I talk to the wind
My words are all carried away
I talk to the wind
The wind does not hear
The wind cannot hear.

I’m on the outside looking inside
What do I see
Much confusion
Disillusion
All around me.

• I reiterate my recommendation from my report on the Police Investigating Police (August 2009) that all RCMP member investigations involving death, serious injury or sexual assault should be referred to an external police force or provincial criminal investigation body for investigation. There should be no RCMP involvement in the investigation.

• If, however, the RCMP continues to investigate such matters, then I recommend that the RCMP implement clear policy directives that all investigations in which death or serious bodily injury are involved and which involve RCMP members investigating other police officers will be considered criminal in nature until demonstrated not to be.

• The requirements of the duty to account statement must be clear to all RCMP members. That is not currently the case within the RCMP nationally. As such, I reiterated the recommendation I made in my report on the death of Ian Bush (November 2007) that the RCMP develop a policy that dictates the requirement, timeliness and use of the duty to account that members are obliged to provide.

• . . . it is my belief that positional asphyxia may occur independent of other contributing factors such as delirium. The RCMP should immediately conduct a review of its policies and training regimen to ensure that members are adequately trained with respect to recognizing the risks inherent in, and signs of, positional asphyxia and in taking steps to mitigate those risks.

• . . . the role of the SRR [Staff Relations Representative] is to filter information as between the involved member and the investigators. That is a practice fraught with potential pitfalls. The investigators, particularly in the early stages of an investigation, require facts which are not adulterated or influenced.

• I reviewed the notes taken by each of the responding members with respect to the interaction with and death of Mr. Dziekanski. I found that the quality, completeness and content were well below the standard expected of police officers. . . . The issue of sub-standard note taking has arisen in a number of previous Commission decisions. To date, the Commission has seen no discernable improvement in note taking.

• . . . it was open to the RCMP to initiate an internal investigation into the actions of both the responding members and the media relations officers in order to ascertain whether disciplinary action was warranted. Other than a confirmation that no such investigation(s) were commenced, I have received no other information from the RCMP against which to assess the appropriateness of this decision, or whether the issue was canvassed within the RCMP. Notwithstanding any recommendation I might make at this point with respect to a review of the decision not to conduct such an investigation, the outcome is moot in that no formal disciplinary hearing into an allegation that a member has contravened the Code of Conduct may be initiated more than one year from the time the contravention and the identity of that member become known to the Commanding Officer of the region in which the impugned member is serving. That one year period has now passed. In light of the foregoing, I recommended that the RCMP review its processes and criteria with respect to the initiation of an internal investigation into the conduct of its members to ensure consistency of application across the country. (emphasis added)

• I noted a number of examples in which the information provided to the media was incorrect, and known to be so by the RCMP. The RCMP, however, decided not to correct those known errors.