739 referrer

Footnote 3740

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 184-185.

Return to footnote 3740 referrer

Footnote 3741

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 183-186.

Return to footnote 3741 referrer

Footnote 3742

National Defence Act, R.S.C. 1985, c. N-5, s. 55-249.

Return to footnote 3742 referrer

Footnote 3743

National Defence Act, R.S.C. 1985, c. N-5, s. 156; Criminal Code, R.S.C. 1985, c.C-46, s.2; QR&O, 22.02, 107.02.

Return to footnote 3743 referrer

Footnote 3744

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 90-94.

Return to footnote 3744 referrer

Footnote 3745

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 105-107.

Return to footnote 3745 referrer

Footnote 3746

Exhibit P-147, tab 2, doc. 1423, pp. 142-453.

Return to footnote 3746 referrer

Footnote 3747

For general discussions of the principles applicable to the various offences, see R. v. F. (J.), [2008] 3 S.C.R. 215, paras. 7-11; R. v. Kazenelson, 2013 CarswellOnt 1765, 2013 ONCJ 63, 105 W.C.B. (2d) 132 (Ont S.C.J.); Military Justice in Action: Annotated National Defence Legislation, p. 261; Létourneau, Gilles and Drapeau, Michel, Canadian Military Law Annotated, (Toronto: Thomson Carswell, 2006), pp. 660-664; R. v. Brocklebank, 1996 CarswellNat 1888, 134 D.L.R. (4th) 377, 106 C.C.C. (3d) 234, 30 W.C.B. (2d) 564, 5 C.M.A.R. 390; R. v. Creighton, [1993] 3 S.C.R. 3, pp. 73-74; Exhibit P-162, doc. 1444; Exhibit P-96, tab 3, doc. 1381, pp. 146-147 and 156-160; Exhibit P-163, doc. 1445; R. v. MCpl Bona, 18/99 (SCM).

Return to footnote 3747 referrer

Footnote 3748

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 70.

Return to footnote 3748 referrer

Footnote 3749

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 113.

Return to footnote 3749 referrer

Footnote 3750

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 204-205.

Return to footnote 3750 referrer

Footnote 3751

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 205-206.

Return to footnote 3751 referrer

Footnote 3752

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 225-228; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1198; Exhibit P-147, tab 3, doc. 1424, p. 64; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, PDF pp. 1145-1149.

Return to footnote 3752 referrer

Footnote 3753

Return to footnote 3753 referrer

Footnote 3754

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, PDF pp. 1145-1149.

Return to footnote 3754 referrer

Footnote 3755

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, PDF pp. 1145-1149.

Return to footnote 3755 referrer

Footnote 3756

Section 4.4, The 2010 Criminal Negligence Investigation; Section 4.5.4, CFNIS Interactions with the Fynes – 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3756 referrer

Footnote 3757

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 236-237.

Return to footnote 3757 referrer

Footnote 3758

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 237-238.

Return to footnote 3758 referrer

Footnote 3759

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 238.

Return to footnote 3759 referrer

Footnote 3760

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 210-217.

Return to footnote 3760 referrer

Footnote 3761

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 238-240.

Return to footnote 3761 referrer

Footnote 3762

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 232-233.

Return to footnote 3762 referrer

Footnote 3763

Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 3763 referrer

Footnote 3764

Section 4.5.4, CFNIS Interactions with the Fynes – 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3764 referrer

Footnote 3765

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 484.

Return to footnote 3765 referrer

Footnote 3766

Exhibit P-4, Collection D, vol. 14, tab 1, doc. 1202, pp. 2-4.

Return to footnote 3766 referrer

Footnote 3767

Testimony of Dr. Bernard Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 53-55.

Return to footnote 3767 referrer

Footnote 3768

Testimony of Dr. Bernard Sowa, Transcript of Proceedings, vol. 4, 3 April 2012, pp. 53-58.

Return to footnote 3768 referrer

Footnote 3769

Exhibit P-5, Collection E, vol. 5, tab 9, doc. 1231, pp. 49-54.

Return to footnote 3769 referrer

Footnote 3770

Exhibit P-5, Collection E, vol. 5, tab 9, doc. 1231, p. 52.

Return to footnote 3770 referrer

Footnote 3771

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 180-181.

Return to footnote 3771 referrer

Footnote 3772

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 180-181.

Return to footnote 3772 referrer

Footnote 3773

Exhibit P-6, Collection F, vol. 1, tab 47, doc. 1194, p. 1.

Return to footnote 3773 referrer

Footnote 3774

Exhibit P-6, Collection F, vol. 1, tab 47, doc. 1194, p. 3 [Emphasis added].

Return to footnote 3774 referrer

Footnote 3775

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 63-64.

Return to footnote 3775 referrer

Footnote 3776

Exhibit P-6, Collection F, vol. 1, tab 47, doc. 1194, p. 2.

Return to footnote 3776 referrer

Footnote 3777

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 60-61.

Return to footnote 3777 referrer

Footnote 3778

Testimony of WO Hiscock, Transcript of Proceedings, vol. 8, 11 April 2012, pp. 16-20.

Return to footnote 3778 referrer

Footnote 3779

Exhibit P-6, Collection F, vol. 1, tab 47, doc. 1194, pp. 2-3.

Return to footnote 3779 referrer

Footnote 3780

Exhibit P-4, Collection D, vol. 4, tab 39, doc. 337, p. 2.

Return to footnote 3780 referrer

Footnote 3781

Testimony of Col Demers, Transcript of Proceedings, vol. 11, 17 April 2012, pp. 68-70.

Return to footnote 3781 referrer

Footnote 3782

Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 3782 referrer

Footnote 3783

Exhibit P-147, tab 2, doc. 1423, pp. 209-453.

Return to footnote 3783 referrer

Footnote 3784

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 227 [Translation].

Return to footnote 3784 referrer

Footnote 3785

Exhibit P-147, tab 2, doc. 1423, p. 310.

Return to footnote 3785 referrer

Footnote 3786

Section 4.5.4, CFNIS Interactions with the Fynes – 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 3786 referrer

Footnote 3787

Exhibit P-147, doc. 1422, pp. 118-120.

Return to footnote 3787 referrer

Footnote 3788

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 8, 9, 13, 26, 30, 32b), 32c) and 33.

Return to footnote 3788 referrer

Footnote 3789

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 104-105.

Return to footnote 3789 referrer

Footnote 3790

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 105.

Return to footnote 3790 referrer

Footnote 3791

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 105.

Return to footnote 3791 referrer

Footnote 3792

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 48.

Return to footnote 3792 referrer

Footnote 3793

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 96-97; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 50-51. See, generally, section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 3793 referrer

Footnote 3794

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 24.

Return to footnote 3794 referrer

Footnote 3795

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 22.

Return to footnote 3795 referrer

Footnote 3796

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 22.

Return to footnote 3796 referrer

Footnote 3797

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 51-52.

Return to footnote 3797 referrer

Footnote 3798

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 104-108 & 254.

Return to footnote 3798 referrer

Footnote 3799

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 109-112 & 256.

Return to footnote 3799 referrer

Footnote 3800

See section 4.1.1, The 2008 Investigation – Investigating the Sudden Death; Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 3800 referrer

Footnote 3801

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 23-24.

Return to footnote 3801 referrer

Footnote 3802

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 109.

Return to footnote 3802 referrer

Footnote 3803

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 77-78.

Return to footnote 3803 referrer

Footnote 3804

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 78-80.

Return to footnote 3804 referrer

Footnote 3805

Email from Geneviève Coutlée, Legal Counsel, MPCC, to Dominique Babin, Legal Counsel, DND/CFLA (30 April 2012 at 1532 hrs) subject: Disclosure Request.

Return to footnote 3805 referrer

Footnote 3806

See Email from Maj Tim Langlois, CFPM Legal Advisor, to Geneviève Coutlée, Legal Counsel, MPCC (4 May 2012 at 1551 hrs) subject: RE: Disclosure Request.

Return to footnote 3806 referrer

Footnote 3807

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 58-60 & 91-92.

Return to footnote 3807 referrer

Footnote 3808

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 52.

Return to footnote 3808 referrer

Footnote 3809

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 131.

Return to footnote 3809 referrer

Footnote 3810

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 131-132.

Return to footnote 3810 referrer

Footnote 3811

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 135-136.

Return to footnote 3811 referrer

Footnote 3812

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 137.

Return to footnote 3812 referrer

Footnote 3813

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 176.

Return to footnote 3813 referrer

Footnote 3814

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 175-176.

Return to footnote 3814 referrer

Footnote 3815

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 132 & 271-272.

Return to footnote 3815 referrer

Footnote 3816

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 272.

Return to footnote 3816 referrer

Footnote 3817

Exhibit P-1, Collection A, vol. 2, tab 12, doc. 001-Q; Testimony of CWO(Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 181-183.

Return to footnote 3817 referrer

Footnote 3818

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 16-17, 26 April 2012 & 7 May 2012; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42-43, 5-6 September 2012.

Return to footnote 3818 referrer

Footnote 3819

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 46.

Return to footnote 3819 referrer

Footnote 3820

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 52.

Return to footnote 3820 referrer

Footnote 3821

See Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012 & Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 200-206 & 207-212.

Return to footnote 3821 referrer

Footnote 3822

Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012, p. 59.

Return to footnote 3822 referrer

Footnote 3823

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001; Section 4.1, The 2008 Investigation.

Return to footnote 3823 referrer

Footnote 3824

See Exhibit P-6, Collection F, vol. 1, tab 36, doc. 1183; Exhibit P-183, tab 1, doc. 1461, p. 4; Exhibit P-183, tab 41, doc. 1501; Exhibit P-52, doc. 1349.

Return to footnote 3824 referrer

Footnote 3825

Exhibit P-6, Collection F, vol. 1, tab 36, doc. 1183, p. 2.

Return to footnote 3825 referrer

Footnote 3826

Exhibit P-6, Collection F, vol. 1, tab 36, doc. 1183, p. 3.

Return to footnote 3826 referrer

Footnote 3827

Exhibit P-52, doc. 1349.

Return to footnote 3827 referrer

Footnote 3828

Exhibit P-52, doc. 1349, s. 9.

Return to footnote 3828 referrer

Footnote 3829

See, generally, Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 3829 referrer

Footnote 3830

See Testimony of CWO(Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 272-273; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 72-73.

Return to footnote 3830 referrer

Footnote 3831

For a discussion of these issues, see Section 4.1.5, The 2008 Investigation – Supervision and Recordkeeping.

Return to footnote 3831 referrer

Footnote 3832

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 143-144 & 521. See, generally, Section 4.1.4, The 2008 Investigation – The Concluding Remarks; Section 4.1.5, The 2008 Investigation – Supervision and Recordkeeping.

Return to footnote 3832 referrer

Footnote 3833

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15.

Return to footnote 3833 referrer

Footnote 3834

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15.

Return to footnote 3834 referrer

Footnote 3835

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, pp. 50-51.

Return to footnote 3835 referrer

Footnote 3836

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15.

Return to footnote 3836 referrer

Footnote 3837

Testimony of S/Sgt Clark, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 202 & 267-268.

Return to footnote 3837 referrer

Footnote 3838

Testimony of Det. Insp. Olinyk, Transcript of Proceedings, vol. 44, 10 September 2012, p. 259.

Return to footnote 3838 referrer

Footnote 3839

Exhibit P-147, doc. 1423, p. 26. See, generally, Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 3839 referrer

Footnote 3840

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 390; Exhibit P-5, Collection E, vol. 5, tab 1, doc. 1223, p. 112; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 2.

Return to footnote 3840 referrer

Footnote 3841

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 15; Exhibit P-147, doc. 1422, p. 18.

Return to footnote 3841 referrer

Footnote 3842

Exhibit P-5, Collection E, vol. 4, tab 7, doc. 1214, p. 390; Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 347; Exhibit P-5, Collection E, vol. 4, tab 14, doc. 1221, pp. 32-33.

Return to footnote 3842 referrer

Footnote 3843

Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 15.

Return to footnote 3843 referrer

Footnote 3844

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 3844 referrer

Footnote 3845

Exhibit P-147, doc. 1422, pp. 13-14.

Return to footnote 3845 referrer

Footnote 3846

Exhibit P-147, doc. 1422, p. 13.

Return to footnote 3846 referrer

Footnote 3847

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 245-246.

Return to footnote 3847 referrer

Footnote 3848

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245

Return to footnote 3848 referrer

Footnote 3849

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 245.

Return to footnote 3849 referrer

Footnote 3850

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 225.

Return to footnote 3850 referrer

Footnote 3851

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 633.

Return to footnote 3851 referrer

Footnote 3852

Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, p. 227. See also Testimony of Maj Angell, Transcript of Proceedings, vol. 26, 23 May 2012, pp. 235-236.

Return to footnote 3852 referrer

Footnote 3853

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 18.

Return to footnote 3853 referrer

Footnote 3854

See Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 344-353; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, pp. 11-15; Exhibit P-147, doc. 1422, pp. 13-14.

Return to footnote 3854 referrer

Footnote 3855

See Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 344-353; Exhibit P-147, doc. 1422, p. 20 & Exhibit P-5, Collection E, vol. 4, tab 9, doc. 1216, pp. 35-45.

Return to footnote 3855 referrer

Footnote 3856

See Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 352-353.

Return to footnote 3856 referrer

Footnote 3857

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 446-447.

Return to footnote 3857 referrer

Footnote 3858

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 66-67.

Return to footnote 3858 referrer

Footnote 3859

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 63.

Return to footnote 3859 referrer

Footnote 3860

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 67-68.

Return to footnote 3860 referrer

Footnote 3861

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 52.

Return to footnote 3861 referrer

Footnote 3862

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 52.

Return to footnote 3862 referrer

Footnote 3863

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 19-20.

Return to footnote 3863 referrer

Footnote 3864

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 196-197; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 70.

Return to footnote 3864 referrer

Footnote 3865

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 70.

Return to footnote 3865 referrer

Footnote 3866

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 70-71.

Return to footnote 3866 referrer

Footnote 3867

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 47-48.

Return to footnote 3867 referrer

Footnote 3868

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 183-184. See, generally, Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 3868 referrer

Footnote 3869

Exhibit P-147, doc. 1422, p. 20.

Return to footnote 3869 referrer

Footnote 3870

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 71 & 74.

Return to footnote 3870 referrer

Footnote 3871

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 72.

Return to footnote 3871 referrer

Footnote 3872

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 3872 referrer

Footnote 3873

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 3873 referrer

Footnote 3874

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 3874 referrer

Footnote 3875

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(a).

Return to footnote 3875 referrer

Footnote 3876

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 19-20.

Return to footnote 3876 referrer

Footnote 3877

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 48.

Return to footnote 3877 referrer

Footnote 3878

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 19.

Return to footnote 3878 referrer

Footnote 3879

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 19.

Return to footnote 3879 referrer

Footnote 3880

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 18.

Return to footnote 3880 referrer

Footnote 3881

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 18.

Return to footnote 3881 referrer

Footnote 3882

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 17.

Return to footnote 3882 referrer

Footnote 3883

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 16.

Return to footnote 3883 referrer

Footnote 3884

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 48.

Return to footnote 3884 referrer

Footnote 3885

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 26.

Return to footnote 3885 referrer

Footnote 3886

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001.

Return to footnote 3886 referrer

Footnote 3887

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523.

Return to footnote 3887 referrer

Footnote 3888

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, p. 171. Compare to Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 256.

Return to footnote 3888 referrer

Footnote 3889

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 193-194, 249-253, 533-563, 566-583, 590-610, 611-613, 614-616 & 620-622 vs Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, which contains none of these entries.

Return to footnote 3889 referrer

Footnote 3890

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 2-7, 11-20, 47-117, 119-125, 127-128, 132-133, 525 & 527-532 vs Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, which contains none of these notes.

Return to footnote 3890 referrer

Footnote 3891

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, p. 434 (the file copy ends with the Concluding Remarks) vs Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-714 (the file ends with extensive clearance information related to each of the items seized or generated during the investigation).

Return to footnote 3891 referrer

Footnote 3892

See Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, pp. 66-88 vs Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 161-173.

Return to footnote 3892 referrer

Footnote 3893

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 141.

Return to footnote 3893 referrer

Footnote 3894

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, p. 57.

Return to footnote 3894 referrer

Footnote 3895

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 15.

Return to footnote 3895 referrer

Footnote 3896

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 26-27 & 28.

Return to footnote 3896 referrer

Footnote 3897

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 16.

Return to footnote 3897 referrer

Footnote 3898

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 16.

Return to footnote 3898 referrer

Footnote 3899

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 16.

Return to footnote 3899 referrer

Footnote 3900

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 15-16.

Return to footnote 3900 referrer

Footnote 3901

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 15-16.

Return to footnote 3901 referrer

Footnote 3902

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 15.

Return to footnote 3902 referrer

Footnote 3903

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 15.

Return to footnote 3903 referrer

Footnote 3904

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 15.

Return to footnote 3904 referrer

Footnote 3905

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 15.

Return to footnote 3905 referrer

Footnote 3906

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 15.

Return to footnote 3906 referrer

Footnote 3907

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 14.

Return to footnote 3907 referrer

Footnote 3908

Exhibit P-138, tab 1, doc. 1403, p. 17.

Return to footnote 3908 referrer

Footnote 3909

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 13.

Return to footnote 3909 referrer

Footnote 3910

R.S.C., 1985, c. P-21.

Return to footnote 3910 referrer

Footnote 3911

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 13.

Return to footnote 3911 referrer

Footnote 3912

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 12 [emphasis in original].

Return to footnote 3912 referrer

Footnote 3913

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 13.

Return to footnote 3913 referrer

Footnote 3914

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 27.

Return to footnote 3914 referrer

Footnote 3915

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, p. 9.

Return to footnote 3915 referrer

Footnote 3916

See Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 3916 referrer

Footnote 3917

Exhibit P-5, Collection E, vol. 4, tab 14, doc. 1221, p. 4.

Return to footnote 3917 referrer

Footnote 3918

Exhibit P-5, Collection E, vol. 4, tab 14, doc. 1221, pp. 3-4.

Return to footnote 3918 referrer

Footnote 3919

Exhibit P-5, Collection E, vol. 4, tab 14, doc. 1221, p. 3.

Return to footnote 3919 referrer

Footnote 3920

Exhibit P-5, Collection E, vol. 4, tab 14, doc. 1221, pp. 1-3.

Return to footnote 3920 referrer

Footnote 3921

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, pp. 9-10.

Return to footnote 3921 referrer

Footnote 3922

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, p. 10.

Return to footnote 3922 referrer

Footnote 3923

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, p. 10.

Return to footnote 3923 referrer

Footnote 3924

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, p. 8.

Return to footnote 3924 referrer

Footnote 3925

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, p. 8.

Return to footnote 3925 referrer

Footnote 3926

Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, pp. 6-7.

Return to footnote 3926 referrer

Footnote 3927

Exhibit P-4, Collection D, vol. 9, tab 84, doc. 808.

Return to footnote 3927 referrer

Footnote 3928

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 48-49.

Return to footnote 3928 referrer

Footnote 3929

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 28.

Return to footnote 3929 referrer

Footnote 3930

See Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524. The document contains 514 pages in total, of which 38 are redacted in full.

Return to footnote 3930 referrer

Footnote 3931

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 108-109, 164-166, 445-475, 478-494, 501-513, 522-527 & 531-533.

Return to footnote 3931 referrer

Footnote 3932

A copy of the Evidence Collection Log was included: Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 80-82, but the clearance information about the chain of custody and disposal of the exhibits remained redacted: Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 534-578 vs Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-714.

Return to footnote 3932 referrer

Footnote 3933

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 57.

Return to footnote 3933 referrer

Footnote 3934

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 2-7, 11-20, 47-117, 119-125, 127-128, 132-133 & 527-532 vs Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, which contains none of these notes.

Return to footnote 3934 referrer

Footnote 3935

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 171.

Return to footnote 3935 referrer

Footnote 3936

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 151 vs Exhibit P-139, tab 3, doc. 1409, p. 151, redacted on grounds that the information was obtained in confidence from a provincial institution and was obtained by a law enforcement institution: Privacy Act, R.S.C., 1985, c. P-21, s. 19(1)(c) & 22.

Return to footnote 3936 referrer

Footnote 3937

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 152-154, 156-159, 170, 172 & 192 vs Exhibit P-139, tab 3, doc. 1409, pp. 152-154, 156-159, 170, 172 & 192 redacted on ground that the information was prepared by a law enforcement body in the course of an investigation: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 3937 referrer

Footnote 3938

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 178-182 vs Exhibit P-139, tab 3, doc. 1409, pp. 178-180, redacted on ground that the information was prepared by a law enforcement body in the course of an investigation: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 3938 referrer

Footnote 3939

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 178-182 vs Exhibit P-139, tab 3, doc. 1409, p. 181, redacted on ground that the information was prepared by a law enforcement body in the course of an investigation: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 3939 referrer

Footnote 3940

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 164 vs Exhibit P-139, tab 3, doc. 1409, p. 164.

Return to footnote 3940 referrer

Footnote 3941

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 413-417, 419-426 & 534-578 vs Exhibit P-139, tab 3, doc. 1409, pp. 413-414, 419-425 & 534-535, redacted on ground that the information was prepared or obtained by a law enforcement body in the course of an investigation: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 3941 referrer

Footnote 3942

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 413-417 vs Exhibit P-139, tab 3, doc. 1409, pp. 416-417, redacted on ground that the information was prepared or obtained by a law enforcement body in the course of an investigation: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 3942 referrer

Footnote 3943

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 419-426 & 431 vs Exhibit P-139, tab 3, doc. 1409, p. 426 & Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517, redacted on grounds that the information was prepared or obtained by a law enforcement body in the course of an investigation and/or was personal information about an individual other than the person requesting the information: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a) & 26.

Return to footnote 3943 referrer

Footnote 3944

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 436 vs Exhibit P-139, tab 3, doc. 1409, p. 436, redacted on ground that the information was prepared or obtained by a law enforcement body in the course of an investigation: Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 3944 referrer

Footnote 3945

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 98-99.

Return to footnote 3945 referrer

Footnote 3946

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B.

Return to footnote 3946 referrer

Footnote 3947

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 14-16; Exhibit P-138, tab 1, doc. 1403, p. 17; Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, pp. 8-9.

Return to footnote 3947 referrer

Footnote 3948

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 98.

Return to footnote 3948 referrer

Footnote 3949

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 101-102.

Return to footnote 3949 referrer

Footnote 3950

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 104.

Return to footnote 3950 referrer

Footnote 3951

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 122-123.

Return to footnote 3951 referrer

Footnote 3952

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 107-108.

Return to footnote 3952 referrer

Footnote 3953

Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, pp. 63-71. See also, Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 3953 referrer

Footnote 3954

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 7-8 & 10-11.

Return to footnote 3954 referrer

Footnote 3955

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 11-12; Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 75.

Return to footnote 3955 referrer

Footnote 3956

See Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523 & tab 25, doc. 524.

Return to footnote 3956 referrer

Footnote 3957

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001.

Return to footnote 3957 referrer

Footnote 3958

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 76-78.

Return to footnote 3958 referrer

Footnote 3959

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 519 & 522.

Return to footnote 3959 referrer

Footnote 3960

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 2-7, 11-20, 47-117, 119-125, 127-128, 132-133 & 527-532 vs Exhibit P-139, tab 3, doc. 1409, which is the copy of the file as received by DAIP, and which contains only some of the notes, all redacted in full: pp. 2-7 & 11-20.

Return to footnote 3960 referrer

Footnote 3961

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-714 vs Exhibit P-139, tab 3, doc. 1409, pp. 537-578.

Return to footnote 3961 referrer

Footnote 3962

Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 164-165.

Return to footnote 3962 referrer

Footnote 3963

Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 154-155.

Return to footnote 3963 referrer

Footnote 3964

Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 156-157.

Return to footnote 3964 referrer

Footnote 3965

Exhibit P-139, tab 3, doc. 1409, pp. 2-8, 11-23, 25 & 431; Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 161-162.

Return to footnote 3965 referrer

Footnote 3966

Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, p. 157.

Return to footnote 3966 referrer

Footnote 3967

Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, p. 157.

Return to footnote 3967 referrer

Footnote 3968

Exhibit P-158, tab 1, doc. 1432, pp. 26, 29, 59, 60 & 84.

Return to footnote 3968 referrer

Footnote 3969

Testimony of Sgt Bomback-Fortin and Mr. Beaulieu, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 157-158.

Return to footnote 3969 referrer

Footnote 3970

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 99-100; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 74-75; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 183-184.

Return to footnote 3970 referrer

Footnote 3971

Testimony of Sgt Bomback-Fortin and Mr. Beaulieu, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 159-160.

Return to footnote 3971 referrer

Footnote 3972

See Exhibit P-140, tab 4, doc. 1413, p. 1; Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 163-164; Exhibit P-146, tab 6, doc. 1420, pp. 540-623 vs Exhibit P-139, tab 3, doc. 1409, pp. 537-578.

Return to footnote 3972 referrer

Footnote 3973

Testimony of Sgt Bomback-Fortin, Transcript of Proceedings, vol. 40, 26 June 2012, pp. 162-163.

Return to footnote 3973 referrer

Footnote 3974

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 7.

Return to footnote 3974 referrer

Footnote 3975

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 7.

Return to footnote 3975 referrer

Footnote 3976

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 8-9, 10, 12-13.

Return to footnote 3976 referrer

Footnote 3977

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 14-15.

Return to footnote 3977 referrer

Footnote 3978

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 15-16.

Return to footnote 3978 referrer

Footnote 3979

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 15.

Return to footnote 3979 referrer

Footnote 3980

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 16-17.

Return to footnote 3980 referrer

Footnote 3981

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 17.

Return to footnote 3981 referrer

Footnote 3982

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 18-20 & 54; Exhibit P-4, Collection D, vol. 9, tab 85, doc. 809.

Return to footnote 3982 referrer

Footnote 3983

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 20.

Return to footnote 3983 referrer

Footnote 3984

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 22-23.

Return to footnote 3984 referrer

Footnote 3985

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 35-36.

Return to footnote 3985 referrer

Footnote 3986

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 44-45.

Return to footnote 3986 referrer

Footnote 3987

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 70-71.

Return to footnote 3987 referrer

Footnote 3988

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 76-78.

Return to footnote 3988 referrer

Footnote 3989

Exhibit P-4, Collection D, vol. 9, tab 85, doc. 809. See also Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 54-55.

Return to footnote 3989 referrer

Footnote 3990

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 75-76.

Return to footnote 3990 referrer

Footnote 3991

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 76-77.

Return to footnote 3991 referrer

Footnote 3992

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 184-185.

Return to footnote 3992 referrer

Footnote 3993

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 185.

Return to footnote 3993 referrer

Footnote 3994

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 185-186.

Return to footnote 3994 referrer

Footnote 3995

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 54-55.

Return to footnote 3995 referrer

Footnote 3996

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 55.

Return to footnote 3996 referrer

Footnote 3997

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 186.

Return to footnote 3997 referrer

Footnote 3998

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 78.

Return to footnote 3998 referrer

Footnote 3999

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 63-64.

Return to footnote 3999 referrer

Footnote 4000

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 82-83.

Return to footnote 4000 referrer

Footnote 4001

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 78.

Return to footnote 4001 referrer

Footnote 4002

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 83-84.

Return to footnote 4002 referrer

Footnote 4003

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 84.

Return to footnote 4003 referrer

Footnote 4004

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 84.

Return to footnote 4004 referrer

Footnote 4005

Exhibit P-138, tab 1, doc. 1403, p. 15.

Return to footnote 4005 referrer

Footnote 4006

Exhibit P-138, tab 1, doc. 1403, p. 15.

Return to footnote 4006 referrer

Footnote 4007

Exhibit P-138, tab 1, doc. 1403, p. 15.

Return to footnote 4007 referrer

Footnote 4008

Exhibit P-138, tab 1, doc. 1403, p. 14.

Return to footnote 4008 referrer

Footnote 4009

Exhibit P-138, tab 1, doc. 1403, p. 14.

Return to footnote 4009 referrer

Footnote 4010

Exhibit P-138, tab 1, doc. 1403, p. 14.

Return to footnote 4010 referrer

Footnote 4011

Exhibit P-138, tab 1, doc. 1403, p. 17.

Return to footnote 4011 referrer

Footnote 4012

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 29.

Return to footnote 4012 referrer

Footnote 4013

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 91.

Return to footnote 4013 referrer

Footnote 4014

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 99-100.

Return to footnote 4014 referrer

Footnote 4015

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 74.

Return to footnote 4015 referrer

Footnote 4016

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 74-75.

Return to footnote 4016 referrer

Footnote 4017

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 183-184.

Return to footnote 4017 referrer

Footnote 4018

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 57.

Return to footnote 4018 referrer

Footnote 4019

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 62-65.

Return to footnote 4019 referrer

Footnote 4020

Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 73.

Return to footnote 4020 referrer

Footnote 4021

Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 73-74.

Return to footnote 4021 referrer

Footnote 4022

Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 73-74.

Return to footnote 4022 referrer

Footnote 4023

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 21.

Return to footnote 4023 referrer

Footnote 4024

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 21.

Return to footnote 4024 referrer

Footnote 4025

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, p. 57.

Return to footnote 4025 referrer

Footnote 4026

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 33.

Return to footnote 4026 referrer

Footnote 4027

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 33.

Return to footnote 4027 referrer

Footnote 4028

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 34.

Return to footnote 4028 referrer

Footnote 4029

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, p. 13.

Return to footnote 4029 referrer

Footnote 4030

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 33.

Return to footnote 4030 referrer

Footnote 4031

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 22-23 & 34.

Return to footnote 4031 referrer

Footnote 4032

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 22-23.

Return to footnote 4032 referrer

Footnote 4033

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 26-27 & 28; Exhibit P-2, collection B, vol. 2, tab 1, doc. 1087-B, pp. 104-106.

Return to footnote 4033 referrer

Footnote 4034

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 102-103.

Return to footnote 4034 referrer

Footnote 4035

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 143 & 187.

Return to footnote 4035 referrer

Footnote 4036

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 143-144 & 187.

Return to footnote 4036 referrer

Footnote 4037

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 39-41 & 43.

Return to footnote 4037 referrer

Footnote 4038

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 42-43.

Return to footnote 4038 referrer

Footnote 4039

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 43-44.

Return to footnote 4039 referrer

Footnote 4040

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 49-50.

Return to footnote 4040 referrer

Footnote 4041

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 55-56.

Return to footnote 4041 referrer

Footnote 4042

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 49.

Return to footnote 4042 referrer

Footnote 4043

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 51.

Return to footnote 4043 referrer

Footnote 4044

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 50-51.

Return to footnote 4044 referrer

Footnote 4045

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 84.

Return to footnote 4045 referrer

Footnote 4046

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 144-145.

Return to footnote 4046 referrer

Footnote 4047

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 103-104.

Return to footnote 4047 referrer

Footnote 4048

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 24-25.

Return to footnote 4048 referrer

Footnote 4049

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 85.

Return to footnote 4049 referrer

Footnote 4050

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 171, paras d) & f) vs Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 256, paras d) & f).

Return to footnote 4050 referrer

Footnote 4051

See Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 171 & Privacy Act, R.S.C., 1985, c. P-21, s. 26.

Return to footnote 4051 referrer

Footnote 4052

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, p. 171 vs Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 256, paras c)-f).

Return to footnote 4052 referrer

Footnote 4053

Exhibit P-4, Collection D, vol. 6, tab 24, doc. 523, p. 171 & Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 4053 referrer

Footnote 4054

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 26-27.

Return to footnote 4054 referrer

Footnote 4055

Exhibit P-6, Collection F, vol. 1, tab 46, doc. 1193, p. 17, s. 37.

Return to footnote 4055 referrer

Footnote 4056

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 178-182 vs Exhibit P-139, tab 3, doc. 1409, pp. 178-180; Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 4056 referrer

Footnote 4057

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 164 vs Exhibit P-139, tab 3, doc. 1409, p. 164.

Return to footnote 4057 referrer

Footnote 4058

See Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 164 & Privacy Act, R.S.C., 1985, c. P-21, s. 26.

Return to footnote 4058 referrer

Footnote 4059

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, p. 436 vs Exhibit P-139, tab 3, doc. 1409, p. 436.

Return to footnote 4059 referrer

Footnote 4060

See Exhibit P-139, tab 3, doc. 1409, p. 436 & Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 4060 referrer

Footnote 4061

Exhibit P-4, Collection D, vol. 6, tab 25, doc. 524, pp. 534-578 vs Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-714; Privacy Act, R.S.C., 1985, c. P-21, s. 22(1)(a).

Return to footnote 4061 referrer

Footnote 4062

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 29.

Return to footnote 4062 referrer

Footnote 4063

Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 29-30.

Return to footnote 4063 referrer

Footnote 4064

See: Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4064 referrer

Footnote 4065

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B.

Return to footnote 4065 referrer

Footnote 4066

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 86.

Return to footnote 4066 referrer

Footnote 4067

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 141.

Return to footnote 4067 referrer

Footnote 4068

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1201; see also Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 142.

Return to footnote 4068 referrer

Footnote 4069

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 145-146.

Return to footnote 4069 referrer

Footnote 4070

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 142-143.

Return to footnote 4070 referrer

Footnote 4071

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 143.

Return to footnote 4071 referrer

Footnote 4072

Exhibit P-147, tab 2, doc. 1423, p. 28.

Return to footnote 4072 referrer

Footnote 4073

Exhibit P-147, tab 2, doc. 1423, p. 28.

Return to footnote 4073 referrer

Footnote 4074

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 36.

Return to footnote 4074 referrer

Footnote 4075

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 36.

Return to footnote 4075 referrer

Footnote 4076

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 36.

Return to footnote 4076 referrer

Footnote 4077

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 36-37.

Return to footnote 4077 referrer

Footnote 4078

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 38-39.

Return to footnote 4078 referrer

Footnote 4079

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 86.

Return to footnote 4079 referrer

Footnote 4080

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 86.

Return to footnote 4080 referrer

Footnote 4081

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 16 & 19; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 74 & 85-86; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 29-30.

Return to footnote 4081 referrer

Footnote 4082

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 70. See, generally, Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact.

Return to footnote 4082 referrer

Footnote 4083

Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 16 & 19.

Return to footnote 4083 referrer

Footnote 4084

See Exhibit P-5, Collection E, vol. 4, tab 13, doc. 1220, pp. 344-353; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 196-197.

Return to footnote 4084 referrer

Footnote 4085

Exhibit P-147, tab 1, doc. 1422, p. 33.

Return to footnote 4085 referrer

Footnote 4086

Exhibit P-147, tab 1, doc. 1422, p. 33.

Return to footnote 4086 referrer

Footnote 4087

Exhibit P-147, tab 1, doc. 1422, p. 33.

Return to footnote 4087 referrer

Footnote 4088

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 18.

Return to footnote 4088 referrer

Footnote 4089

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 33-50.

Return to footnote 4089 referrer

Footnote 4090

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 189-190.

Return to footnote 4090 referrer

Footnote 4091

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 9.

Return to footnote 4091 referrer

Footnote 4092

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 10-16.

Return to footnote 4092 referrer

Footnote 4093

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 35-36.

Return to footnote 4093 referrer

Footnote 4094

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 37.

Return to footnote 4094 referrer

Footnote 4095

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 8-9.

Return to footnote 4095 referrer

Footnote 4096

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 38.

Return to footnote 4096 referrer

Footnote 4097

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 189-190.

Return to footnote 4097 referrer

Footnote 4098

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 37-38.

Return to footnote 4098 referrer

Footnote 4099

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 129.

Return to footnote 4099 referrer

Footnote 4100

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 105.

Return to footnote 4100 referrer

Footnote 4101

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 131.

Return to footnote 4101 referrer

Footnote 4102

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 20-21, 188 & 190.

Return to footnote 4102 referrer

Footnote 4103

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 20-21.

Return to footnote 4103 referrer

Footnote 4104

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 151.

Return to footnote 4104 referrer

Footnote 4105

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 31-32.

Return to footnote 4105 referrer

Footnote 4106

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 172-173 & 228-229.

Return to footnote 4106 referrer

Footnote 4107

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 54-55.

Return to footnote 4107 referrer

Footnote 4108

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 54-55.

Return to footnote 4108 referrer

Footnote 4109

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 37.

Return to footnote 4109 referrer

Footnote 4110

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 174.

Return to footnote 4110 referrer

Footnote 4111

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 37.

Return to footnote 4111 referrer

Footnote 4112

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 37.

Return to footnote 4112 referrer

Footnote 4113

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 39-40.

Return to footnote 4113 referrer

Footnote 4114

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-714; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 41-42.

Return to footnote 4114 referrer

Footnote 4115

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 42.

Return to footnote 4115 referrer

Footnote 4116

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 44-45, 47 & 52-53. See also Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 630-713.

Return to footnote 4116 referrer

Footnote 4117

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 30; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 147; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332.

Return to footnote 4117 referrer

Footnote 4118

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B.

Return to footnote 4118 referrer

Footnote 4119

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 30.

Return to footnote 4119 referrer

Footnote 4120

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 14-19, 23-26, 35-37, 39-40, 48-58, 61-68, 70-74, 81-84 & 120-122.

Return to footnote 4120 referrer

Footnote 4121

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 46 & 49-50.

Return to footnote 4121 referrer

Footnote 4122

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 129-130, 132-135.

Return to footnote 4122 referrer

Footnote 4123

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 1, 77, 89-91, 92, 94-97 & 109.

Return to footnote 4123 referrer

Footnote 4124

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 4124 referrer

Footnote 4125

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 115-116. See also Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 11-15 & 123-129.

Return to footnote 4125 referrer

Footnote 4126

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 521.

Return to footnote 4126 referrer

Footnote 4127

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 520.

Return to footnote 4127 referrer

Footnote 4128

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 116-118. See also Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 11-15 & 123-129.

Return to footnote 4128 referrer

Footnote 4129

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 3-5, 7-8 & 96-97.

Return to footnote 4129 referrer

Footnote 4130

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 19.

Return to footnote 4130 referrer

Footnote 4131

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 30-32 & 134-135.

Return to footnote 4131 referrer

Footnote 4132

Exhibit P-147, tab 2, doc. 1423, p. 30.

Return to footnote 4132 referrer

Footnote 4133

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 68, 77-80 & 109.

Return to footnote 4133 referrer

Footnote 4134

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 31 & 135-136.

Return to footnote 4134 referrer

Footnote 4135

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 98-100 & 104-106. See Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4135 referrer

Footnote 4136

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 130-132.

Return to footnote 4136 referrer

Footnote 4137

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 135.

Return to footnote 4137 referrer

Footnote 4138

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 59-60.

Return to footnote 4138 referrer

Footnote 4139

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 129.

Return to footnote 4139 referrer

Footnote 4140

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 130-131.

Return to footnote 4140 referrer

Footnote 4141

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4141 referrer

Footnote 4142

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76-77, 88-89 & 93-97.

Return to footnote 4142 referrer

Footnote 4143

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76, 90 & 93.

Return to footnote 4143 referrer

Footnote 4144

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 76-77.

Return to footnote 4144 referrer

Footnote 4145

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 93-94 & 96.

Return to footnote 4145 referrer

Footnote 4146

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 94.

Return to footnote 4146 referrer

Footnote 4147

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 4-5 & 10-11.

Return to footnote 4147 referrer

Footnote 4148

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 9-10.

Return to footnote 4148 referrer

Footnote 4149

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death; Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 4149 referrer

Footnote 4150

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 9.

Return to footnote 4150 referrer

Footnote 4151

Exhibit P-5, Collection E, vol. 6, tab 28, doc. 1261, pp. 1 & 7; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 134.

Return to footnote 4151 referrer

Footnote 4152

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 68-69.

Return to footnote 4152 referrer

Footnote 4153

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 69.

Return to footnote 4153 referrer

Footnote 4154

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 69.

Return to footnote 4154 referrer

Footnote 4155

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 69-70.

Return to footnote 4155 referrer

Footnote 4156

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 648-649, 656-657, 658-660 & 662-663. See also Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 174.

Return to footnote 4156 referrer

Footnote 4157

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 82-83; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 174-175.

Return to footnote 4157 referrer

Footnote 4158

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 175-176; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 44, 46, 49-50, 53-54;

Return to footnote 4158 referrer

Footnote 4159

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 176

Return to footnote 4159 referrer

Footnote 4160

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 176-179. See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 516-517.

Return to footnote 4160 referrer

Footnote 4161

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 136.

Return to footnote 4161 referrer

Footnote 4162

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 98-100, 104-106 & 122-123; Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4162 referrer

Footnote 4163

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 104 & 122-123. See also, Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 129-130.

Return to footnote 4163 referrer

Footnote 4164

See Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4164 referrer

Footnote 4165

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1201.

Return to footnote 4165 referrer

Footnote 4166

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 110-111 & 137-138; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 198.

Return to footnote 4166 referrer

Footnote 4167

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 110-111.

Return to footnote 4167 referrer

Footnote 4168

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 125-126.

Return to footnote 4168 referrer

Footnote 4169

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 129.

Return to footnote 4169 referrer

Footnote 4170

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332.

Return to footnote 4170 referrer

Footnote 4171

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332.

Return to footnote 4171 referrer

Footnote 4172

Exhibit P-147, tab 2, doc. 1423, p. 30.

Return to footnote 4172 referrer

Footnote 4173

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 150.

Return to footnote 4173 referrer

Footnote 4174

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 87-88 & 102-103.

Return to footnote 4174 referrer

Footnote 4175

Exhibit P-147, tab 2, doc. 1423, p. 30.

Return to footnote 4175 referrer

Footnote 4176

Exhibit P-147, tab 2, doc. 1423, p. 30.

Return to footnote 4176 referrer

Footnote 4177

Exhibit P-147, tab 2, doc. 1423, p. 30.

Return to footnote 4177 referrer

Footnote 4178

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 202-203.

Return to footnote 4178 referrer

Footnote 4179

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-C.

Return to footnote 4179 referrer

Footnote 4180

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 519. See also Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 91.

Return to footnote 4180 referrer

Footnote 4181

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 204.

Return to footnote 4181 referrer

Footnote 4182

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 114-115.

Return to footnote 4182 referrer

Footnote 4183

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 522.

Return to footnote 4183 referrer

Footnote 4184

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 519.

Return to footnote 4184 referrer

Footnote 4185

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 40-41.

Return to footnote 4185 referrer

Footnote 4186

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 41-42.

Return to footnote 4186 referrer

Footnote 4187

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 42.

Return to footnote 4187 referrer

Footnote 4188

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 41, 44 & 73.

Return to footnote 4188 referrer

Footnote 4189

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 14-27.

Return to footnote 4189 referrer

Footnote 4190

Exhibit P-4, Collection D, vol. 1, tab 5, doc. 004; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 291; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 224-227; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 115-116.

Return to footnote 4190 referrer

Footnote 4191

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 32-36.

Return to footnote 4191 referrer

Footnote 4192

Exhibit P-161, doc. 1087-O.

Return to footnote 4192 referrer

Footnote 4193

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 32-36, 114 & 126-127; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 198-199. See also, Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4193 referrer

Footnote 4194

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 198-199.

Return to footnote 4194 referrer

Footnote 4195

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 109. See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4195 referrer

Footnote 4196

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 91-92 & 108-109.

Return to footnote 4196 referrer

Footnote 4197

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 109.

Return to footnote 4197 referrer

Footnote 4198

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 110.

Return to footnote 4198 referrer

Footnote 4199

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 110.

Return to footnote 4199 referrer

Footnote 4200

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 110-114 & 116.

Return to footnote 4200 referrer

Footnote 4201

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 199.

Return to footnote 4201 referrer

Footnote 4202

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 89-90 & 100.

Return to footnote 4202 referrer

Footnote 4203

Exhibit P-4, Collection D, vol. 1, tab 13, doc. 010-B, pp. 1-2; Exhibit P-4, Collection D, vol. 1, tab 10, doc. 009; Exhibit P-4, Collection D, vol. 1, tab 11, doc. 010. See, generally, Section 4.5.6, CFNIS Interactions with the Fynes – CFNIS Answers to the Col Blais Questions.

Return to footnote 4203 referrer

Footnote 4204

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 190-191.

Return to footnote 4204 referrer

Footnote 4205

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 190.

Return to footnote 4205 referrer

Footnote 4206

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 190.

Return to footnote 4206 referrer

Footnote 4207

Exhibit P-2, Collection B, vol. 2, tab 2, doc 1087-C, p. 158.

Return to footnote 4207 referrer

Footnote 4208

Exhibit P-4, Collection D, vol. 1, tab 13, doc. 010-B, p. 1; Exhibit P-4, Collection D, vol. 1, tab 10, doc. 009; Exhibit P-4, Collection D, vol. 1, tab 11, doc. 010. See, generally, Section 4.5.6, CFNIS Interactions with the Fynes – CFNIS Answers to the Col Blais Questions.

Return to footnote 4208 referrer

Footnote 4209

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 198.

Return to footnote 4209 referrer

Footnote 4210

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 60-61.

Return to footnote 4210 referrer

Footnote 4211

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 61.

Return to footnote 4211 referrer

Footnote 4212

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 74-80, 157-166 & 168-173; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 171.

Return to footnote 4212 referrer

Footnote 4213

National Defence Act, RSC 1985, c N-5, s. 250.21(1).

Return to footnote 4213 referrer

Footnote 4214

National Defence Act, RSC 1985, c N-5, s. 250.21(2).

Return to footnote 4214 referrer

Footnote 4215

National Defence Act, RSC 1985, c N-5, s. 250.26(1).

Return to footnote 4215 referrer

Footnote 4216

National Defence Act, RSC 1985, c N-5, s. 250.27(1).

Return to footnote 4216 referrer

Footnote 4217

National Defence Act, RSC 1985, c N-5, s. 250.28(2).

Return to footnote 4217 referrer

Footnote 4218

National Defence Act, RSC 1985, c N-5, ss. 250.28(1) & 250.29.

Return to footnote 4218 referrer

Footnote 4219

National Defence Act, RSC 1985, c N-5, s. 250.31(1).

Return to footnote 4219 referrer

Footnote 4220

National Defence Act, RSC 1985, c N-5, s. 250.38(1).

Return to footnote 4220 referrer

Footnote 4221

Exhibit P-173, doc. 1454, p. 4, s. 4.

Return to footnote 4221 referrer

Footnote 4222

Exhibit P-173, doc. 1454, p. 4, s. 4.

Return to footnote 4222 referrer

Footnote 4223

Exhibit P-173, doc. 1454, p. 8, s. 14 [Emphasis added].

Return to footnote 4223 referrer

Footnote 4224

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 220-221.

Return to footnote 4224 referrer

Footnote 4225

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 174-175 & Exhibit P-4, Collection D, vol. 13, tab 3, doc. 1150.

Return to footnote 4225 referrer

Footnote 4226

See Exhibit P-4, Collection D, vol. 13, tab 3, doc. 1150. See also Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 2, 3, 4, 5, 7, 13(a), 18, 26, 27 & 28.

Return to footnote 4226 referrer

Footnote 4227

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 215-216.

Return to footnote 4227 referrer

Footnote 4228

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 216.

Return to footnote 4228 referrer

Footnote 4229

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 216.

Return to footnote 4229 referrer

Footnote 4230

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 216.

Return to footnote 4230 referrer

Footnote 4231

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 218.

Return to footnote 4231 referrer

Footnote 4232

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 221-222.

Return to footnote 4232 referrer

Footnote 4233

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 217.

Return to footnote 4233 referrer

Footnote 4234

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 217.

Return to footnote 4234 referrer

Footnote 4235

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 87, 89 & 97-98.

Return to footnote 4235 referrer

Footnote 4236

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 100.

Return to footnote 4236 referrer

Footnote 4237

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 100.

Return to footnote 4237 referrer

Footnote 4238

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 100-102.

Return to footnote 4238 referrer

Footnote 4239

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 102.

Return to footnote 4239 referrer

Footnote 4240

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 102.

Return to footnote 4240 referrer

Footnote 4241

Exhibit P-2, Collection B, vol. 2, tab 2, pp. 156-159.

Return to footnote 4241 referrer

Footnote 4242

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 157-158.

Return to footnote 4242 referrer

Footnote 4243

Exhibit P-2, Collection B, vol. 2, tab 2, pp. 157-158.

Return to footnote 4243 referrer

Footnote 4244

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 135-136.

Return to footnote 4244 referrer

Footnote 4245

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 213.

Return to footnote 4245 referrer

Footnote 4246

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 10.

Return to footnote 4246 referrer

Footnote 4247

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 96-97.

Return to footnote 4247 referrer

Footnote 4248

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 96-97.

Return to footnote 4248 referrer

Footnote 4249

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 97.

Return to footnote 4249 referrer

Footnote 4250

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 138.

Return to footnote 4250 referrer

Footnote 4251

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 212.

Return to footnote 4251 referrer

Footnote 4252

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 73; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 17, 196-201 & 230-231.

Return to footnote 4252 referrer

Footnote 4253

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 90.

Return to footnote 4253 referrer

Footnote 4254

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 94-96.

Return to footnote 4254 referrer

Footnote 4255

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 206.

Return to footnote 4255 referrer

Footnote 4256

Exhibit P-2, Collection B, vol. 2, tab 5, doc. 1087-F, pp. 44-47.

Return to footnote 4256 referrer

Footnote 4257

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 136.

Return to footnote 4257 referrer

Footnote 4258

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 116-118.

Return to footnote 4258 referrer

Footnote 4259

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 115-116.

Return to footnote 4259 referrer

Footnote 4260

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 522.

Return to footnote 4260 referrer

Footnote 4261

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 3.

Return to footnote 4261 referrer

Footnote 4262

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 200.

Return to footnote 4262 referrer

Footnote 4263

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 296-297.

Return to footnote 4263 referrer

Footnote 4264

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 296.

Return to footnote 4264 referrer

Footnote 4265

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 202.

Return to footnote 4265 referrer

Footnote 4266

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 121.

Return to footnote 4266 referrer

Footnote 4267

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 166.

Return to footnote 4267 referrer

Footnote 4268

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 18.

Return to footnote 4268 referrer

Footnote 4269

See Exhibit P-5, Collection E, vol. 6, tab 17, doc. 1250, p. 30; Testimony of CWO(ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 215.

Return to footnote 4269 referrer

Footnote 4270

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 109-110.

Return to footnote 4270 referrer

Footnote 4271

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 217-218.

Return to footnote 4271 referrer

Footnote 4272

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 101.

Return to footnote 4272 referrer

Footnote 4273

National Defence Act, RSC 1985, c N-5, s. 250.28(2); Exhibit P-173, doc. 1454, p. 13, s. 27.

Return to footnote 4273 referrer

Footnote 4274

See, generally, Section 4.2 The Suicide Note Left by Cpl Langridge; Section 4.5.6, CFNIS Interactions with the Fynes – CFNIS Answers to the Col Blais Questions.

Return to footnote 4274 referrer

Footnote 4275

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4275 referrer

Footnote 4276

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 333.

Return to footnote 4276 referrer

Footnote 4277

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332.

Return to footnote 4277 referrer

Footnote 4278

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 332.

Return to footnote 4278 referrer

Footnote 4279

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 171-172.

Return to footnote 4279 referrer

Footnote 4280

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 206-207 & 209.

Return to footnote 4280 referrer

Footnote 4281

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 205-207 & 208-209.

Return to footnote 4281 referrer

Footnote 4282

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 519 [Emphasis added].

Return to footnote 4282 referrer

Footnote 4283

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 40; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 214-215; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 46.

Return to footnote 4283 referrer

Footnote 4284

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 263-264; Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death; Section 4.1.2, The 2008 Investigation – Investigating Negligence; Section 4.1.3, The 2008 Investigation – The Investigation Plan.

Return to footnote 4284 referrer

Footnote 4285

Final Submissions of the subjects of the complaint, pp. 64-65.

Return to footnote 4285 referrer

Footnote 4286

Exhibit P-5, Collection E, vol. 6, tab 13, doc. 1246-B, p. 15.

Return to footnote 4286 referrer

Footnote 4287

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 79-81.

Return to footnote 4287 referrer

Footnote 4288

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 83.

Return to footnote 4288 referrer

Footnote 4289

See Exhibit P-119, doc. 1396, pp. 7 & 11-12.

Return to footnote 4289 referrer

Footnote 4290

Exhibit P-119, doc. 1396, p. 11.

Return to footnote 4290 referrer

Footnote 4291

Exhibit P-119, doc. 1396, p. 11.

Return to footnote 4291 referrer

Footnote 4292

Exhibit P-119, doc. 1396, p. 11.

Return to footnote 4292 referrer

Footnote 4293

Exhibit P-119, doc. 1396, p. 11.

Return to footnote 4293 referrer

Footnote 4294

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13.

Return to footnote 4294 referrer

Footnote 4295

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33.

Return to footnote 4295 referrer

Footnote 4296

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4296 referrer

Footnote 4297

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4297 referrer

Footnote 4298

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 291 and 294.

Return to footnote 4298 referrer

Footnote 4299

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 291 and 294. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 53-54.

Return to footnote 4299 referrer

Footnote 4300

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C.

Return to footnote 4300 referrer

Footnote 4301

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B; Exhibit P-4, Collection D, vol. 9, tab 75; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1023; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 125.

Return to footnote 4301 referrer

Footnote 4302

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13.

Return to footnote 4302 referrer

Footnote 4303

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 13(b), 13(d), 13(e), 30, 32(b) & 32(c).

Return to footnote 4303 referrer

Footnote 4304

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C.

Return to footnote 4304 referrer

Footnote 4305

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 5.

Return to footnote 4305 referrer

Footnote 4306

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 97.

Return to footnote 4306 referrer

Footnote 4307

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 101.

Return to footnote 4307 referrer

Footnote 4308

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 101.

Return to footnote 4308 referrer

Footnote 4309

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 116-118. See also Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 18-19.

Return to footnote 4309 referrer

Footnote 4310

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 117-118.

Return to footnote 4310 referrer

Footnote 4311

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 55-56.

Return to footnote 4311 referrer

Footnote 4312

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 55 and 57-58.

Return to footnote 4312 referrer

Footnote 4313

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 94-96.

Return to footnote 4313 referrer

Footnote 4314

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 51.

Return to footnote 4314 referrer

Footnote 4315

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 51.

Return to footnote 4315 referrer

Footnote 4316

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 17.

Return to footnote 4316 referrer

Footnote 4317

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 5-8.

Return to footnote 4317 referrer

Footnote 4318

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 24-26.

Return to footnote 4318 referrer

Footnote 4319

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 10.

Return to footnote 4319 referrer

Footnote 4320

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 174.

Return to footnote 4320 referrer

Footnote 4321

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 14.

Return to footnote 4321 referrer

Footnote 4322

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 51-52. See, generally, Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4322 referrer

Footnote 4323

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 42-43.

Return to footnote 4323 referrer

Footnote 4324

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 130.

Return to footnote 4324 referrer

Footnote 4325

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 163-165.

Return to footnote 4325 referrer

Footnote 4326

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 159-161.

Return to footnote 4326 referrer

Footnote 4327

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 131.

Return to footnote 4327 referrer

Footnote 4328

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 130.

Return to footnote 4328 referrer

Footnote 4329

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 133-134.

Return to footnote 4329 referrer

Footnote 4330

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 134.

Return to footnote 4330 referrer

Footnote 4331

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 170.

Return to footnote 4331 referrer

Footnote 4332

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087; Exhibit P-4, Collection D, vol. 9, tab 75, doc. 799; Exhibit P-4, Collection D, vol. 12, tab 75, doc. 1102; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 50-51.

Return to footnote 4332 referrer

Footnote 4333

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 38.

Return to footnote 4333 referrer

Footnote 4334

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 38.

Return to footnote 4334 referrer

Footnote 4335

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 39.

Return to footnote 4335 referrer

Footnote 4336

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 39.

Return to footnote 4336 referrer

Footnote 4337

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 39.

Return to footnote 4337 referrer

Footnote 4338

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 39 and 40-41.

Return to footnote 4338 referrer

Footnote 4339

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 39-41; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 53 and 57.

Return to footnote 4339 referrer

Footnote 4340

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 53 and 57.

Return to footnote 4340 referrer

Footnote 4341

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 57 [Emphasis added].

Return to footnote 4341 referrer

Footnote 4342

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 40-41.

Return to footnote 4342 referrer

Footnote 4343

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 168-169.

Return to footnote 4343 referrer

Footnote 4344

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 169.

Return to footnote 4344 referrer

Footnote 4345

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 114 [Emphasis added].

Return to footnote 4345 referrer

Footnote 4346

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 167.

Return to footnote 4346 referrer

Footnote 4347

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 167-168 [Emphasis added].

Return to footnote 4347 referrer

Footnote 4348

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 39-40.

Return to footnote 4348 referrer

Footnote 4349

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 40.

Return to footnote 4349 referrer

Footnote 4350

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 167.

Return to footnote 4350 referrer

Footnote 4351

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 168 [Emphasis added].

Return to footnote 4351 referrer

Footnote 4352

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 168.

Return to footnote 4352 referrer

Footnote 4353

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1025; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 72.

Return to footnote 4353 referrer

Footnote 4354

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1025.

Return to footnote 4354 referrer

Footnote 4355

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 72.

Return to footnote 4355 referrer

Footnote 4356

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1030-1031; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, pp. 73-74.

Return to footnote 4356 referrer

Footnote 4357

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1031; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 74.

Return to footnote 4357 referrer

Footnote 4358

Exhibit P-4, Collection D, vol. 9, tab 71, doc. 795, p. 1.

Return to footnote 4358 referrer

Footnote 4359

Exhibit P-4, Collection D, vol. 9, tab 71, doc. 795, p. 1.

Return to footnote 4359 referrer

Footnote 4360

Exhibit P-4, Collection D, vol. 12, tab 69, doc. 1096.

Return to footnote 4360 referrer

Footnote 4361

Exhibit P-4, Collection D, vol. 12, tab 69, doc. 1096.

Return to footnote 4361 referrer

Footnote 4362

Exhibit P-119, doc. 1396, pp. 88-89.

Return to footnote 4362 referrer

Footnote 4363

Exhibit P-119, doc. 1396, p. 88.

Return to footnote 4363 referrer

Footnote 4364

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 69.

Return to footnote 4364 referrer

Footnote 4365

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 200.

Return to footnote 4365 referrer

Footnote 4366

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 54.

Return to footnote 4366 referrer

Footnote 4367

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 54.

Return to footnote 4367 referrer

Footnote 4368

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 201; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1370.

Return to footnote 4368 referrer

Footnote 4369

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1370.

Return to footnote 4369 referrer

Footnote 4370

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 237-238.

Return to footnote 4370 referrer

Footnote 4371

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 238.

Return to footnote 4371 referrer

Footnote 4372

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 53.

Return to footnote 4372 referrer

Footnote 4373

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 53.

Return to footnote 4373 referrer

Footnote 4374

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 53; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 55-56; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095.

Return to footnote 4374 referrer

Footnote 4375

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 237.

Return to footnote 4375 referrer

Footnote 4376

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 237.

Return to footnote 4376 referrer

Footnote 4377

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 237.

Return to footnote 4377 referrer

Footnote 4378

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 237-238.

Return to footnote 4378 referrer

Footnote 4379

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 161; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 137.

Return to footnote 4379 referrer

Footnote 4380

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 161.

Return to footnote 4380 referrer

Footnote 4381

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 161.

Return to footnote 4381 referrer

Footnote 4382

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 244.

Return to footnote 4382 referrer

Footnote 4383

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 251.

Return to footnote 4383 referrer

Footnote 4384

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 244.

Return to footnote 4384 referrer

Footnote 4385

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 251-252 [Emphasis added].

Return to footnote 4385 referrer

Footnote 4386

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 243.

Return to footnote 4386 referrer

Footnote 4387

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 243.

Return to footnote 4387 referrer

Footnote 4388

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 243-244.

Return to footnote 4388 referrer

Footnote 4389

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 197-198.

Return to footnote 4389 referrer

Footnote 4390

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 197.

Return to footnote 4390 referrer

Footnote 4391

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 52; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 53.

Return to footnote 4391 referrer

Footnote 4392

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 52; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 237-238.

Return to footnote 4392 referrer

Footnote 4393

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 52 [Emphasis added].

Return to footnote 4393 referrer

Footnote 4394

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 268; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 27-28.

Return to footnote 4394 referrer

Footnote 4395

Exhibit P-6, Collection F, vol. 1, tab 36, doc. 1183, p. 3; Exhibit P-183, tab 42, doc. 1502, p. 1; Exhibit P-52, doc. 1349, p. 3. The current MP policy no longer requires contact to be made every 30 days, but continues to require “regular and continuous contact” be made to discuss assistance requirements and to provide updates: Exhibit P-183, tab 41, doc. 1501, p. 2. The CFNIS SOP remains unchanged: Exhibit P-183, tab 1, doc. 1461, p. 4.

Return to footnote 4395 referrer

Footnote 4396

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 58-60 and 91-92.

Return to footnote 4396 referrer

Footnote 4397

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 57-58.

Return to footnote 4397 referrer

Footnote 4398

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 237-238.

Return to footnote 4398 referrer

Footnote 4399

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 97 and 117-118; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 5-8 and 10; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 222-223, 1348-1350 and 1351-1357; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4399 referrer

Footnote 4400

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4400 referrer

Footnote 4401

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 101 and 116-118; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 174; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4401 referrer

Footnote 4402

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 5; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 5-8, 10 and 24-26; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4402 referrer

Footnote 4403

See Section 4.3, The 2009 PNOK Investigation; Exhibit P-70, doc. 1358, pp. 3-5; Exhibit P-103; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087.

Return to footnote 4403 referrer

Footnote 4404

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 101; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 17; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 32.

Return to footnote 4404 referrer

Footnote 4405

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 14 vs. Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 29-30 and Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4405 referrer

Footnote 4406

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 94-96 vs. Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 29-30 and Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 280-281.

Return to footnote 4406 referrer

Footnote 4407

See Section 4.3, The 2009 PNOK Investigation; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 32; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 134-135 and 153-154.

Return to footnote 4407 referrer

Footnote 4408

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 64-67.

Return to footnote 4408 referrer

Footnote 4409

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 64-65; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4409 referrer

Footnote 4410

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4410 referrer

Footnote 4411

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 84 and 88.

Return to footnote 4411 referrer

Footnote 4412

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4412 referrer

Footnote 4413

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 138.

Return to footnote 4413 referrer

Footnote 4414

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 126 and 138.

Return to footnote 4414 referrer

Footnote 4415

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 126; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 138.

Return to footnote 4415 referrer

Footnote 4416

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 126-129.

Return to footnote 4416 referrer

Footnote 4417

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, p. 138; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 151.

Return to footnote 4417 referrer

Footnote 4418

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 127-128.

Return to footnote 4418 referrer

Footnote 4419

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 137-138.

Return to footnote 4419 referrer

Footnote 4420

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 42-43, 133-134, 160 and 163-165; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4420 referrer

Footnote 4421

See Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4421 referrer

Footnote 4422

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 145-146.

Return to footnote 4422 referrer

Footnote 4423

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 149 [Emphasis added].

Return to footnote 4423 referrer

Footnote 4424

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 145-146 and 151-152.

Return to footnote 4424 referrer

Footnote 4425

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 130, 159-161 and 163-165; Section 4.4, The 2010 Criminal Negligence Investigation; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 145.

Return to footnote 4425 referrer

Footnote 4426

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 144-145, 152-153 and 157-158.

Return to footnote 4426 referrer

Footnote 4427

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 147, 151 and 288-289.

Return to footnote 4427 referrer

Footnote 4428

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 147-148 and 288-291.

Return to footnote 4428 referrer

Footnote 4429

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 289-291.

Return to footnote 4429 referrer

Footnote 4430

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 130-131 and 133-134.

Return to footnote 4430 referrer

Footnote 4431

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 23.

Return to footnote 4431 referrer

Footnote 4432

Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4432 referrer

Footnote 4433

See Section 4.4, The 2010 Criminal Negligence Investigation; Section 4.6, CFNIS Independence and Impartiality; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 224.

Return to footnote 4433 referrer

Footnote 4434

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 170; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 217.

Return to footnote 4434 referrer

Footnote 4435

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 232-233. See also pp. 217-218.

Return to footnote 4435 referrer

Footnote 4436

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1025 and 1031; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 41, 88-93 and 132-133; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 93.

Return to footnote 4436 referrer

Footnote 4437

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 68.

Return to footnote 4437 referrer

Footnote 4438

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 65-66.

Return to footnote 4438 referrer

Footnote 4439

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 92-94.

Return to footnote 4439 referrer

Footnote 4440

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 150; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 73.

Return to footnote 4440 referrer

Footnote 4441

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B.

Return to footnote 4441 referrer

Footnote 4442

See Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 72; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 237-238; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 54 and 57-58; Exhibit P-4, Collection D, vol. 13, tab 3, doc. 1150, p. 4.

Return to footnote 4442 referrer

Footnote 4443

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 55.

Return to footnote 4443 referrer

Footnote 4444

Exhibit P-4, Collection D, vol. 9, tab 71, doc. 795, p. 1.

Return to footnote 4444 referrer

Footnote 4445

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 23-24.

Return to footnote 4445 referrer

Footnote 4446

See Exhibit P-147, tab 2, doc. 1423, pp. 202-208; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4446 referrer

Footnote 4447

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 248.

Return to footnote 4447 referrer

Footnote 4448

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 227 [Translation].

Return to footnote 4448 referrer

Footnote 4449

Exhibit P-119, doc. 1396, pp. 88-89. Because Sgt Shannon had not yet been assigned to work on this investigation when he contacted Mrs. Fynes in September 2010, he could not have provided any information: Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 115 and 232; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4449 referrer

Footnote 4450

Exhibit P-119, doc. 1396, pp. 88-89; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 200; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 69 and 94.

Return to footnote 4450 referrer

Footnote 4451

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 70 and 94.

Return to footnote 4451 referrer

Footnote 4452

Exhibit P-4, Collection D, vol. 13, tab 3, doc. 1150, p. 4.

Return to footnote 4452 referrer

Footnote 4453

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 23-24.

Return to footnote 4453 referrer

Footnote 4454

See Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015.

Return to footnote 4454 referrer

Footnote 4455

Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 62-63.

Return to footnote 4455 referrer

Footnote 4456

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, p. 138.

Return to footnote 4456 referrer

Footnote 4457

Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 137-138.

Return to footnote 4457 referrer

Footnote 4458

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 23.

Return to footnote 4458 referrer

Footnote 4459

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 23-24.

Return to footnote 4459 referrer

Footnote 4460

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 24.

Return to footnote 4460 referrer

Footnote 4461

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095.

Return to footnote 4461 referrer

Footnote 4462

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 53-54.

Return to footnote 4462 referrer

Footnote 4463

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 54.

Return to footnote 4463 referrer

Footnote 4464

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095.

Return to footnote 4464 referrer

Footnote 4465

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 239-240.

Return to footnote 4465 referrer

Footnote 4466

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 54; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 239-240.

Return to footnote 4466 referrer

Footnote 4467

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 239-240.

Return to footnote 4467 referrer

Footnote 4468

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095.

Return to footnote 4468 referrer

Footnote 4469

Exhibit P-4, Collection D, vol. 12, tab 68, doc. 1095; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095.

Return to footnote 4469 referrer

Footnote 4470

Exhibit P-4, Collection D, vol. 12, tab 68, doc. 1095.

Return to footnote 4470 referrer

Footnote 4471

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(d). See also Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4471 referrer

Footnote 4472

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 50-54, 56, 83-84 and 88-90 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 165-166; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 106-107.

Return to footnote 4472 referrer

Footnote 4473

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 166-167; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 107-111; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, p. 52 [Translation]. See also Exhibit P-4, Collection D, vol. 1, tab 18, doc. 014, p. 2.

Return to footnote 4473 referrer

Footnote 4474

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, p. 88 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 166; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 108.

Return to footnote 4474 referrer

Footnote 4475

Exhibit P-4, Collection D, vol. 12, tab 68, doc. 1095.

Return to footnote 4475 referrer

Footnote 4476

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1096.

Return to footnote 4476 referrer

Footnote 4477

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1100.

Return to footnote 4477 referrer

Footnote 4478

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 30.

Return to footnote 4478 referrer

Footnote 4479

Exhibit P-2, Collection B, vol. 1, doc. 1087, p. 1198; Exhibit P-147, tab 3, doc. 1424, pp. 64-68; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 225.

Return to footnote 4479 referrer

Footnote 4480

Exhibit P-147, tab 2, doc. 1423, p. 70.

Return to footnote 4480 referrer

Footnote 4481

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 24.

Return to footnote 4481 referrer

Footnote 4482

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 268; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 27-28.

Return to footnote 4482 referrer

Footnote 4483

Exhibit P-147, tab 1, doc. 1422, p. 102.

Return to footnote 4483 referrer

Footnote 4484

Exhibit P-147, tab 1, doc. 1422, p. 102.

Return to footnote 4484 referrer

Footnote 4485

Exhibit P-147, tab 1, doc. 1422, p. 102.

Return to footnote 4485 referrer

Footnote 4486

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 29.

Return to footnote 4486 referrer

Footnote 4487

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 29.

Return to footnote 4487 referrer

Footnote 4488

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 29-30.

Return to footnote 4488 referrer

Footnote 4489

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1101; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 113.

Return to footnote 4489 referrer

Footnote 4490

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1; Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, p. 1.

Return to footnote 4490 referrer

Footnote 4491

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(e).

Return to footnote 4491 referrer

Footnote 4492

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 240 [Emphasis added].

Return to footnote 4492 referrer

Footnote 4493

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 55.

Return to footnote 4493 referrer

Footnote 4494

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 227-229; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 21; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 168 and 170.

Return to footnote 4494 referrer

Footnote 4495

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 228.

Return to footnote 4495 referrer

Footnote 4496

Exhibit P-147, tab 3, doc. 1424, pp. 12-62; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 148-149.

Return to footnote 4496 referrer

Footnote 4497

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 112.

Return to footnote 4497 referrer

Footnote 4498

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 168 and 170.

Return to footnote 4498 referrer

Footnote 4499

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 228-229.

Return to footnote 4499 referrer

Footnote 4500

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 168.

Return to footnote 4500 referrer

Footnote 4501

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 170.

Return to footnote 4501 referrer

Footnote 4502

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 171.

Return to footnote 4502 referrer

Footnote 4503

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015.

Return to footnote 4503 referrer

Footnote 4504

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 1.

Return to footnote 4504 referrer

Footnote 4505

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 2.

Return to footnote 4505 referrer

Footnote 4506

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4506 referrer

Footnote 4507

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4507 referrer

Footnote 4508

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4508 referrer

Footnote 4509

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(e); Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 247-248.

Return to footnote 4509 referrer

Footnote 4510

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 247-248.

Return to footnote 4510 referrer

Footnote 4511

See Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 4-5, 97, 101 and 116-118; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 7-8, 10, 17, 24-26 and 174; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4511 referrer

Footnote 4512

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4512 referrer

Footnote 4513

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 3.

Return to footnote 4513 referrer

Footnote 4514

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 3.

Return to footnote 4514 referrer

Footnote 4515

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 170.

Return to footnote 4515 referrer

Footnote 4516

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 218; Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015.

Return to footnote 4516 referrer

Footnote 4517

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 218.

Return to footnote 4517 referrer

Footnote 4518

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 218-219.

Return to footnote 4518 referrer

Footnote 4519

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 219.

Return to footnote 4519 referrer

Footnote 4520

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 219.

Return to footnote 4520 referrer

Footnote 4521

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 219.

Return to footnote 4521 referrer

Footnote 4522

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 220.

Return to footnote 4522 referrer

Footnote 4523

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 1 [Emphasis added].

Return to footnote 4523 referrer

Footnote 4524

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 3.

Return to footnote 4524 referrer

Footnote 4525

See Section 4.4, The 2010 Criminal Negligence Investigation; Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 4525 referrer

Footnote 4526

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 23.

Return to footnote 4526 referrer

Footnote 4527

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 23-24.

Return to footnote 4527 referrer

Footnote 4528

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 228-229.

Return to footnote 4528 referrer

Footnote 4529

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 228.

Return to footnote 4529 referrer

Footnote 4530

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 229-230; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 85-86.

Return to footnote 4530 referrer

Footnote 4531

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 20.

Return to footnote 4531 referrer

Footnote 4532

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 21.

Return to footnote 4532 referrer

Footnote 4533

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 21.

Return to footnote 4533 referrer

Footnote 4534

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 32(b) & 32(c).

Return to footnote 4534 referrer

Footnote 4535

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 32(b); Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 241-242.

Return to footnote 4535 referrer

Footnote 4536

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 55.

Return to footnote 4536 referrer

Footnote 4537

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 242-243 and 256.

Return to footnote 4537 referrer

Footnote 4538

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4538 referrer

Footnote 4539

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4539 referrer

Footnote 4540

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4540 referrer

Footnote 4541

Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 1.

Return to footnote 4541 referrer

Footnote 4542

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 186-187.

Return to footnote 4542 referrer

Footnote 4543

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 186.

Return to footnote 4543 referrer

Footnote 4544

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4544 referrer

Footnote 4545

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, pp. 1-2.

Return to footnote 4545 referrer

Footnote 4546

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 32(c); Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 1.

Return to footnote 4546 referrer

Footnote 4547

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 256-257.

Return to footnote 4547 referrer

Footnote 4548

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 257.

Return to footnote 4548 referrer

Footnote 4549

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4549 referrer

Footnote 4550

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4550 referrer

Footnote 4551

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4551 referrer

Footnote 4552

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4552 referrer

Footnote 4553

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, pp. 1-2.

Return to footnote 4553 referrer

Footnote 4554

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 27, 29, 221, 284 and 286.

Return to footnote 4554 referrer

Footnote 4555

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4555 referrer

Footnote 4556

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4556 referrer

Footnote 4557

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, p. 2.

Return to footnote 4557 referrer

Footnote 4558

Exhibit P-4, Collection D, vol. 1, tab 19, doc. 015, pp. 1 and 3.

Return to footnote 4558 referrer

Footnote 4559

See Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4559 referrer

Footnote 4560

Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, pp. 127-128; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4560 referrer

Footnote 4561

See Section 4.4, The 2010 Criminal Negligence Investigation; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 157 and 183.

Return to footnote 4561 referrer

Footnote 4562

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 208-209.

Return to footnote 4562 referrer

Footnote 4563

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 209-210.

Return to footnote 4563 referrer

Footnote 4564

See, generally, Section 4.5.1, CFNIS Interactions with the Fynes – Early Contact; Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing; Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4564 referrer

Footnote 4565

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 9.

Return to footnote 4565 referrer

Footnote 4566

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 9.

Return to footnote 4566 referrer

Footnote 4567

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 29-31, 38 and 41-42.

Return to footnote 4567 referrer

Footnote 4568

Exhibit P-4, Collection D, vol. 12, tab 65, doc. 1091, pp. 1-2.

Return to footnote 4568 referrer

Footnote 4569

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 26-27.

Return to footnote 4569 referrer

Footnote 4570

Testimony of Maj Parkinson, Transcript of Proceedings, vol. 18, 8 May 2012, p. 81.

Return to footnote 4570 referrer

Footnote 4571

Exhibit P-4, Collection D, vol. 12, tab 65, doc. 1091, p. 1.

Return to footnote 4571 referrer

Footnote 4572

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 238-239 and 242; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 29.

Return to footnote 4572 referrer

Footnote 4573

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 239.

Return to footnote 4573 referrer

Footnote 4574

Exhibit P-84.

Return to footnote 4574 referrer

Footnote 4575

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B.

Return to footnote 4575 referrer

Footnote 4576

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 29.

Return to footnote 4576 referrer

Footnote 4577

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 35-36.

Return to footnote 4577 referrer

Footnote 4578

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 247.

Return to footnote 4578 referrer

Footnote 4579

Testimony of MCpl Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 187.

Return to footnote 4579 referrer

Footnote 4580

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 4.

Return to footnote 4580 referrer

Footnote 4581

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 12 and 29-30.

Return to footnote 4581 referrer

Footnote 4582

Exhibit P-181, doc. 1460, pp. 3-6.

Return to footnote 4582 referrer

Footnote 4583

Exhibit P-181, doc. 1460, p. 1.

Return to footnote 4583 referrer

Footnote 4584

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4584 referrer

Footnote 4585

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 160, 189-190, 193, 204-206 and 233-237.

Return to footnote 4585 referrer

Footnote 4586

See, generally, Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13, pp. 2-3.

Return to footnote 4586 referrer

Footnote 4587

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 33(b), 33(c) & 33(d), p. 6; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 190 and 236-237.

Return to footnote 4587 referrer

Footnote 4588

Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, p. 3.

Return to footnote 4588 referrer

Footnote 4589

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 187-188; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 56 and 65-66; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 19-21 [Translation].

Return to footnote 4589 referrer

Footnote 4590

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 188.

Return to footnote 4590 referrer

Footnote 4591

Exhibit P-4, Collection D, vol. 1, tab 10, doc. 009; Exhibit P-4, Collection D, vol. 1, tab 13, doc. 010-B.

Return to footnote 4591 referrer

Footnote 4592

Exhibit P-4, Collection D, vol. 1, tab 10, doc. 009, p. 1.

Return to footnote 4592 referrer

Footnote 4593

Exhibit P-5, Collection E, vol. 5, tab 4, doc. 1226, pp. 40-41; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, p. 19 [Translation].

Return to footnote 4593 referrer

Footnote 4594

Exhibit P-119, doc. 1396, p. 75; Exhibit P-147, tab 1, doc. 1422, p. 98.

Return to footnote 4594 referrer

Footnote 4595

Exhibit P-147, tab 2, doc. 1423, p. 35; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 269-272.

Return to footnote 4595 referrer

Footnote 4596

Exhibit P-147, tab 2, doc. 1423, pp. 35-43.

Return to footnote 4596 referrer

Footnote 4597

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 31-35.

Return to footnote 4597 referrer

Footnote 4598

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 31-35 vs. Exhibit P-147, tab 2, doc. 1423, pp. 35-43.

Return to footnote 4598 referrer

Footnote 4599

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 32-34 vs. Exhibit P-147, tab 2, doc. 1423, pp. 38-40.

Return to footnote 4599 referrer

Footnote 4600

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 34-35 vs. Exhibit P-147, tab 2, doc. 1423, pp. 40-41.

Return to footnote 4600 referrer

Footnote 4601

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 22-23 [Translation].

Return to footnote 4601 referrer

Footnote 4602

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 268; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 27-28.

Return to footnote 4602 referrer

Footnote 4603

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 268; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 27-28.

Return to footnote 4603 referrer

Footnote 4604

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 272 and 290; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 2-5.

Return to footnote 4604 referrer

Footnote 4605

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 4-5.

Return to footnote 4605 referrer

Footnote 4606

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 272 and 290.

Return to footnote 4606 referrer

Footnote 4607

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A.

Return to footnote 4607 referrer

Footnote 4608

See Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4608 referrer

Footnote 4609

See Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4609 referrer

Footnote 4610

Exhibit P-4, Collection D, vol. 1, tab 16, doc. 013, p. 1; Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A.

Return to footnote 4610 referrer

Footnote 4611

Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 1-2 and 129-130; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 157-160.

Return to footnote 4611 referrer

Footnote 4612

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4612 referrer

Footnote 4613

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4613 referrer

Footnote 4614

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4614 referrer

Footnote 4615

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4615 referrer

Footnote 4616

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4616 referrer

Footnote 4617

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4617 referrer

Footnote 4618

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4618 referrer

Footnote 4619

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4619 referrer

Footnote 4620

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4620 referrer

Footnote 4621

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4621 referrer

Footnote 4622

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 273-274.

Return to footnote 4622 referrer

Footnote 4623

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4623 referrer

Footnote 4624

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 190. See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4624 referrer

Footnote 4625

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33(b), p. 6.

Return to footnote 4625 referrer

Footnote 4626

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4626 referrer

Footnote 4627

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4627 referrer

Footnote 4628

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4628 referrer

Footnote 4629

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4629 referrer

Footnote 4630

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4630 referrer

Footnote 4631

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 147 and 149. See, generally, Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4631 referrer

Footnote 4632

See Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4632 referrer

Footnote 4633

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4633 referrer

Footnote 4634

See Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 2.

Return to footnote 4634 referrer

Footnote 4635

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 275.

Return to footnote 4635 referrer

Footnote 4636

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 138; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 275.

Return to footnote 4636 referrer

Footnote 4637

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 116-118.

Return to footnote 4637 referrer

Footnote 4638

Exhibit P-4, Collection D, vol. 1, tab 35, doc. 032, p. 2.

Return to footnote 4638 referrer

Footnote 4639

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 189-190 and 193-194.

Return to footnote 4639 referrer

Footnote 4640

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4640 referrer

Footnote 4641

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4641 referrer

Footnote 4642

See, generally, Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 4642 referrer

Footnote 4643

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 181, 568 and 627; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 98; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 58-59.

Return to footnote 4643 referrer

Footnote 4644

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 128-130; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 52-53 and 160; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 62-63; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, pp. 626-628.

Return to footnote 4644 referrer

Footnote 4645

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4645 referrer

Footnote 4646

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4646 referrer

Footnote 4647

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4647 referrer

Footnote 4648

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 204-206.

Return to footnote 4648 referrer

Footnote 4649

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33(c), p. 6.

Return to footnote 4649 referrer

Footnote 4650

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 67-68; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 71-72; Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4650 referrer

Footnote 4651

Testimony of Dennis Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 45-46; Exhibit P-6, Collection F, vol. 3, tab 4, doc 1323, p. 2. See, generally, Section 4.6, CFNIS Independence and Impartiality.

Return to footnote 4651 referrer

Footnote 4652

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4652 referrer

Footnote 4653

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4653 referrer

Footnote 4654

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4654 referrer

Footnote 4655

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4655 referrer

Footnote 4656

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 3.

Return to footnote 4656 referrer

Footnote 4657

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4657 referrer

Footnote 4658

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4658 referrer

Footnote 4659

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4 [Emphasis added].

Return to footnote 4659 referrer

Footnote 4660

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 233-236.

Return to footnote 4660 referrer

Footnote 4661

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33(d) p. 6; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 195-196.

Return to footnote 4661 referrer

Footnote 4662

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 160.

Return to footnote 4662 referrer

Footnote 4663

See Exhibit P-6, Collection F, vol. 1, tab 42, doc. 1189.

Return to footnote 4663 referrer

Footnote 4664

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 286-287.

Return to footnote 4664 referrer

Footnote 4665

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 287.

Return to footnote 4665 referrer

Footnote 4666

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 283.

Return to footnote 4666 referrer

Footnote 4667

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 283-284.

Return to footnote 4667 referrer

Footnote 4668

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 47-50 and 57-59 [Translation].

Return to footnote 4668 referrer

Footnote 4669

See Section 4.2, The Suicide Note Left by Cpl Langridge; Section 4.1.7, The 2008 Investigation – Return of Exhibits.

Return to footnote 4669 referrer

Footnote 4670

See Section 4.2, The Suicide Note Left by Cpl Langridge; Section 4.1.7, The 2008 Investigation – Return of Exhibits.

Return to footnote 4670 referrer

Footnote 4671

See Section 4.2, The Suicide Note Left by Cpl Langridge; Section 4.1.7, The 2008 Investigation – Return of Exhibits; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 217.

Return to footnote 4671 referrer

Footnote 4672

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4672 referrer

Footnote 4673

Exhibit P-4, Collection D, vol. 1, tab 35, doc. 032, p. 5.

Return to footnote 4673 referrer

Footnote 4674

Exhibit P-4, Collection D, vol. 1, tab 35, doc. 032, p. 5. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 236-237.

Return to footnote 4674 referrer

Footnote 4675

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 291-292.

Return to footnote 4675 referrer

Footnote 4676

Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, p. 230.

Return to footnote 4676 referrer

Footnote 4677

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 34 vs. Exhibit P-147, tab 2, doc. 1423, p. 40.

Return to footnote 4677 referrer

Footnote 4678

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4678 referrer

Footnote 4679

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4679 referrer

Footnote 4680

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4680 referrer

Footnote 4681

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4681 referrer

Footnote 4682

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4682 referrer

Footnote 4683

See Section 4.5.4, CFNIS Interactions with the Fynes – The 2009/2010 Investigations Interviews, Updates and Briefing.

Return to footnote 4683 referrer

Footnote 4684

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4684 referrer

Footnote 4685

Exhibit P-2, Collection B, vol. 2, tab 3, doc. 1087-D; Exhibit P-2, Collection B, vol. 2, tab 4, doc. 1087-E; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4685 referrer

Footnote 4686

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 5.

Return to footnote 4686 referrer

Footnote 4687

See Section 4.5.4, CFNIS Interactions with the Fynes – The 2009/2010 Investigations Interviews, Updates and Briefing.

Return to footnote 4687 referrer

Footnote 4688

See Section 4.5.4, CFNIS Interactions with the Fynes – The 2009/2010 Investigations Interviews, Updates and Briefing.

Return to footnote 4688 referrer

Footnote 4689

See Section 4.5.4, CFNIS Interactions with the Fynes – The 2009/2010 Investigations Interviews, Updates and Briefing.

Return to footnote 4689 referrer

Footnote 4690

See Section 4.5.4, CFNIS Interactions with the Fynes – The 2009/2010 Investigations Interviews, Updates and Briefing.

Return to footnote 4690 referrer

Footnote 4691

See Section 4.2, The Suicide Note Left by Cpl Langridge; Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4691 referrer

Footnote 4692

See Section 4.2, The Suicide Note Left by Cpl Langridge; Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4692 referrer

Footnote 4693

Exhibit P-147, tab 2, doc. 1423, pp. 35-43.

Return to footnote 4693 referrer

Footnote 4694

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 34-35 vs. Exhibit P-147, tab 2, doc. 1423, pp. 40-41; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 22-23 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 272 and 290; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 2-5.

Return to footnote 4694 referrer

Footnote 4695

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4695 referrer

Footnote 4696

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4696 referrer

Footnote 4697

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4697 referrer

Footnote 4698

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4698 referrer

Footnote 4699

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4699 referrer

Footnote 4700

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4700 referrer

Footnote 4701

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4701 referrer

Footnote 4702

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4702 referrer

Footnote 4703

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4703 referrer

Footnote 4704

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4704 referrer

Footnote 4705

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4705 referrer

Footnote 4706

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4706 referrer

Footnote 4707

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4707 referrer

Footnote 4708

See Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4708 referrer

Footnote 4709

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 33 p. 6.

Return to footnote 4709 referrer

Footnote 4710

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 4.

Return to footnote 4710 referrer

Footnote 4711

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4711 referrer

Footnote 4712

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 269; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 52.

Return to footnote 4712 referrer

Footnote 4713

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 269; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 52.

Return to footnote 4713 referrer

Footnote 4714

Exhibit P-5, Collection E, vol. 5, tab 4, doc. 1226, pp. 40-41; Exhibit P-119, doc. 1396, p. 75; Exhibit P-147, tab 1, doc. 1422, p. 98; Exhibit P-147, tab 2, doc. 1423, p. 35.

Return to footnote 4714 referrer

Footnote 4715

See Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 184-185, 264, 272-274 and 315; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, p. 149; Testimony of CWO (Ret’d) Watson, Transcript of Proceedings, vol. 55, 1 October 2012, pp. 149-150, 156-157, 213 and 241; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 161; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 20-21 and 56-57. See also Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4715 referrer

Footnote 4716

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001.

Return to footnote 4716 referrer

Footnote 4717

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 18; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 3-4 [Translation].

Return to footnote 4717 referrer

Footnote 4718

See Section 4.5.3, CFNIS Interactions with the Fynes – The November 2009 Briefing.

Return to footnote 4718 referrer

Footnote 4719

See Section 4.5.4, CFNIS Interactions with the Fynes – The 2009/2010 Investigations Interviews, Updates and Briefing.

Return to footnote 4719 referrer

Footnote 4720

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 94 [Emphasis added].

Return to footnote 4720 referrer

Footnote 4721

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 1-13, pp. 1-3.

Return to footnote 4721 referrer

Footnote 4722

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 1-2 and 11-13, pp. 1-3; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 196; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85, 89-90, 96-97 and 207-208; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 103-104; Closing Submission of the Complainants, pp. 65 and 79-80.

Return to footnote 4722 referrer

Footnote 4723

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 2, p. 1; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 200 and 212-213; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 96-97; Closing Submission of the Complainants, pp. 68 and 79-80.

Return to footnote 4723 referrer

Footnote 4724

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 5.

Return to footnote 4724 referrer

Footnote 4725

See Section 4.1, The 2008 Investigation; Section 4.3, The 2009 PNOK Investigation; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4725 referrer

Footnote 4726

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 1, p. 1.

Return to footnote 4726 referrer

Footnote 4727

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 62; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 139; Closing Submission of the Complainants, pp. 49, 57-60 and 78.

Return to footnote 4727 referrer

Footnote 4728

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 11 and 12, p. 2; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85, 96-97 and 207-208; Closing Submission of the Complainants, pp. 65, 72, 85 and Prologue, p. 6.

Return to footnote 4728 referrer

Footnote 4729

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13, pp. 2-3. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 86-87, 89-90 and 96-97; Closing Submission of the Complainants, pp. 67-68 and 72-74.

Return to footnote 4729 referrer

Footnote 4730

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 1 and 2, p. 1.

Return to footnote 4730 referrer

Footnote 4731

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 3, 5 and 8, pp. 1-2.

Return to footnote 4731 referrer

Footnote 4732

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 196-197 and 212; Closing Submission of the Complainants, pp. 28 and 61.

Return to footnote 4732 referrer

Footnote 4733

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 103; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85. See also Closing Submission of the Complainants, pp. 16-17 and 27-28.

Return to footnote 4733 referrer

Footnote 4734

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 96.

Return to footnote 4734 referrer

Footnote 4735

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 212.

Return to footnote 4735 referrer

Footnote 4736

See Final Submissions of the Subjects of the Complaint, pp. 98-100; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 191-192; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 75-78; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, pp. 192-194; Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 309-311 and 318-320; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 282-284, 298-299 and 303; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 268-271; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 173-176; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 154-155; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 196-198; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 12-16; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 88-89; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 203-204; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 95-96. See also Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 343-344.

Return to footnote 4736 referrer

Footnote 4737

See Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 193; Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 196-197.

Return to footnote 4737 referrer

Footnote 4738

See Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 319; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 282-283; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 269-270; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 154-155.

Return to footnote 4738 referrer

Footnote 4739

Testimony of MWO Tourout, Transcript of Proceedings, vol. 54, 27 September 2012, pp. 196-197.

Return to footnote 4739 referrer

Footnote 4740

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 15-16; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 65-67; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 262-263; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 95-96 and 102-103; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 155; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 19; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 280-282 and 343-344; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 78.

Return to footnote 4740 referrer

Footnote 4741

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 75.

Return to footnote 4741 referrer

Footnote 4742

Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, p. 299.

Return to footnote 4742 referrer

Footnote 4743

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 16.

Return to footnote 4743 referrer

Footnote 4744

See Exhibit P-176, doc. 1435, p. 2; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 6-7.

Return to footnote 4744 referrer

Footnote 4745

Exhibit P-176, doc. 1435, p. 2.

Return to footnote 4745 referrer

Footnote 4746

See Exhibit P-176, doc. 1435, pp. 3 and 7; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 11.

Return to footnote 4746 referrer

Footnote 4747

Exhibit P-176, doc. 1435, pp. 2-3; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 11.

Return to footnote 4747 referrer

Footnote 4748

Exhibit P-176, doc. 1435, pp. 2-3; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 10-11.

Return to footnote 4748 referrer

Footnote 4749

See Exhibit P-176, doc. 1435, pp. 2-3, 7, 10-11 and 13; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 10-11 and 13-14.

Return to footnote 4749 referrer

Footnote 4750

Exhibit P-176, doc. 1435, pp. 7, 10-12 and 14; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 13-14 and 45.

Return to footnote 4750 referrer

Footnote 4751

See Exhibit P-176, doc. 1435, pp. 9-14; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 7 and 10-12.

Return to footnote 4751 referrer

Footnote 4752

Exhibit P-176, doc. 1435, p. 3.

Return to footnote 4752 referrer

Footnote 4753

See Exhibit P-176, doc. 1435, pp. 3 and 36; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 9-11, 17, 19 and 55.

Return to footnote 4753 referrer

Footnote 4754

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 8-10, 16-17, 24 and 57. See also Exhibit P-176, doc. 1435, pp. 22-24 and 35.

Return to footnote 4754 referrer

Footnote 4755

See Exhibit P-176, doc. 1435, pp. 3, 22-23 and 34.

Return to footnote 4755 referrer

Footnote 4756

See Exhibit P-176, doc. 1435, pp. 3 and 46; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 8.

Return to footnote 4756 referrer

Footnote 4757

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 66-68; Exhibit P-176, doc. 1435, pp. 3-4, 24-28 and 33-34.

Return to footnote 4757 referrer

Footnote 4758

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 12-15, 19-22, 24, 29, 36, 39-42, 45 and 57.

Return to footnote 4758 referrer

Footnote 4759

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 12, 22 and 46-47.

Return to footnote 4759 referrer

Footnote 4760

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 24 and 39.

Return to footnote 4760 referrer

Footnote 4761

See Exhibit P-75, tab 2, doc. 1087-K, pp. 3-5; Exhibit P-147, tab 1, doc. 1422, p. 55; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 232-234.

Return to footnote 4761 referrer

Footnote 4762

See Exhibit P-147, tab 1, doc. 1422, pp. 53 and 55; Exhibit P-103, p. 3; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 239-240.

Return to footnote 4762 referrer

Footnote 4763

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 427-1023, 1025 and 1037-1040; Exhibit P-70, doc. 1358; Exhibit P-71, doc. 1087-I; Exhibit P-103; Exhibit P-104; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 126-130; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 120-121 and 184.

Return to footnote 4763 referrer

Footnote 4764

Exhibit P-75, tab 2, doc. 1087-K, pp. 3 and 5.

Return to footnote 4764 referrer

Footnote 4765

See Exhibit P-75, tab 2, doc. 1087-K, p. 3; Exhibit P-4, Collection D, vol. 3, tab 53, doc. 251; Exhibit P-4, Collection D, vol. 11, tab 76, doc. 1000, pp. 10-13, 17-18 and 21-23; Exhibit P-4, Collection D, vol. 4, tab 96, doc. 394; Exhibit P-4, Collection D, vol. 4, tab 63, doc. 361; Exhibit P-4, Collection D, vol. 4, tab 62, doc. 360; Exhibit P-4, Collection D, vol. 4, tab 60, doc. 358; Exhibit P-4, Collection D, vol. 1, tab 48, doc. 045. See also, Testimony of LCol King, Transcript of Proceedings, vol. 25, 22 May 2012, pp. 138-139 and 151-153; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 15-16 and 85-86.

Return to footnote 4765 referrer

Footnote 4766

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 28 and 221; Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4766 referrer

Footnote 4767

See Exhibit P-102, doc. 1390, pp. 24-25 and 28-30.

Return to footnote 4767 referrer

Footnote 4768

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 1037 and 1039-1040; Exhibit P-75, tabs 1-5, doc. 1087-J to 1087-N; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 121-124 and 179-180; Exhibit P-102, doc. 1390, pp. 17-30.

Return to footnote 4768 referrer

Footnote 4769

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 38-39. See, generally, Exhibit P-176, doc. 1435, pp. 53-54; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 17 and 37.

Return to footnote 4769 referrer

Footnote 4770

See Closing Submission of the Complainants, pp. 57-59 and 61.

Return to footnote 4770 referrer

Footnote 4771

Exhibit P-147, tab 1, doc. 1422, p. 55; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 233-234 and 256.

Return to footnote 4771 referrer

Footnote 4772

Exhibit P-147, tab 1, doc. 1422, p. 53.

Return to footnote 4772 referrer

Footnote 4773

Exhibit P-147, tab 1, doc. 1422, p. 55.

Return to footnote 4773 referrer

Footnote 4774

Exhibit P-147, tab 1, doc. 1422, p. 55.

Return to footnote 4774 referrer

Footnote 4775

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 236-237, 240-241, 251-252 and 255-257.

Return to footnote 4775 referrer

Footnote 4776

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, p. 256.

Return to footnote 4776 referrer

Footnote 4777

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 256-257.

Return to footnote 4777 referrer

Footnote 4778

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 256-257.

Return to footnote 4778 referrer

Footnote 4779

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 81-82.

Return to footnote 4779 referrer

Footnote 4780

Exhibit P-103, p. 3; Exhibit P-147, tab 1, doc. 1422, pp. 53 and 55; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 239-240.

Return to footnote 4780 referrer

Footnote 4781

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 239-240, 251-252 and 255-257.

Return to footnote 4781 referrer

Footnote 4782

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 27 vs. Exhibit P-75, tab 2, doc. 1087-K, pp. 3-5 and Exhibit P-70, doc. 1358, pp. 8-10 and 28-31; Exhibit P-103; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 243-250.

Return to footnote 4782 referrer

Footnote 4783

See Exhibit P-103, p. 3; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 241-243; Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 518; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 27 and 286.

Return to footnote 4783 referrer

Footnote 4784

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 250-251.

Return to footnote 4784 referrer

Footnote 4785

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 105-106.

Return to footnote 4785 referrer

Footnote 4786

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 427-1023, 1025 and 1037-1040; Exhibit P-70, doc. 1358; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 126-130; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 120-121 and 184.

Return to footnote 4786 referrer

Footnote 4787

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 429-1022; Exhibit P-71, doc. 1087-I; Exhibit P-103; Exhibit P-104; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 127.

Return to footnote 4787 referrer

Footnote 4788

See Exhibit P-70, doc. 1358, pp. 3-5; Exhibit P-103; Exhibit P-104.

Return to footnote 4788 referrer

Footnote 4789

Return to footnote 4789 referrer

Footnote 4790

Exhibit P-102, doc. 1390, pp. 28-30.

Return to footnote 4790 referrer

Footnote 4791

Exhibit P-102, doc. 1390, p. 24.

Return to footnote 4791 referrer

Footnote 4792

Exhibit P-102, doc. 1390, p. 25.

Return to footnote 4792 referrer

Footnote 4793

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 126-127; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 167, 171-175, 182-184 and 217; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 61-62; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 110; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 40-41.

Return to footnote 4793 referrer

Footnote 4794

See Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 171-175, 180-182 and 217.

Return to footnote 4794 referrer

Footnote 4795

See Exhibit P-176, doc. 1435, p. 54; Section 4.3, The 2009 PNOK Investigation; Exhibit P-75, tab 2, doc. 1087-K, pp. 3-4; Exhibit P-70, doc. 1358, pp. 8-10 and 28-31.

Return to footnote 4795 referrer

Footnote 4796

Testimony of LCol MacGregor, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 2-5.

Return to footnote 4796 referrer

Footnote 4797

Testimony of LCol MacGregor, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 59-60 and 143.

Return to footnote 4797 referrer

Footnote 4798

Testimony of LCol MacGregor, Transcript of Proceedings, vol. 44, 10 September 2012, pp. 143-144.

Return to footnote 4798 referrer

Footnote 4799

Testimony of LCol MacGregor, Transcript of Proceedings, vol. 44, 10 September 2012, p. 144.

Return to footnote 4799 referrer

Footnote 4800

See Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 42-45; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 182-184.

Return to footnote 4800 referrer

Footnote 4801

Exhibit P-176, doc. 1435, p. 54; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 37-38.

Return to footnote 4801 referrer

Footnote 4802

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 8-10.

Return to footnote 4802 referrer

Footnote 4803

See, for example, Exhibit P-103, pp. 1, 5 and 6.

Return to footnote 4803 referrer

Footnote 4804

See Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 127-132.

Return to footnote 4804 referrer

Footnote 4805

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 222-223, 1348-1350 and 1351-1357; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 88-93 and 132-133; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 130, 158-160 and 194-197; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 134-136; Section 4.3, The 2009 PNOK Investigation; Exhibit P-70, doc. 1358, pp. 3-5. Of the 18 SI witnesses, approximately 10 to 13 had information relevant to the matters investigated by the CFNIS: see Exhibit P-70, doc. 1358, pp. 3-5 and Exhibit P-103.

Return to footnote 4805 referrer

Footnote 4806

Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 130, 158-160 and 194-197; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 134-136. See, generally, Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4806 referrer

Footnote 4807

See Section 4.3, The 2009 PNOK Investigation.

Return to footnote 4807 referrer

Footnote 4808

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 301-406; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 38 and 171; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 1-3; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 223-224; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 183-184; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 120-121.

Return to footnote 4808 referrer

Footnote 4809

Testimony of Maj Parlee, Transcript of Proceedings, vol. 14, 24 April 2012, pp. 17-18 and 198-199.

Return to footnote 4809 referrer

Footnote 4810

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 302; Exhibit P-4, Collection D, vol. 3, tab 53, doc. 251; Exhibit P-4, Collection D, vol. 11, tab 76, doc. 1000, pp. 10-13, 17-18 and 21-23; Testimony of LCol King, Transcript of Proceedings, vol. 25, 22 May 2012, p. 143; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 15-16.

Return to footnote 4810 referrer

Footnote 4811

See Exhibit P-4, Collection D, vol. 4, tab 25, doc. 323, pp. 3-4; Section 4.3, The 2010 Criminal Negligence Investigation. See, generally, Exhibit P-176, doc. 1435, p. 54.

Return to footnote 4811 referrer

Footnote 4812

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 131-132; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, p. 77.

Return to footnote 4812 referrer

Footnote 4813

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 71-72 and 114-115; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 76-78; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 119, 125-126 and 130-132; Exhibit P-4, Collection D, vol. 9, tab 71, doc. 795, p. 1.

Return to footnote 4813 referrer

Footnote 4814

See Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, p. 171; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 23.

Return to footnote 4814 referrer

Footnote 4815

Closing Submission of the Complainants, pp. 49 and 60.

Return to footnote 4815 referrer

Footnote 4816

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 62.

Return to footnote 4816 referrer

Footnote 4817

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 139.

Return to footnote 4817 referrer

Footnote 4818

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 139.

Return to footnote 4818 referrer

Footnote 4819

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 3, p. 1; Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 11-15, 115-118 and 123-129; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 200.

Return to footnote 4819 referrer

Footnote 4820

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 71-72 and 114-115; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 76-78; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 119, 125-126 and 130-132; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 136-139; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 76.

Return to footnote 4820 referrer

Footnote 4821

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 139.

Return to footnote 4821 referrer

Footnote 4822

See Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4822 referrer

Footnote 4823

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42-43, 130 and 133-134.

Return to footnote 4823 referrer

Footnote 4824

See Exhibit P-5, Collection E, vol. 5, tab 11, doc. 1233, pp. 525-530 and 534-535.

Return to footnote 4824 referrer

Footnote 4825

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 352 and 384.

Return to footnote 4825 referrer

Footnote 4826

See Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4826 referrer

Footnote 4827

See Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 171-172; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 1-3; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 183-184; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 115-122, 154-161 and 169-213; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4827 referrer

Footnote 4828

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 110, 224, 231 and 249; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 225-233 and 238-240 [Translation]. But see Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 149, for a contrary view.

Return to footnote 4828 referrer

Footnote 4829

See Final Submissions of the Subjects of the Complaint, pp. 38 and 101-102.

Return to footnote 4829 referrer

Footnote 4830

See Section 4.4, The 2010 Criminal Negligence Investigation; Section 2.0, The Hearing Process.

Return to footnote 4830 referrer

Footnote 4831

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 171-172; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 1-3; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 183-184; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 120-121.

Return to footnote 4831 referrer

Footnote 4832

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 223-224; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4832 referrer

Footnote 4833

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 113.

Return to footnote 4833 referrer

Footnote 4834

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 113-114.

Return to footnote 4834 referrer

Footnote 4835

See Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4835 referrer

Footnote 4836

See Section 4.4, The 2010 Criminal Negligence Investigation; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 171-172; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, pp. 1-3; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 50, 19 September 2012, pp. 183-184; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 120-121.

Return to footnote 4836 referrer

Footnote 4837

See Exhibit P-3, Collection C, vol. 1, tab 1, doc. 1088, PDF pp. 127 and 131; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4837 referrer

Footnote 4838

See Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 4838 referrer

Footnote 4839

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 42-43, 130 and 133-134.

Return to footnote 4839 referrer

Footnote 4840

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 12, p. 2. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 49.

Return to footnote 4840 referrer

Footnote 4841

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85, 96-97 and 207-208.

Return to footnote 4841 referrer

Footnote 4842

See Exhibit P-176, doc. 1435, pp. 2-3 and 25; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 10-12 and 17.

Return to footnote 4842 referrer

Footnote 4843

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 13.

Return to footnote 4843 referrer

Footnote 4844

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 55.

Return to footnote 4844 referrer

Footnote 4845

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 84.

Return to footnote 4845 referrer

Footnote 4846

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 55.

Return to footnote 4846 referrer

Footnote 4847

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 52-55; Exhibit P-102, doc. 1390, pp. 22-26; Exhibit P-147, tab 2, doc. 1423, pp. 32-33.

Return to footnote 4847 referrer

Footnote 4848

Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 83.

Return to footnote 4848 referrer

Footnote 4849

Exhibit P-5, Collection E, vol. 4, tab 1, doc. 1131-B, p. 1.

Return to footnote 4849 referrer

Footnote 4850

See Testimony of Col Hammond, Transcript of Proceedings, vol. 40, 26 June 2012, p. 83; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 68-69.

Return to footnote 4850 referrer

Footnote 4851

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 57; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 71-72.

Return to footnote 4851 referrer

Footnote 4852

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 55.

Return to footnote 4852 referrer

Footnote 4853

See Exhibit P-5, Collection E, vol. 4, tab 1, doc. 1131-B, p. 1; Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 55-57; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 32-36, 114 and 126-127.

Return to footnote 4853 referrer

Footnote 4854

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 32-36, 114 and 126-127.

Return to footnote 4854 referrer

Footnote 4855

See Exhibit P-176, doc. 1435, pp. 2-3 and 25; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 10-12 and 17.

Return to footnote 4855 referrer

Footnote 4856

See Exhibit P-147, tab 1, doc. 1422, p. 126.

Return to footnote 4856 referrer

Footnote 4857

Exhibit P-5, Collection E, vol. 4, tab 1, doc. 1131-B, p. 1.

Return to footnote 4857 referrer

Footnote 4858

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 35-36.

Return to footnote 4858 referrer

Footnote 4859

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 65-67.

Return to footnote 4859 referrer

Footnote 4860

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 52 and 57-58; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 68, 77-78, 110 and 255-256.

Return to footnote 4860 referrer

Footnote 4861

Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 32, 34 and 36.

Return to footnote 4861 referrer

Footnote 4862

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 12, p. 2. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 49.

Return to footnote 4862 referrer

Footnote 4863

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 12, p. 2; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 48-49 and 202.

Return to footnote 4863 referrer

Footnote 4864

See Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 81-88; Exhibit P-2, Collection B, vol. 2, tab 2, doc. 1087-C, pp. 14-27 and 43-44; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 33-36.

Return to footnote 4864 referrer

Footnote 4865

See Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 5.

Return to footnote 4865 referrer

Footnote 4866

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 33-36.

Return to footnote 4866 referrer

Footnote 4867

See Section 4.3, The 2009 PNOK Investigation; Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, p. 33.

Return to footnote 4867 referrer

Footnote 4868

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 90-91.

Return to footnote 4868 referrer

Footnote 4869

See Exhibit P-70, doc. 1358, pp. 15-17.

Return to footnote 4869 referrer

Footnote 4870

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 50-51; Exhibit P-147, tab 1, doc. 1422, p. 80.

Return to footnote 4870 referrer

Footnote 4871

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 48 and 50-51.

Return to footnote 4871 referrer

Footnote 4872

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 51.

Return to footnote 4872 referrer

Footnote 4873

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85, 96-97 and 207-208.

Return to footnote 4873 referrer

Footnote 4874

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85.

Return to footnote 4874 referrer

Footnote 4875

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, p. 278 [Translation]. See also Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 280-283 [Translation]; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 19-21 [Translation].

Return to footnote 4875 referrer

Footnote 4876

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 48; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 86-88 and 252.

Return to footnote 4876 referrer

Footnote 4877

Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 40.

Return to footnote 4877 referrer

Footnote 4878

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 278 and 280-283 [Translation]; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 19-21 [Translation].

Return to footnote 4878 referrer

Footnote 4879

Exhibit P-147, tab 2, doc. 1423, p. 45.

Return to footnote 4879 referrer

Footnote 4880

Exhibit P-147, tab 2, doc. 1423, p. 45.

Return to footnote 4880 referrer

Footnote 4881

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 45.

Return to footnote 4881 referrer

Footnote 4882

See Exhibit P-5, Collection E, vol. 5, tab 19, doc. 1241, pp. 120 and 126.

Return to footnote 4882 referrer

Footnote 4883

See Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 46 and 51; Exhibit P-5, Collection E, vol. 5, tab 4, doc. 1226, p. 28.

Return to footnote 4883 referrer

Footnote 4884

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 44-45 [Translation].

Return to footnote 4884 referrer

Footnote 4885

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 10, 11, 12 and 13(a) to 13(e), pp. 2-3. See also Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85; Closing Submission of the Complainants, pp. 65, 70-72, 85 and Prologue, p. 6.

Return to footnote 4885 referrer

Footnote 4886

See, generally, Exhibit P-176, doc. 1435, pp. 7, 10-12, 14 and 54-59; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 13-14, 35-36, 39-43 and 45.

Return to footnote 4886 referrer

Footnote 4887

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13, pp. 2-3.

Return to footnote 4887 referrer

Footnote 4888

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 13(a) to 13(e), pp. 2-3.

Return to footnote 4888 referrer

Footnote 4889

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(c), p. 3; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 56 and 64.

Return to footnote 4889 referrer

Footnote 4890

Exhibit P-4, Collection D, vol. 10, tab 22, doc. 846.

Return to footnote 4890 referrer

Footnote 4891

See Section 4.5.4, CFNIS Interactions with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4891 referrer

Footnote 4892

See Section 4.5.4, CFNIS Interactions with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing; Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 237; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 161-162; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 244-245 and 251-252; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, p. 137; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 150 and 157-159.

Return to footnote 4892 referrer

Footnote 4893

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 158; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 244-245; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, p. 17 [Translation].

Return to footnote 4893 referrer

Footnote 4894

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 245; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, p. 18 [Translation].

Return to footnote 4894 referrer

Footnote 4895

Exhibit P-4, Collection D, vol. 10, tab 22, doc. 846.

Return to footnote 4895 referrer

Footnote 4896

See Section 4.5.4, CFNIS Interactions with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4896 referrer

Footnote 4897

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095.

Return to footnote 4897 referrer

Footnote 4898

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 54; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 239-240; Exhibit P-4, Collection D, vol. 12, tab 68, doc. 1095. See also, Section 4.5.4, CFNIS Interactions with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4898 referrer

Footnote 4899

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(d), p. 3; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 86-87.

Return to footnote 4899 referrer

Footnote 4900

Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 89-90.

Return to footnote 4900 referrer

Footnote 4901

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 50-54, 56, 83-84 and 88-91 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 165-166; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 106-108; Exhibit P-4, Collection D, vol. 1, tab 18, doc. 014, p. 2. See also, Section 4.5.4, CFNIS Interactions with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4901 referrer

Footnote 4902

See Section 4.5.4, CFNIS Interactions with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4902 referrer

Footnote 4903

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 235-236.

Return to footnote 4903 referrer

Footnote 4904

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 49-51 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 219-220; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 63-65 and 109; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 165.

Return to footnote 4904 referrer

Footnote 4905

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 50-54, 56, 83-84 and 88-91 [Translation].

Return to footnote 4905 referrer

Footnote 4906

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 165-166.

Return to footnote 4906 referrer

Footnote 4907

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 166-167.

Return to footnote 4907 referrer

Footnote 4908

See Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 106-108.

Return to footnote 4908 referrer

Footnote 4909

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 109-110.

Return to footnote 4909 referrer

Footnote 4910

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 9-10 and 16-17; Exhibit P-176, doc. 1435, p. 35.

Return to footnote 4910 referrer

Footnote 4911

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 17.

Return to footnote 4911 referrer

Footnote 4912

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(e), p. 3.

Return to footnote 4912 referrer

Footnote 4913

See Section 4.5.4, CFNIS Interaction with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4913 referrer

Footnote 4914

See Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 225-229; Section 4.5.4, CFNIS Interaction with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4914 referrer

Footnote 4915

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 12-17; Exhibit P-147, tab 2, doc. 1423, p. 70; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1096; Section 4.5.4, CFNIS Interaction with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4915 referrer

Footnote 4916

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 235.

Return to footnote 4916 referrer

Footnote 4917

See Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, p. 229; Section 4.5.4, CFNIS Interaction with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4917 referrer

Footnote 4918

See Testimony of Sgt Shannon, Transcript of Proceedings, vol. 51, 20 September 2012, pp. 225-229.

Return to footnote 4918 referrer

Footnote 4919

See Section 4.5.4, CFNIS Interaction with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4919 referrer

Footnote 4920

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 10, p. 2; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 62; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 239; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 56-57 and 83-84.

Return to footnote 4920 referrer

Footnote 4921

See Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 1095; Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 19-21; Section 4.5.4, CFNIS Interaction with the Fynes 2009/2010 Investigations – Interviews, Updates and Briefing.

Return to footnote 4921 referrer

Footnote 4922

See Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, p. 3; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 19-21 [Translation]; Section 4.5.6, CFNIS Interactions with the Fynes CFNIS Answers to the Col Blais Questions.

Return to footnote 4922 referrer

Footnote 4923

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 26-27; Exhibit P-4, Collection D, vol. 1, tab 16, doc. 013; Exhibit P-4, Collection D, vol. 1, tab 31, doc. 028; Exhibit P-4. Collection D, vol. 1, tab 33, doc. 030; Exhibit P-4, Collection D, vol. 1, tab 40, doc. 037; Exhibit P-5, Collection E, vol. 5, tab 4, doc. 1226, pp. 32-33.

Return to footnote 4923 referrer

Footnote 4924

See Exhibit P-4, Collection D, vol. 1, tab 16, doc. 013; Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 26-27.

Return to footnote 4924 referrer

Footnote 4925

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 187-188; Exhibit P-5, Collection E, vol. 5, tab 4, doc. 1226, p. 41; Exhibit P-147, tab 2, doc. 1423, pp. 45-58. See, generally, Section 4.5.6, CFNIS Interactions with the Fynes CFNIS Answers to the Col Blais Questions.

Return to footnote 4925 referrer

Footnote 4926

Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A.

Return to footnote 4926 referrer

Footnote 4927

See Exhibit P-4, Collection D, vol. 1, tab 10, doc. 009; Exhibit P-4, Collection D, vol. 1, tab 16, doc. 013, p. 29; Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 31-35; Exhibit P-5, Collection E, vol. 5, tab 4, doc. 1226, pp. 40-41; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, p. 19 [Translation]; Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, p. 65; Section 4.5.6, CFNIS Interactions with the Fynes CFNIS Answers to the Col Blais Questions.

Return to footnote 4927 referrer

Footnote 4928

See Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, pp. 1-2, 4 and 5.

Return to footnote 4928 referrer

Footnote 4929

See Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, p. 5 and Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 66-68, indicating responses related to post-death administration issues relevant to the CFNIS’ 2009 PNOK Investigation were provided by LFWA, the Area in charge of the LDSH Regiment. See also Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, pp. 1-2, for a response provided by the CF Health Services Group about the medical care received by Cpl Langridge, an issue directly relevant to the CFNIS’ 2010 Criminal Negligence Investigation.

Return to footnote 4929 referrer

Footnote 4930

See Exhibit P-4, Collection D, vol. 1, tab 16, doc. 013, pp. 30-31; Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 60-61.

Return to footnote 4930 referrer

Footnote 4931

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 31-34 vs Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, pp. 2-4. See also Testimony of Col Blais, Transcript of Proceedings, vol. 27, 24 May 2012, p. 65.

Return to footnote 4931 referrer

Footnote 4932

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, pp. 31-34 vs Exhibit P-4, Collection D, vol. 1, tab 17, doc. 013-A, pp. 2-4.

Return to footnote 4932 referrer

Footnote 4933

See Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 32-33 [Translation]; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, pp. 17-19.

Return to footnote 4933 referrer

Footnote 4934

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 19.

Return to footnote 4934 referrer

Footnote 4935

Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 20-21 [Translation].

Return to footnote 4935 referrer

Footnote 4936

See Exhibit P-176, doc. 1435, pp. 54-57; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 39-41.

Return to footnote 4936 referrer

Footnote 4937

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13(a), p. 3.

Return to footnote 4937 referrer

Footnote 4938

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13, pp. 2-3.

Return to footnote 4938 referrer

Footnote 4939

See Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report; Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 14, 44-45 and 70-71; Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 63.

Return to footnote 4939 referrer

Footnote 4940

See Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 8-14, 22-23 and 52; Exhibit P-6, Collection F, vol. 1, tab 46, doc. 1193, p. 10.

Return to footnote 4940 referrer

Footnote 4941

See Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, pp. 69-70 and 72; Exhibit P-183, tab 51, doc. 1511.

Return to footnote 4941 referrer

Footnote 4942

See Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report; Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, p. 7; Exhibit P-6, Collection F, vol. 1, tab 46, doc. 1193, p. 10.

Return to footnote 4942 referrer

Footnote 4943

See Access to Information Act, R.S.C., 1985, c. A-1, s. 73; Privacy Act, R.S.C., 1985, c. P-21, s. 73.

Return to footnote 4943 referrer

Footnote 4944

See Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, pp. 65-68; Testimony of Ms. Jansen, Transcript of Proceedings, vol. 24, 17 May 2012, pp. 8-9, 10 and 12-13; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 84.

Return to footnote 4944 referrer

Footnote 4945

See Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 67; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 84-85; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 18; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 291-294.

Return to footnote 4945 referrer

Footnote 4946

See Exhibit P-176, doc. 1435, pp. 54-57; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 35-36 and 40-41.

Return to footnote 4946 referrer

Footnote 4947

Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 67.

Return to footnote 4947 referrer

Footnote 4948

Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 68.

Return to footnote 4948 referrer

Footnote 4949

See Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 14-16; Exhibit P-138, tab 1, doc. 1403, p. 17; Exhibit P-4, Collection D, vol. 1, tab 7, doc. 006, pp. 8-9; Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, pp. 104, 107-108 and 122-123. See, generally, Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4949 referrer

Footnote 4950

See Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4950 referrer

Footnote 4951

Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4951 referrer

Footnote 4952

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 26-27 and 28; Exhibit P-4, Collection D, vol. 1, tab 8, doc. 007, pp. 15-16; Exhibit P-2, collection B, vol. 2, tab 1, doc. 1087-B, pp. 104-106. See, generally, Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4952 referrer

Footnote 4953

Section 4.5.2, CFNIS Interactions with the Fynes – Obtaining the 2008 Investigation Report.

Return to footnote 4953 referrer

Footnote 4954

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 84-85; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, p. 18; Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, p. 72.

Return to footnote 4954 referrer

Footnote 4955

See Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 291-294.

Return to footnote 4955 referrer

Footnote 4956

See Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, pp. 71-73; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 292-293.

Return to footnote 4956 referrer

Footnote 4957

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 83-84; Testimony of Maj Wight, Transcript of Proceedings, vol. 23, 16 May 2012, pp. 61 and 73.

Return to footnote 4957 referrer

Footnote 4958

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 293-294.

Return to footnote 4958 referrer

Footnote 4959

See Exhibit P-176, doc. 1435, pp. 55-57; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 41.

Return to footnote 4959 referrer

Footnote 4960

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 11, p. 2; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85; Closing Submission of the Complainants, p. 65.

Return to footnote 4960 referrer

Footnote 4961

See Exhibit P-176, doc. 1435, pp. 7, 10-12, 14, 54-57 and 59; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 13-14, 35-36, 40-41 and 45.

Return to footnote 4961 referrer

Footnote 4962

See Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 126-130; Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, pp. 41-42; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 63 and 699-701; Exhibit P-147, tab 1, doc. 1422, pp. 111-113. See also Final Submissions of the Subjects of the Complaint, p. 39.

Return to footnote 4962 referrer

Footnote 4963

See Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 134-135 and 170-171; Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, pp. 38, 40-41 and 54-55; Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, p. 42; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 1-6, 13, 33, 48, 91-95 and 227; Exhibit P-5, Collection E, vol. 2, tab 17, doc. 1132-B, p. 11; Exhibit P-93, doc. 1378.

Return to footnote 4963 referrer

Footnote 4964

See Section 4.2, The Suicide Note Left by Cpl Langridge; Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 246-351, 442-659, 668-672, 680-688, 697-701, 726-732, 735-744, 768-775, 779-781, 796-798 and 808-810; Exhibit P-93, doc. 1378; Final Submissions of the Subjects of the Complaint, pp. 39-40.

Return to footnote 4964 referrer

Footnote 4965

Return to footnote 4965 referrer

Footnote 4966

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 60-62 and 93-94. See also, Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 296-298; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 51.

Return to footnote 4966 referrer

Footnote 4967

Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, p. 102.

Return to footnote 4967 referrer

Footnote 4968

Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, p. 103.

Return to footnote 4968 referrer

Footnote 4969

See Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 295 and 297-298; Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, pp. 3-4.

Return to footnote 4969 referrer

Footnote 4970

See Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 164-165; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, p. 299.

Return to footnote 4970 referrer

Footnote 4971

Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 133-137, 164-165 and 173-174; Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, pp. 42-44 and 60; Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, pp. 38-39 and 113; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, p. 61; Testimony of LCol Frei, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 203-204; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 49-51 and 197-198.

Return to footnote 4971 referrer

Footnote 4972

See Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 133-134; Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, p. 43; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 298-299; Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 19-20.

Return to footnote 4972 referrer

Footnote 4973

Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 298-299.

Return to footnote 4973 referrer

Footnote 4974

See Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, p. 102. But see Testimony of Maj Muralt, Transcript of Proceedings, vol. 31, 7 June 2012, pp. 78 and 89-90.

Return to footnote 4974 referrer

Footnote 4975

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 11 and 12, p. 2; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85; Closing Submission of the Complainants, pp. 65 and 70-72.

Return to footnote 4975 referrer

Footnote 4976

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 80-81, 158-162, 220, 227, 451-455 and 704-712; Exhibit P-93, doc. 1378.

Return to footnote 4976 referrer

Footnote 4977

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 276-281, 292, 491, 500-501, 548-550 and 737-739; Testimony of Maj Poulin, Transcript of Proceedings, vol. 27, 24 May 2012, pp. 170-173; Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, pp. 54-55.

Return to footnote 4977 referrer

Footnote 4978

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 256-257, 262, 453-454, 488, 535, 542-543 and 738. See, generally, Section 4.2, The Suicide Note Left by Cpl Langridge.

Return to footnote 4978 referrer

Footnote 4979

Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 61-62.

Return to footnote 4979 referrer

Footnote 4980

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 254.

Return to footnote 4980 referrer

Footnote 4981

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 255.

Return to footnote 4981 referrer

Footnote 4982

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, pp. 697-698; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 200 and 213-214. But note the messages in the 2009/2010 investigations MRL were not delivered to the public: see Testimony of Capt Holder, Transcript of Proceedings, vol. 32, 11 June 2012, pp. 60-62.

Return to footnote 4982 referrer

Footnote 4983

Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 213-214.

Return to footnote 4983 referrer

Footnote 4984

Testimony of Maj Dandurand, Transcript of Proceedings, vol. 59, 5 October 2012, p. 34.

Return to footnote 4984 referrer

Footnote 4985

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 43 and 46-47.

Return to footnote 4985 referrer

Footnote 4986

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 42.

Return to footnote 4986 referrer

Footnote 4987

See Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 808; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 205-206; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 261.

Return to footnote 4987 referrer

Footnote 4988

Exhibit P-5, Collection E, vol. 1, tab 2, doc. 1132, p. 808.

Return to footnote 4988 referrer

Footnote 4989

See Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 205 and 207-209; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, pp. 261-262. See, generally, Section 4.3, The 2009 PNOK Investigation; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 4989 referrer

Footnote 4990

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 43-44.

Return to footnote 4990 referrer

Footnote 4991

See Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 43-44.

Return to footnote 4991 referrer

Footnote 4992

See Final Submissions of the Subjects of the Complaint, p. 40.

Return to footnote 4992 referrer

Footnote 4993

Exhibit P-176, doc. 1435, p. 59.

Return to footnote 4993 referrer

Footnote 4994

Exhibit P-176, doc. 1435, pp. 57-59 and 61-62; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 55-56.

Return to footnote 4994 referrer

Footnote 4995

Exhibit P-176, doc. 1435, p. 59.

Return to footnote 4995 referrer

Footnote 4996

Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, p. 43.

Return to footnote 4996 referrer

Footnote 4997

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 13, pp. 2-3.

Return to footnote 4997 referrer

Footnote 4998

See Exhibit P-176, doc. 1435, pp. 49-51; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 27-28 and 30-32.

Return to footnote 4998 referrer

Footnote 4999

Exhibit P-176, doc. 1435, pp. 51-52; Testimony of Prof Roach, Transcript of Proceedings, vol. 60, 9 October 2012, pp. 28-30 and 32.

Return to footnote 4999 referrer

Footnote 5000

See Exhibit P-5, Collection E, vol. 1, tab 1, doc. 1131, p. 18; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, p. 165. See, generally, Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 5000 referrer

Footnote 5001

See, generally, Section 2.0, The Hearing Process.

Return to footnote 5001 referrer

Footnote 5002

See Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 21, 115 and 146-152; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 301-302; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 33, 12 June 2012, pp. 200-203 [Translation]; Testimony of Maj Bolduc, Transcript of Proceedings, vol. 34, 13 June 2012, pp. 1-5 and 95-98 [Translation]; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 10-11 and 220; Exhibit P-6, Collection F, vol. 3, tab 3, doc. 1317, pp. 17-27.

Return to footnote 5002 referrer

Footnote 5003

Exhibit P-6, Collection F, vol. 1, tab 55, doc. 1292, p. 3.

Return to footnote 5003 referrer

Footnote 5004

See Testimony of LCol King, Transcript of Proceedings, vol. 25, 22 May 2012, pp. 113-114.

Return to footnote 5004 referrer

Footnote 5005

See Exhibit P-75, tab 2, doc. 1087-K, p. 3; Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, p. 302; Exhibit P-4, Collection D, vol. 1, tab 48, doc. 045; Exhibit P-4, Collection D, vol. 3, tab 53, doc. 251; Exhibit P-4, Collection D, vol. 4, tab 60, doc. 358; Exhibit P-4, Collection D, vol. 4, tab 62, doc. 360; Exhibit P-4, Collection D, vol. 4, tab 63, doc. 361; Exhibit P-4, Collection D, vol. 4, tab 96, doc. 394; Exhibit P-4, Collection D, vol. 11, tab 76, doc. 1000, pp. 10-13, 17-18 and 21-23. See also, Testimony of LCol King, Transcript of Proceedings, vol. 25, 22 May 2012, pp. 138-139, 143 and 151-153; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 15-16 and 85-86.

Return to footnote 5005 referrer

Footnote 5006

Exhibit P-2, Collection B, vol. 1, tab 1, doc. 1087, pp. 28 and 221. See, generally, Section 4.3, The 2009 PNOK Investigation.

Return to footnote 5006 referrer

Footnote 5007

See Testimony of LCol King, Transcript of Proceedings, vol. 25, 22 May 2012, pp. 156-157; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 57, 3 October 2012, pp. 273-274; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 223-228.

Return to footnote 5007 referrer

Footnote 5008

Testimony of Mr. Martel, Transcript of Proceedings, vol. 41, 27 June 2012, pp. 25 and 27-28.

Return to footnote 5008 referrer

Footnote 5009

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 1, 2 and 3, p. 1.

Return to footnote 5009 referrer

Footnote 5010

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 3 and 5, p. 1.

Return to footnote 5010 referrer

Footnote 5011

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegations 6 and 7, p. 2.

Return to footnote 5011 referrer

Footnote 5012

Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 8, p. 2.

Return to footnote 5012 referrer

Footnote 5013

See Section 4.1, The 2008 Investigation; Section 4.3, The 2009 PNOK Investigation; Section 4.4, The 2010 Criminal Negligence Investigation.

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Footnote 5014

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 150; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 176. See, generally, Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 5014 referrer

Footnote 5015

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 6, p. 2.

Return to footnote 5015 referrer

Footnote 5016

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 196-197; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 77; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 48, 14 September 2012, p. 193; Section 4.1.1, The 2008 Investigation – Investigating the Sudden Death.

Return to footnote 5016 referrer

Footnote 5017

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 155.

Return to footnote 5017 referrer

Footnote 5018

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 71-72; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 67-68.

Return to footnote 5018 referrer

Footnote 5019

Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, p. 68.

Return to footnote 5019 referrer

Footnote 5020

See Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, p. 71-72; Testimony of Sgt Ritco, Transcript of Proceedings, vol. 47, 13 September 2012, pp. 67-68.

Return to footnote 5020 referrer

Footnote 5021

See Testimony of Dennis Caufield, Transcript of Proceedings, vol. 13, 19 April 2012, pp. 45-46; Exhibit P-6, Collection F, vol. 3, tab 4, doc. 1323, p. 2.

Return to footnote 5021 referrer

Footnote 5022

See Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 259; Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 7, p. 2; Closing Submission of the Complainants, p. 23; Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, p. 60; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 196-197 and 203-206.

Return to footnote 5022 referrer

Footnote 5023

Exhibit P-6, Collection F, vol. 3, tab 4, doc. 1323, p. 3.

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Footnote 5024

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 8, p. 2; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 227-229; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 44-47.

Return to footnote 5024 referrer

Footnote 5025

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 59-61; Exhibit P-70, doc. 1358, pp. 16 and 18.

Return to footnote 5025 referrer

Footnote 5026

Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 187-192.

Return to footnote 5026 referrer

Footnote 5027

See Exhibit P-3, Collection C, vol. 1, tab 2, doc. 1088-B, pp. 7-8, 24-26, 62 and 134-135. See also Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 28, 4 June 2012, pp. 191-192.

Return to footnote 5027 referrer

Footnote 5028

Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 29-31, 38 and 41-42.

Return to footnote 5028 referrer

Footnote 5029

See Section 4.5.5, CFNIS Interactions with the Fynes – The ‘Stockholm Syndrome’ Comment.

Return to footnote 5029 referrer

Footnote 5030

Exhibit P-1, Collection A, vol. 1, tab 1, doc. 001, p. 44.

Return to footnote 5030 referrer

Footnote 5031

See Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 94-95.

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Footnote 5032

See Testimony of Mrs. Fynes, Transcript of Proceedings, vol. 17, 7 May 2012, pp. 103-104; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 196, 200 and 212-213; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 84-85, 89-90, 96-97 and 207-208.

Return to footnote 5032 referrer

Footnote 5033

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, p. 212; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, p. 96.

Return to footnote 5033 referrer

Footnote 5034

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 95-96; Closing Submission of the Complainants, pp. 16-17.

Return to footnote 5034 referrer

Footnote 5035

See Exhibit P-1, Collection A, vol. 2, tabs 1-5, docs 001-C to 001-G.

Return to footnote 5035 referrer

Footnote 5036

See Exhibit P-1, Collection A, vol. 2, tabs 6 and 7, docs 001-H and 001-I.

Return to footnote 5036 referrer

Footnote 5037

See Testimony of Mr. Fynes, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 95-96 and 119; Closing Submission of the Complainants, pp. 17, 27 and 61. See, generally, Section 4.1.2, The 2008 Investigation – Investigating Negligence, for a discussion of the CFNIS’ apparent acceptance of the statements made by CWO Ross and Capt Hannah about the conditions put in place for Cpl Langridge and the lack of a suicide watch, and Sections 4.3 and 4.4, The 2009 PNOK Investigation and The 2010 Criminal Negligence Investigation, for a discussion of the CFNIS’ failure to interview members of the Regiment CoC about the allegations.

Return to footnote 5037 referrer

Footnote 5038

See Section 4.3, The 2008 Investigation – Investigating Negligence; Section 4.4, the 2010 Criminal Negligence Investigation.

Return to footnote 5038 referrer

Footnote 5039

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 5, p. 1; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 209-210; Section 4.1.2, The 2008 Investigation – Investigating Negligence.

Return to footnote 5039 referrer

Footnote 5040

See Exhibit P-6, Collection F, vol. 1, tab 5, doc. 1151, Allegation 3, p. 1; Testimony of Mr. Fynes, Transcript of Proceedings, vol. 42, 5 September 2012, pp. 199-200; Exhibit P-2, Collection B, vol. 2, tab 1, doc. 1087-B, p. 117; Section 4.1.4, The 2008 Investigation – The Concluding Remarks.

Return to footnote 5040 referrer

Footnote 5041

See Section 4.1.5, The 2008 Investigation – Supervision and Recordkeeping; Closing Submission of the Complainants, pp. 19-20 and 28.

Return to footnote 5041 referrer

Footnote 5042

See Section 4.1, The 2008 Investigation; Section 4.3, The 2009 PNOK Investigation; Section 4.4, The 2010 Criminal Negligence Investigation.

Return to footnote 5042 referrer

Footnote 5043

Testimony of LCol Delaney, Transcript of Proceedings, vol. 15, 25 April 2012, pp. 10-13; Testimony of Col Lander, Transcript of Proceedings, vol. 43, 6 September 2012, pp. 280-282; Testimony of LCol Sansterre, Transcript of Proceedings, vol. 61, 10 October 2012, pp. 13-15; Testimony of LCol (Ret’d) Garrick, Transcript of Proceedings, vol. 56, 2 October 2012, pp. 102-103.

Return to footnote 5043 referrer

Footnote 5044

Testimony of WO Bigelow, Transcript of Proceedings, vol. 46, 12 September 2012, pp. 310-311 and 318-319; Testimony of PO2 McLaughlin, Transcript of Proceedings, vol. 49, 18 September 2012, pp. 282-284 and 298-299; Testimony of WO (Ret’d) Bonneteau, Transcript of Proceedings, vol. 52, 21 September 2012, pp. 173-175; Testimony of WO Hart, Transcript of Proceedings, vol. 53, 24 September 2012, pp. 154-155; Testimony of Maj Dandurand, Transcript of Proceedings, vol. 58, 4 October 2012, p. 55; Testimony of Sgt Mitchell, Transcript of Proceedings, vol. 29, 5 June 2012, p. 78.

Return to footnote 5044 referrer

Footnote 5045

See Section 4.1.2, The 2008 Investigation – Investigating Negligence; Section 4.3, The 2009 PNOK Investigation; Section 3.3, The 2010 Criminal Negligence Investigation.

Return to footnote 5045 referrer

Volume 1 | Volume 2 | Volume 3

Date modified:: 2017-10-02

Final Report on the Fynes Public Interest Hearing (MPCC 2011‑004) - Volume 2

Table of Contents

IV. The Investigations

4.0 The Subjects of the Complaint: Role, Involvement and Background

The 2008 Sudden Death Investigation

Master Corporal Matthew Ritco

Sergeant Jon Bigelow

Warrant Officer Ross Tourout

Master Warrant Officer Barry Watson

Major Brian Frei

Lieutenant-Colonel Bud Garrick

The 2009 and 2010 Investigations: Primary Next of Kin and Criminal Negligence

Master Seaman Eric McLaughlin

Master Corporal David Mitchell

Sergeant Scott Shannon

Warrant Officer Blair Hart

Warrant Officer Sean Bonneteau

Major Daniel Dandurand

Lieutenant-Colonel Gilles Sansterre

4.1 The 2008 Investigation

4.1.1 Investigating the Sudden Death

Issues Raised by the Complainants

Initial Response to Cpl Langridge’s Death

CFNIS investigators attend at the scene

Arrival of investigator from the Alberta Chief Medical Examiner’s office

Understanding the Allegations: Some Key Questions

What was done and why?

What did the CFNIS members do to analyze the information and evidence available?

Was disrespect shown to Cpl Langridge’s body?

How was the scene processed following the removal of the body? How should this be done for a sudden death?

Processing the Scene: What Was Done and Why?

Expert testimony on processing a death scene

Initial investigation failures at the death scene

Incorrect understanding of jurisdiction by CFNIS investigators

Assessing the Scene and the Evidence

Determining whether the death was suspicious

Drawing inferences from the body

Failing to apprehend the clear indications

Specific Issues Regarding the Processing of the Scene: Handling the Suicide Note

Expert views on handling suicide notes

How was the suicide note handled by the CFNIS?

Specific Issues Regarding the Processing of the Scene: Was Disrespect Shown to Cpl Langridge’s Body?

Who had authority over Cpl Langridge’s body?

Why was Cpl Langridge’s body not lowered sooner?

Assessing the investigative steps taken by CFNIS investigators before the body was removed

Should Cpl Langridge’s body have been covered?

Was Cpl Langridge’s body exposed to passersby?

Contact with the body

Processing the Scene After the Removal of the Body

An erratic approach

Preserving evidence and preventing contamination

Developing a Flexible Approach to Sudden Death Investigations

Proceeding With the Sudden Death Investigation

Understanding what to investigate

Witness interviews

Scope of the investigation

Ruling out foul play

Too much investigation?

MP and CFNIS Policies

The policies in force at the time: MPPTP Chapter 7

What is to be investigated according to the MPPTP

A new protocol: CFNIS SOP 237

The respective roles of the CFNIS and coroners according to the SOP

Guidance as to actions and responses at a death scene

4.1.2 Investigating Negligence

Allegations

Response to the Allegations

Negligence and the Suicide Watch

What was done to investigate potential negligence?

Interview with Capt Lubiniecki

Interview with Cpl Rohmer

Interview with Sgt Hiscock

Interview with Cpl Hurlburt

Interview with MCpl Fitzpatrick

Interview with MCpl Bowden

Interview with CWO Ross

Interview with Capt Hannah

MCpl Ritco’s conclusions about the suicide watch

Misunderstanding Negligence

What was missed: Interviews not conducted

4.1.7 Return of Exhibits^{Footnote 2071}