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Renfrew County Inquest Recommendations for Change

January 6, 2023 |

Renfrew County Inquest Recommendations for Change

86 Recommendations for Change from the Inquest into the Death of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam

The Government of Ontario should:

Oversight and Accountability

  1. Formally declare intimate partner violence as an epidemic.
  2. Establish an independent Intimate Partner Violence Commission dedicated to eradicating intimate partner violence (IPV) and acting as a voice that speaks on behalf of survivors and victims’ families, raising public awareness, and ensuring the transparency and accountability of government and other organizations in addressing IPV in all its forms. The Commissioner should have sufficient authority to ensure meaningful access to any person, document or information required to accomplish the Commission’s mandate. The Commission should be provided with adequate and stable funding to ensure effectiveness.
  3. Engage in meaningful consultation with IPV stakeholders and experts in the field, to determine the mandate and responsibilities of the IPV Commission, which may include: a. Driving change towards the goal of eradicating IPV in Ontario, b. Evaluating the effectiveness of existing IPV programs and strategies, including the adequacy of existing funding, c. Analyzing and reporting on all IPV-related issues with a view to improving awareness of IPV issues and potential solutions, d. Advocating for survivors and their families having regard to addressing the systemic concerns of survivors navigating the legal system. Consideration should be given to the United Kingdom’s Domestic Abuse Commissioner model in developing the mandate of the Commission.
  4. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system.
  5. Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. The committee should include senior members of relevant ministries central to IPV and an equal number of community IPV experts. It should be chaired by an independent IPV expert who could speak freely on progress made on implementation.
  6. Amend the Coroners Act to require the recipient of an inquest recommendation to advise the Office of the Chief Coroner if a recommendation is complied with or to provide an explanation if it is not implemented.

System Approaches, Collaboration and Communication

7. Ensure that IPV issues are addressed using an all-of-government approach across
ministries, and cooperate and coordinate with federal, provincial, and territorial
partners in seeking to end IPV.

8. Require that all justice system participants who work with IPV survivors and
perpetrators are trained and engage in a trauma-informed approach to interacting
and dealing with survivors and perpetrators.

9. Explore incorporating restorative justice and community-based approaches in
dealing with appropriate IPV cases to ensure safety and best outcomes for

10. Encourage that IPV be integrated into every municipality’s community safety and
well-being plan.

11. Study the feasibility of, and implement if feasible, justice sector participants having
access to relevant findings made in family and civil law proceedings for use in
criminal proceedings, including at bail and sentencing stages. The study would, in
part, inquire into the following:
a. The process to identify relevant findings and for sharing those findings with other
justice participants,
b. Which justice participants should have access to the findings made by a civil or
family court,
c. What documents from civil and family law proceedings should be shared with
justice sector participants, and how to facilitate sharing of such documents,
d. What permissible uses could be made of the documents and findings in a
criminal proceeding,
e. Models in other jurisdictions that identify relevant IPV cases in different courts.

12. Ensure that survivors and those assisting survivors have direct and timely
communication with probation officers to assist in safety planning.

13. Require all police services to immediately inform the Chief Firearms Officer (CFO) of
IPV-related charges after they are laid, and provide any relevant records, including
Firearms Interest Police information.

14. Create a “Universal RMS” records management system accessible by all police
services (including federal, provincial, municipal, military and First Nations) in
Ontario, with appropriate read/write access to all IPV stakeholders, including
Probation, CFO, Crown’s offices, Ontario Court of Justice, Superior Court of Justice,
correctional institutions and parole boards. Police services that wish to use their own
RMS are to update IPV information into the Universal RMS.

15. Require primary actors involved in a major incident to conduct a formal de-brief and
write a report identifying lessons learned and recommendations for improvement, if

16. Review policies to ensure the timely, reliable, consistent, and accurate dissemination
of information, including the use of emergency alerts and media releases, where the
police are aware of circumstances that could put the public in danger, and that the
focus is on safety when developing policies regarding what information to share with
whom and when. Consideration should be given to disseminating information
through alternative methods where cellular service is not consistently available.

17. Establish clear guidelines regarding the flagging of perpetrators or potential IPV
victims in police databases, immediate dispatch and police access to the identities
and contact information of potential targets, and how to notify those targets.


18. Recognize that the implementation of the recommendations from this Inquest,
including the need for adequate and stable funding for all organizations providing
IPV support services, will require a significant financial investment and commit to
provide such funding.

19. Create an emergency fund, such as the “She C.A.N Fund”, in honour of Carol
Culleton, Anastasia Kuzyk and Nathalie Warmerdam to support women living with
IPV who are taking steps to seek safety. This fund should include the following:
a. Easy, low-barrier access for IPV survivors seeking to improve their safety,
b. Referral to the fund through IPV service providers,
c. Small grants of up to $7000,
d. It should have no impact on Ontario Works or Ontario Disability Support Plan
e. Consideration for the needs of rural and geographically remote survivors of
f. Funding to be provided on an annualized basis, with adequacy assessed and
considered after the first three years,
g. Inject a significant one-time investment into IPV related support services.

20. Realign the approach to public funding provided to IPV service providers with a view
to removing unnecessary reporting obligations with a focus on service. Draw on
best practices in Canada and internationally, and adopt and implement improved,
adequate, stable, and recurring funding that incorporates the following:

a. IPV services are core programming and should receive annualized funding
like other public services,
b. Service providers provide one annual report for all funders across
government to account for the funds received, articulate results and highlight
key challenges, learnings, and accomplishments,
c. Recognition that, in remote and rural areas, funding cannot be the per-capita
equivalent to funding in urban settings as this does not take into account rural
realities, including that:
i. IPV is more prominent in rural areas,
ii. Economies of scale for urban settings supporting larger numbers of
iii. The need to travel to access and provide services where telephone
and internet coverage is not available,
iv. The lack of public transit,
v. The cost of transportation for survivors and service providers.
d. Consideration of the remoteness quotient used to calculate funding in other
social services, such as education and policing,
e. Enhanced funding for IPV service providers, including shelters, sexual assault
support centres, victim services, and counselling services, considering urban
and rural realities,
f. Designated funding for transportation for those receiving IPV-related support
services where public transportation is inadequate or unavailable, such as in
Renfrew County,
g. Funding to ensure mental health supports for IPV service providers, as well
as timely access to trauma supports immediately following a traumatic event,
h. Funding for services provided to survivors that allows for the hiring and
retention of skilled and experienced staff so that they are not required to rely
on volunteers and fundraisers in order to provide services to survivors,
i. Funding for mobile tracking system alarms and other security supports for
survivors of IPV,
j. Funding for counselling for IPV survivors,

k. Funding for services dedicated to perpetrators of IPV.

  1. Develop a plan for enhanced second-stage housing for IPV survivors.
  2. Fund for “safe rooms” to be installed in survivors’ homes in high-risk cases.
    Education and Training
  3. Develop and implement a new approach to public education campaigns to promote
    awareness about IPV, including finding opportunities to reach a wider audience in
    rural communities. These messages should promote broad recognition of how to
    seek support, risk factors, and warning signs of IPV, community and bystander
    engagement, be accessible in multiple languages and in multiple formats, and
    ensure that rural residents can identify themselves in the messaging and materials.
  4. Complete a yearly annual review of public attitudes through public opinion research,
    and revise and strengthen public education material based on these reviews,
    feedback from communities and experts, international best practices, and
    recommendations from the Domestic Violence Death Review Committee (DVDRC)
    and other IPV experts.
  5. Use and build on existing age-appropriate education programs for primary and
    secondary schools, and universities and colleges. Such programs should include:
    violence prevention, recognizing healthy and abusive relationships, identifying subtle
    indicators of coercive control, understanding risk factors (such as stalking, fear
    caused by IPV, strangulation, threats to kill), managing and processing feelings,
    dispute resolution, community and bystander obligations, the need for safety
    planning and risk management, and the unique experiences in rural and urban
  6. Ensure teachers are trained to deliver the IPV-related curriculum and utilize IPV
    professionals regularly to provide support for the delivery of primary, secondary, and
    post-secondary programming.
  7. Develop a roster of resources available to support classroom teachers in the delivery
    of primary, secondary, and post-secondary programming where local IPV
    professionals are not available.
  8. Review existing training for justice system personnel who are within the purview of
    the provincial government or police services.
  9. Provide professional education and training for justice system personnel on IPVrelated issues, which should include:
    a. Annual refresher courses,
    b. Risk assessment training with the most up-to-date research on tools and risk
    c. Trauma-informed practices, including an understanding of why survivors may
    recant or may not cooperate with a criminal investigation, best practices for
    managing this reality, and investigation and prosecution of perpetrators,
    d. Crisis management training,
    e. The availability and use of weapons prohibition orders in IPV cases,
    f. Meaningful screening of sureties,
    g. Greater use of court-ordered language ensuring alleged and convicted
    offenders will not reside in homes that have firearms,
    h. Indicators of IPV including coercive control, and awareness of risk factors for
    lethality (including destruction of property, especially by fire, harm to pets,
    strangulation, criminal harassment, stalking, sexual violence, and threatening
    i. Unique rural factors,
    j. Firearm risks, including the links between firearm ownership and IPV,
    k. Opportunities for communities, friends, and families to play a role in the
    prevention and reporting of IPV.
  10. Provide specialized and enhanced training of police officers with a goal of
    developing an IPV specialist in each police detachment
  11. Track whether mandated IPV-related professional education and training is
    completed by all justice system personnel.
    Measures Addressing Perpetrators of IPV
  12. Establish a province-wide 24/7 hotline for men who need support to prevent them
    from engaging in IPV.
  13. Provide services aimed at addressing perpetrators of IPV that should include:
    a. An approach that is not one-size-fits-all,
    b. A variety of group-based interventions augmented with individual counseling
    and case management sessions to assess and manage risk and to
    supplement services, as needed, to address individual needs,
    c. Peer support and appropriate circles of support, d. Prioritizing the development of cross-agency and cross-system collaborative services, e. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services, f. The ability to respond immediately with risk management services in collaboration with IPV service providers, g. Being accessible by clients voluntarily and via referral, and not just through the criminal justice system, h. Programs are funded at a level that anticipates an increased stream of referrals, i. Make in-custody IPV programs available in the community as well so that offenders can complete programs started in custody, j. Conducting audits of PARs and other perpetrator intervention programs for efficacy, consistency, and currency, k. Increasing program availability and develop flexible options for IPV perpetrators on remand, serving sentences, and in the community.
  14. Recognize the specialized knowledge and expertise of IPV service providers
    involved in perpetrator intervention and support the development of workforce
    capacity within the sector by developing and providing competency-based training
    opportunities. Service contracts should include funding for supervision and ongoing
    professional development, and mental health support.
  15. Address barriers and create opportunities and pathways to services for IPV
    perpetrators that can be accessed in the community. Referrals to service providers
    should be made as early as possible and should be repeatedly and persistently
    offered to both engage perpetrators and reinforce the need for perpetrators to be
    accountable for their abusive behaviours.
  16. Improve the coordination of services addressing substance use, mental health, child
    protection, and IPV perpetration, and encourage cross-agency service provision and
    case management.
  17. As new services are funded, include aims and outcomes associated with building an
    underlying network of specialized services to address IPV perpetration and
    developing messaging around its availability.
  18. Ensure that IPV-related public education campaigns address IPV perpetration and
    should include men’s voices, represent men’s experiences, and prompt men to seek help to address their own abusive behaviours. They should highlight opening the door to conversations about concerning behaviours.
  19. Endeavour to minimize destabilizing factors for perpetrators of IPV that increase risk,
    correlates of IPV, and barriers for survivors to leave violence. Specific consideration
    should be given to financial instability, housing insecurity, and mental health issues,
    including addictions treatment options, and how these factors and potential solutions
    are affected by rural contexts. Intervention
  20. Explore amending the Family Law Act, following meaningful consultation with
    stakeholders, including survivors and IPV service providers, to provide authority to
    order counselling for the perpetrator where IPV findings are made by the family
  21. Investigate and develop a common framework for risk assessment in IPV cases,
    which includes a common understanding of IPV risk factors and lethality. This should
    be done in meaningful consultation and collaboration with those impacted by and
    assisting survivors of IPV, and consider key IPV principles, including victim-centred,
    intersectional, gender-specific, trauma-informed, anti-oppressive, and evidencebased approaches.
  22. Co-train justice system personnel and IPV service providers on the risk assessment
    framework and tools so that there is a common understanding of the framework and
    tools for those who support or deal with survivors.
  23. Ensure that survivor-informed risk assessments are incorporated into the decisions
    and positions taken by Crowns relating to bail, pleas, sentencing, and eligibility for
    Early Intervention Programs.
  24. Clarify and enhance the use of high-risk committees by:
    a. Strengthening provincial guidelines by identifying high-risk cases that should
    be referred to committee,
    b. Identifying and including local IPV service providers that are in a position to
    assist with case identification, safety planning, and risk management.
    Consideration should be given to including IPV service providers supporting
    perpetrators, c. Ensuring that involved IPV service providers at high-risk committees are given the necessary information to facilitate their active participation, subject to victim consent where applicable.
  25. Establish policies making clear that, absent exceptional circumstances, those
    assessed as high risk or where the allegations involve strangulation should not
    qualify for early intervention. Crowns should also consider a history of IPV whether
    or not convictions resulted when determining whether early intervention is
    appropriate. Safety
  26. Study the best approach for permitting disclosure of information about a perpetrator’s history of IPV and the potential risk to new and future partners who request such information, with a view to developing and implementing legislation. In doing so, study Clare’s law in the United Kingdom and similar legislation in Saskatchewan, Alberta and Manitoba, Bill 274 (Intimate Partner Violence Disclosure Act, 2021), and any other relevant legislation and policy. In the interim, develop a draft policy that can address this issue.
  27. Set up IPV Registry for repeat IPV offenders similar to the Sex Offender Information
    Registry Act registry.
  28. Explore the implementation of electronic monitoring to enable the tracking of those
    charged or found guilty of an IPV-related offence and enable the notification of
    authorities and survivors if the individual enters a prohibited area relating to a
    survivor. In determining the appropriateness of such a tool in Ontario, monitor the
    development of programs utilizing such technology in other provinces, with specific
    consideration given to: a. Coverage of cellular networks, particularly in remote and rural regions, b. Storage rules and protocols for tracking data, c. Appropriate perpetrator programs and supports needed to accompany electronic monitoring, d. Whether the tool exacerbates risk factors and contributes to recidivism, e. Understanding any impacts after an order for such technology expires, f. Frequency and impact of false alarms, g. The appropriateness of essential services being provided by private, for-profit partners.
  29. Start grassroots “Safe Spaces” program that businesses can participate in where
    survivors can feel safe and ask for information (i.e. pamphlets and handouts from
    women’s shelters, VWAP and men’s programs).
  30. In referrals made by the OPP to Victim Services, ensure adequate information is
    provided, including relevant history, safety concerns and known risk factors.
  31. Ensure that OPP conduct a study on improving tactical response timelines as it
    applies to rural environments generally and in IPV cases in particular.
  32. Expand cell service and high-speed internet in rural and remote areas of Ontario to
    improve safety and access to services.
  33. Set up satellite offices for police officers to work safely and comfortably to spread
    police resources more evenly over wide rural areas (i.e. consider asking schools and
    municipal governments to provide office space).
  34. Enhance court supports for IPV survivors and develop an IPV-focused model for
    criminal courts similar to the Family Court Support Worker Program. Consideration
    should be given to the independent legal advice program for survivors of sexual
    violence as a model for IPV survivors.
  35. Encourage Crowns to consult with the Regional Designated High-Risk Offender
    Crown for any case of IPV involving a high-risk offender that may meet the criteria
    for Dangerous or Long-term Offender designations.
  36. Crowns should actively oppose variation requests to have firearms returned for any
    purpose, such as hunting.
  37. Strengthen annual education for Crowns regarding applications for Dangerous and
    Long-term Offender designations in high-risk IPV cases.
  38. Commission a comprehensive, independent, and evidence-based review of the
    mandatory charging framework employed in Ontario, with a view to assessing its
    effect on IPV rates and recidivism, with particular attention to any unintended
    negative consequences.
  39. Conduct study of judges’ decisions in IPV cases and track in longitudinal studies for
    recidivism, violence escalation, and future victims.
  40. Review and amend, where appropriate, standard language templates for bail and
    probation conditions in IPV cases, and develop a framework for identifying the
    appropriate conditions based on level of risk in collaboration with stakeholders,
    including judges, justices of the peace, police, probation, crown attorneys, the CFO,
    and community providers with subject matter expertise in IPV risk management. The
    following factors should be considered:
    a. Enforceability,
    b. Plan for removal or surrender of firearms and the Possession and
    Acquisition License (PAL),
    c. Residence distance from victims,
    d. Keeping probation aware,
    e. Safety of current and previous victims,
    f. Possibility of a "firearm free home" condition,
    g. Past disregard for conditions as a risk factor.
  41. Require that primary actors advise the CFO in a timely manner of expected and
    changed residential addresses of individuals who have been placed under weapons
  42. When evaluating the suitability of a prospective surety in IPV cases, Crowns should
    make inquiries as to whether residential sureties have firearms in their home or a
  43. Develop a process, in consultation with the judiciary, to confirm that release
    conditions are properly documented.
  44. Ensure that Probation Services reviews and, if necessary, develops standardized
    protocols and policies for probation officers with respect to intake of IPV offenders
    and with respect to victim safety.
  45. Review the mandate of Probation Services to prioritize:
    a. Condition compliance,
    b. Victim safety,
    c. Offender rehabilitation.
  46. Require that probation officers, in a timely manner, ensure:
    a. There is an up-to-date risk assessment in the file, b. Probation conditions are appropriate for the level of risk of the client and written in a way they can enforce, and, if not, request a variation, c. They contact the survivor to inform her of the offender’s living situation, any conditions or limitations on his movement or activities, and what she should do in the event of a possible breach by the offender, d. Regular contact with survivors to receive updates, provide information regarding the offender’s residence and locations frequented, and any changes to such circumstances, and seek input from survivors and justice system personnel before making decisions that may impact her safety, e. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivor’s needs and safety, f. Risk assessments and risks of lethality are taken into account when making enforcement decisions.
  47. Ensure existing policy and guidelines require probation officers to follow through on
    enforcement of non-compliance by requiring delivery and documentation of clear
    instructions regarding expectations to supervised offenders in a way that allows for
    direct and progressive enforcement decisions. This should be a focus for
    performance management and quality assurance processes.
  48. Ensure collaboration between corrections and probation staff to improve
    rehabilitation and risk management services. Consideration should be given to twoway information sharing including of case notes, and opportunities to order treatment
    in institutions for those with existing probation orders who are on remand. To the Chief Firearms Officer: The Chief Firearms Officer should work with appropriate decision-makers to:
  49. Review the mandate and approach of the CFO’s Spousal Support line to:
    a. Change its name to one that better reflects its purpose. It should be clear that
    it is broadly accessible and not limited to a particular kind of relationship,
    b. Be staffed 24 hours a day and 7 days a week,
    c. Be publicized to enhance public awareness, and become better known
    among policing partners possibly through All Chiefs’ bulletins.
  50. Create guidelines for staff in making decisions regarding whether to issue, review,
    revoke, or add conditions to PALs to ensure consistency among staff and through time. Particular attention should be paid to red flags and risk factors around IPV, including where there is no conviction.
  51. Require that a PAL is automatically reviewed when someone is charged with an IPVrelated offence.
  52. Require PAL applicants and holders to report to the CFO in a timely manner any
    change in information provided in application and renewal forms submitted to the
    CFO, including when an individual with weapons restrictions comes to reside in their
  53. Amend PAL application and renewal forms to require identification as a surety. To the Office of the Chief Coroner The Office of the Chief Coroner should:
  54. Ensure that the DVDRC reviews its mandate with a view to enhancing its impact on
    IPV and provide the DVDRC with improved supports.
  55. Ensure DVDRC annual reports are published online in a timely manner.
  56. Ensure that DVDRC reports and responses to recommendations are publicly
    available and will continue to be available without charge.
  57. Consider adopting Femicide as one of the categories for manner of death.
    To the Information and Privacy Commissioner of Ontario
    The Information and Privacy Commissioner of Ontario should:
  58. Working together with the DVDRC, justice partners and IPV service providers,
    develop a plain language tool to empower IPV professionals to make informed
    decisions about privacy, confidentiality, and public safety. To the Government of Canada The Government of Canada should:
  59. Explore adding the term “Femicide” and its definition to the Criminal Code to be used where appropriate in the context of relevant crimes.
  60. Consider amendments to the Dangerous Offender provisions of the Criminal Code,
    or the inclusion of a new classification of Offender under the Criminal Code, that better reflects the realities of IPV charges and takes into account risk factors for serious violence and lethality in an IPV context.
  61. Undertake an analysis of the application of s. 264 of the Criminal Code with a view
    to evaluating whether the existing factors adequately capture the impact on
    survivors. Consider the removal of the subjective requirement that the action causes
    the victim to fear for their safety.
  62. Consider finding alternate means for survivors to attend and testify in court, such as
    by video conferencing.
  63. Implement the National Action Plan on Gender-based Violence in a timely manner.
  64. Establish a Royal Commission to review and recommend changes to the Criminal
    Justice system to make it more victim-centric, more responsive to root causes of
    crime and more adaptable as society evolves.
  65. Include “coercive control”, as defined in the Divorce Act, as a criminal offence on its
    own or as a type of assault under s. 265 of the Criminal Code.
    To the Parties to this Inquest
    The Parties to this Inquest should:
  66. Reconvene one year following the Verdict to discuss the progress in implementing
    these recommendations. Source: https://lukesplace.ca/86-recommendations-for-change-from-the-renfrew-county-inquest/

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