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
Formally declare intimate partner violence as an epidemic.
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.
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.
Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system.
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.
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 survivors.
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 appropriate.
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 payments, e. Consideration for the needs of rural and geographically remote survivors of IPV, 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 survivors, 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.
Develop a plan for enhanced second-stage housing for IPV survivors.
Fund for “safe rooms” to be installed in survivors’ homes in high-risk cases. Education and Training
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.
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.
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 settings.
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.
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.
Review existing training for justice system personnel who are within the purview of the provincial government or police services.
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 factors, 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 police), 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.
Provide specialized and enhanced training of police officers with a goal of developing an IPV specialist in each police detachment
Track whether mandated IPV-related professional education and training is completed by all justice system personnel. Measures Addressing Perpetrators of IPV
Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in IPV.
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.
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.
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.
Improve the coordination of services addressing substance use, mental health, child protection, and IPV perpetration, and encourage cross-agency service provision and case management.
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.
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.
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
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 court.
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.
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.
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.
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.
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
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.
Set up IPV Registry for repeat IPV offenders similar to the Sex Offender Information Registry Act registry.
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.
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).
In referrals made by the OPP to Victim Services, ensure adequate information is provided, including relevant history, safety concerns and known risk factors.
Ensure that OPP conduct a study on improving tactical response timelines as it applies to rural environments generally and in IPV cases in particular.
Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services.
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).
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.
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.
Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting.
Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk IPV cases.
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.
Conduct study of judges’ decisions in IPV cases and track in longitudinal studies for recidivism, violence escalation, and future victims.
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.
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 conditions.
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 PAL.
Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented.
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.
Review the mandate of Probation Services to prioritize: a. Condition compliance, b. Victim safety, c. Offender rehabilitation.
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.
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.
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:
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.
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.
Require that a PAL is automatically reviewed when someone is charged with an IPVrelated offence.
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 home.
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:
Ensure that the DVDRC reviews its mandate with a view to enhancing its impact on IPV and provide the DVDRC with improved supports.
Ensure DVDRC annual reports are published online in a timely manner.
Ensure that DVDRC reports and responses to recommendations are publicly available and will continue to be available without charge.
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:
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:
Explore adding the term “Femicide” and its definition to the Criminal Code to be used where appropriate in the context of relevant crimes.
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.
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.
Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing.
Implement the National Action Plan on Gender-based Violence in a timely manner.
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.
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:
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/