Here are all 57 jury recommendations from Abdirahman Abdi’s inquest

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After weeks of testimony from police, bystanders, paramedics, doctors and more, a five-person jury ruled Abdirahman Abdi’s death a homicide, and issued 57 recommendations to prevent future deaths.

These are their recommendations to the police force, its board, various provincial ministries and more.

The Ottawa Police Service:

1. The Ottawa Police Service (“OPS”), subject to the oversight of the Ottawa Police Service Board (the “OPSB” or “Board”), should establish an enduring advisory council (the “Mental Health Advisory Council”) tasked with providing recommendations to the OPS relating to its interactions with members of the public with mental health issues and/or who are experiencing a mental health crisis.

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2. The Mental Health Advisory Council should include members of executive leadership of the OPS and peer-run organizations representing the community of persons with lived experience and should engage regularly with the Board.

3. The Mental Health Advisory Council should provide recommendations with respect to:

• a) Developing a coordinated and cohesive OPS-wide mental health strategy specific to improving outcomes where police interact with those in crisis;
• b) Prioritizing available resources to ensure the greatest likelihood of improved outcomes (and defining outcomes sought to the extent not specifically set out in the Strategic Plan);
• c) Providing recommendations for data/ research collection, and expert analysis, relating to mental health and policing in Ottawa;
• d) Providing recommendations relating to policies and procedures of OPS involving OPS’ response to calls for service involving mental health;
• e) Facilitating effective information sharing between OPS and other mental health agencies and service providers in Ottawa to maximize coordination; and
• f) Developing effective mandatory training for all OPS members interacting with the public with significant inputs from organizations of persons with lived and living experience.

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4. The recommendations flowing from the Mental Health Advisory Council should be reported to the OPSB and considered by OPS and OPSB in their respective areas of decision making, including by the Board in review of its policy relating to police response to persons in mental health crisis or those who are living with mental health issues (Policy LE-013).

5. The Mental Health Advisory Council should make recommendations to assist the OPS in developing a strategy to address mandatory and effective training of OPS members on issues relating to mental health. This training strategy should include the following:

• a) Review of existing use of force training module to ensure it adequately emphasizes trauma-informed de-escalation, provides de-escalation strategies specific to those in mental health crisis, and provides intersectional guidance to officers on bias-free policing that addresses stereotypes and biases toward people with mental health issues including how these biases can intersect with other biases such as anti-Black racism;
• b) Creation of evidence-based mandatory training module for all front-line police officers specifically aimed at improving their ability to effectively and sensitively respond to persons in mental health crisis with topics to include de-escalation, crisis intervention, and bias-free policing;
• c) Creation of process by which OPS members should be tested or evaluated on the above-noted mental health training to ensure members are qualified to interact with those in mental health crisis;
• d) Strategy for proper evaluation of the efficacy of any mental health training; and
• e) Strategy for implementing new mental health training module in a manner which incorporates persons with lived experience connected with an organization of persons with lived experience, which is reflective of capacity of OPS and its partners, and which ensures consistent refresher training as appropriate

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6. Any training recommended by the Mental Health Advisory Council should address intersectionality between race, social identity and mental health, as well as specifically recognize the unique challenges Black people who also have serious mental health issues face when they come into contact with police. This unique intersection of Blackness and lived experience of mental health issues should be specifically addressed in any training on Use of Force, de-escalation, and police interaction with such persons.

7. Continue to expand the OPS Mental Health Unit to support sufficient training of Officers and to be a resource in instances where police presence is required for a person in crisis.

8. Continue to refer mental health calls to Alternate Neighbourhood Crisis Response (“ANCHOR”) when suitable.

9. Continue to consistently emphasize the primary goal of non-application of force through any training addressing trauma informed de-escalation.

10. Develop a revised method for identifying and recording call type for the purpose of data collection to allow for recognition that the call includes a mental health component, including where there is an allegation of criminality.

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11. Improve knowledge and awareness for police communicators, including call takers and dispatchers, on the signs of mental health crisis, and ensure that communicators are trained to ask questions directed at determining whether a call involves a mental health crisis.

12. Review and amend policies and procedures for police communicators, including call takers and dispatchers, to ensure that the attending police officer is given all of the relevant and necessary information, including whether there is a potential mental health component involved, to respond to any call.

13. Consider changing Communication Centre communication codes to add a code that will clearly signal to the attending police officer that there is a mental health component to a call to which the officer is being dispatched.

14. Direct attending officers to record sufficient details in their Investigative Actions to identify a call as having a mental health component in order to more accurately track mental health data.

15. Consult with the Community Equity Council (“CEC”) to review and update mandatory training for OPS members to address implicit bias, cultural competency, and anti-Black racism. In conducting this review, OPS and CEC shall consider the following:

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• a) Strategies for reducing structural and logistical inefficiencies to the delivery of the training so that it can be delivered annually. This may include, for example, the creation of a team of trainers qualified to deliver the training;
• b) The incorporation of feedback from external consultants, reputable educators, Black public interest groups, academic sources, and community members of the Black community with relevant lived experiences;
• c) Strategy for evaluating the efficacy of the training module and updating the training as appropriate;
• d) The utility of a scenario-based component to the course which addresses specific stereotypes about members of the Black community that negatively influences police behaviour in use of force events;
• e) Strategy for incorporating a testing or evaluation component to the training; and
• f) Review of existing OPS use of force training module to ensure it is trauma informed and adequately emphasizes implicit bias, cultural competency, anti-racism, and anti-Black racism.

16. Consult with CEC on mandatory anti-Black racism training to ensure that the course:

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• a) Has clear goals, objectives and core competencies, including the identification and elimination of anti-Black racial biases and the net reduction of racial disparities in police use of force events; and
• b) Addresses anti-Black racial biases specific to policing duties, including biases relating to perceptions of dangerousness and threat based on racial stereotypes.

17. Consult with the Mental Health Advisory Council and the CEC regarding the use of Active Bystander for Law Enforcement (“ABLE”) training materials and ways to include an evaluation component to the training, such as using scenario-based training evaluation during training and Body-Worn Camera (“BWC”) reviews in performance supervision.

18. Ensure that OPS Annual Use of Force Requalification Training includes data and analysis on the disparities impacting racial groups and persons in mental health crisis, with officers participating in the training being advised that the data is being provided to expose them to the disparities in an effort to eliminate those disparities.

19. Reformat Annual Use of Force Reports provided to the Board, in consultation with the Board, in order to allow for a ready comparison of year-to-year data on racial disparities and mental health incidents.

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20. In assessing whether, when and/or how to introduce Body-Worn Cameras (BWCs), consider the important role of BWCs in a supervisor’s review of Use of Force incidents and the evaluation of the effectiveness of Use of Force and de-escalation training, as well as the opportunity for BWC recordings to serve as learning tools in such training.

21. Where a person is hospitalized after an interaction with an officer, and there are investigations underway, ensure that officers cooperate with the hospital to allow family members to visit with their loved one, while taking such measures as are necessary to protect the integrity of the investigation(s) and also ensure public safety.

22. The Chief should develop policies and procedures regarding Community Safety and Policing Act, 2019 (“CSPA”) section 81 reports, which must address:

• a) Clear requirements regarding the nature of information and level of detail required;
• b) Qualification, training and knowledge of a report writer in any area that they are reviewing;
• c) Process for consulting subject matter experts in any areas outside the report writer’s qualification, training and knowledge;
• d) A quality assurance process involving review by an officer or supervisor not involved in the investigation; and
• e) A formal tracking system to ensure that the OPSB receives all reports.

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23. The mandatory anti-Black racism courses must include competency and scenario-based training. This training must include an evaluation of each competency covered in the training. Failure to “pass” the evaluation must require re-attendance and reevaluation.

24. The Ottawa Police Service should prepare and provide a report to the Ottawa Police Services Board outlining the history of use of force in the Ottawa Police Service over the past five years and its plan to reduce the racial disparities in use of force. The plan to reduce the racial disparities in use of force should employ a trauma-informed and anti-racist approach.

25. Ensure that the Professional Development Centre (PDC) keeps reliable records of use of force and mandatory course training. These records should be kept in accordance with the applicable legislation and regulations, and they should note: (1) the identity of the trainer(s); (2) the participants; (3) the persons approving the training; (4) the name of the course; (5) a copy of all the materials used to prepare and deliver the course; (6) an explanation for the materials being used; (7) grades of the participants where applicable and the specific competences successfully demonstrated; and (8) any other relevant information.

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The Ottawa Police Services Board:

26. The Board should continue developing a policy for CSPA section 81 reports that specifies the information and level of detail required and includes a formal tracking system to ensure that the Board receives all reports.

27. The Board should provide new Board members with recent relevant inquest recommendations as part of their onboarding package.

28. The Board should consult with external experts in the field of statistics upon receiving the Annual Use of Force Report to ensure an accurate interpretation of the data is applied to strategic and other oversight decisions.

The Ministry of the Solicitor General:

29. Create provincial training framework under the CSPA in consultation with affected communities and stakeholders setting out mandatory training metrics relating to bias, including bias to people with mental health issues, cultural competency, anti-Black racism and the experience of racialized communities.

30. Revise the Provincial Use of Force Report Form to allow officers to identify where an incident has multiple components, including a mental health component.

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31. Increase funding to the Ontario Police College, as well as to municipalities across the province to provide additional funds to police services, to allow for the implementation of recommendations made in this inquest relating to mandatory police training.

The Ontario Police College:

32. Continue assessing and revising, as required, training for police officers on de-escalation techniques, implicit bias awareness, crisis intervention, mechanisms for combating stressful encounters and negotiation techniques. Continue to consult organizations of people with relevant lived experience, including those living with mental health issues.

33. Consider establishing useful means of dialogue with municipal police services to ensure information sharing and knowledge transfer regarding best practices for training for police officers, including, but not limited to, training on de-escalation techniques, implicit bias awareness, crisis intervention, mechanisms for combating stressful encounters and negotiation techniques.

34. Following the death of an individual in police custody, consult with the involved municipal police service to consider developing training scenarios that incorporate lessons learned from the section 81 CSPA investigation and/ or the SIU investigation relating to the death.

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35. Include use of force data and expert analysis on the disparities impacting racial groups and persons in mental health crisis in:

• a) Training for new recruits; and
• b) Training for annual use of force qualification

36. Develop videos by peer run organizations representing people with lived experience involving skilled people who have had experience of crisis to assist officers in understanding best practices in interacting with persons in crisis. The videos are to be made available to municipal police services.

37. With the consent of affected families, expose officers to recordings of real fatal use of force events involving racialized minorities, to be followed by exposure to videos of trained actors simulating best practices with respect to the same events.

38. Shall revise Defensive Tactics Study Guide (Ontario Police College Basic Constable Training Program) to reflect that strikes to the head, aside from being a risk of injury to the Officer’s hand, can be harmful and result in significant injuries to the recipient.

The Ottawa Police Service and the Ontario Police College:

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39. Continue to train officers to take a trauma-informed approach when interacting with members of public.

40. Ensure that, in addition to standard first aid training, all officers receive additional instruction on police duty of care, including, but not limited to:

• a) Their obligation to follow their first aid and CPR training in relation to the care of apparently unconscious persons;
• b) How to manage officer safety in pulse-taking and other components of CPR when the subject has shown previous aggression; and
• c) The importance of communicating to paramedics and hospital staff all known information about the cause of any injury.

41. Train officers to recognize and avoid the risk of positional asphyxia and prone restraint cardiac arrest.

The Ottawa Guiding Council for Mental Health and Addictions:

42. Invite people from groups representing people with lived experience to participate in ongoing and future projects to address the mental health needs of the Ottawa community members.

The City of Ottawa and Ottawa Public Health:

43. Consider how to coordinate efforts across all responding organizations (i.e. police, ANCHOR, paramedics, etc.) to maximize resources and efficiency in servicing individuals in mental health crisis.

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44. Work in tandem with peer run organization(s) of people with lived experience community agencies and initiatives to promote and raise awareness of alternate responses and mental health resources and services and to reduce stigma. Peer run organization of people with lived experience would Co-Chair this initiative.

The City of Ottawa, Ministry of Health and Ministry of the Solicitor General:

45. Consult on ways, and provide funding, to evaluate and expand the availability of ANCHOR or similar community-based, peer led 24/7 crisis intervention programs to the entire City of Ottawa. Such programs should be developed with input from and collaboration with community-led bodies, particularly peer run organizations representing people with lived experience with representation from local and impacted populations.

The City of Ottawa:

46. Prioritize and assist with the development of a mental health response strategy based on the Guiding Council’s ongoing consultations with Ottawa’s Somali and African, Caribbean and Black communities, including the introduction of a community centre offering a safe space to gather, culturally appropriate counselling and other mental health services and resources.

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47. Prioritize and assist with the development of wrap around supports and community-based mental health peer supports in priority neighbourhoods with a goal of reducing or preventing incidents of crisis.

The Centretown Community Health Centre and the Somerset West Community Health Centres:

48. Ensure that the advertising of ANCHOR to the geographic area served provides clear information to assist individuals in accessing the service.

The Ministry of The Solicitor General and the Ministry of Health:

49. Consider expanding the availability of community-based, peer led 24/7 crisis intervention programs to all municipalities in Ontario. Such programs should be developed with input from and collaboration with community-led bodies, particularly peer run organizations representing people with lived experience with representation from local and impacted populations.

The Ministry of Health:

50. Prioritize providing sufficient funding to the Ottawa Paramedic Service Mental Wellbeing Response Team to allow for 24/7 operation in the City of Ottawa.

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51. Provide funding for facilities in Ottawa that provide persons in crisis short-term supportive care in a non-hospital environment, including:

• a) Crisis Receiving and Stabilization Facilities where persons may receive clinical, medical and/or other care; and/or
• b) Peer Respite Centres where persons may receive non-clinical and non-coercive care from skilled persons with lived experience.

52. Increase funding for community-based case management supports and services targeted towards persons living with significant mental health and life challenges, following consultation with peer organizations of people with lived experience that include people with this history.

The Ottawa Paramedic Service:

53. Include training by a peer-run organization representing persons with lived experience in the training of paramedics who are part of the Mental Wellbeing Response Team.

The Office of the Chief Coroner:

54. Conduct inquests in as expeditious a manner as possible from the date of the death, recognizing:

• a) A trauma-informed approach for family, witnesses and community; and
• b) Preserving best evidence.

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The Public Health Agency of Canada, Public Health Ontario and Ottawa Public Health:

55. Collaborate on the creation of public awareness campaigns that address:

• a) The unique mental health challenges facing Black and immigrant communities to reduce stigma around seeking mental health support;
• b) The cultural, religious, systemic, and socio-economic factors that impact these communities;
• c) Public education on recognizing persons in crisis and responding with a trauma-informed approach; and
• d) Information about how members of the public can connect with mental health services and resources in their communities, in accordance with the “no wrong door” approach.

The Canadian Psychiatric Association:

56. Consider issuing updated detailed guidance to psychiatrists on offering patients the option of treatment with long-acting injectable antipsychotic medication, in accordance with patient preference.

The Province of Ontario:

57. Provide funding to allow for the implementation of recommendations made in this inquest.

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