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

Table of Contents

  1. Overview
  2. The Hearing Process
  3. Narrative
  4. The Investigations
    1. 4.0 The Subjects of the Complaint: Role, Involvement and Background
    2. 4.1 The 2008 Investigation
      1. 4.1.1 Investigating the Sudden Death
      2. 4.1.2 Investigating Negligence
      3. 4.1.3 The Investigation Plan
      4. 4.1.4 The Concluding Remarks
      5. 4.1.5 Supervision and Recordkeeping
      6. 4.1.6 Search Warrants
      7. 4.1.7 Return of Exhibits
      8. 4.1.8 The Quality Assurance Review
      9. 4.1.9 The Consequences of Inexperience
    3. 4.2 The Suicide Note Left by Cpl Langridge
    4. 4.3 The 2009 PNOK Investigation
    5. 4.4 The 2010 Criminal Negligence Investigation
    6. 4.5 CFNIS Interactions with the Fynes
    7. 4.6 CFNIS Independence and Impartiality
  5. Findings
  6. Recommendations
  7. The Military Police Response
    1. 7.0 The Military Police Response
    2. 7.1 The Notice of Action | PDF version (as released March 10, 2015)
  1. 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 (as released March 10, 2015)

I. Overview


1. There are at least three separate and distinct audiences for this report.

2. The first audience consists of the parties, namely the complainants and the subjects of the complaint. Their focus will be on the findings and conclusions reached by the Commission with respect to each of the 30 allegations making up the complaint.

3. A second audience is the Canadian Forces National Investigation Service (CFNIS) and the Canadian Forces Provost Marshal (CFPM), who is the head of the Military Police, of which the CFNIS is a part. While also obviously a primary audience for the Commission’s specific findings on each allegation, the CFPM will also focus on the Commission’s recommendations arising from those conclusions.

4. A third audience is the Canadian public at large. The National Defence Act (NDA) allows the MPCC to hold a public hearing where warranted. One obvious reason for public hearings is to promote confidence in the Military Police complaints resolution process through open and transparent hearings. Since public hearings also deal with systemic issues of public importance, a report of the proceedings can promote awareness of the issues underlying the particular complaints, explain why they are important and point out the implications of the Commission’s conclusions.

5. Each of these interests of the three respective audiences is dealt with in the body of this report. The Commission’s conclusions as to each of the allegations are set out in one place in the chapter entitled “Findings”, which also provides a short explanation of the reasons for each finding. The Commission’s recommendations, aimed at addressing any deficiencies, gaps or other concerns identified in the Findings or the report as a whole, are addressed in the “Recommendations” chapter. That chapter sets out, under topic headings, the Commission’s specific recommendations on each subject along with a brief rationale. The necessary facts and other background information to allow for an understanding of the Findings and the Recommendations is to be found in the body of the report in chapters 2.0 to 4.6, which are organized by topic. In the report, unless otherwise specified, the ranks of individual CF members mentioned are their ranks at the time of the event(s).

6. In recognition of the potential usefulness of a roadmap and explanatory comments, the Commission also offers this Overview, which is intended to orient the general reader to the contents of the report.

7. The status of this Overview as road map and commentary means it is not a substitute for reading the report itself, nor is it an executive summary in the usual sense of a précis of the full contents. Not every issue addressed in the report is set out in this Overview. While the sections of the Overview correspond to a number of the chapter headings of the report, some issues dealt with in several chapters of the report are brought together in one section of the Overview. Some linkages made explicit in the Overview may only seem implicit in the report, and the order in which issues are discussed may be different.

8. In reading this Overview as well as the full report, the reader should bear in mind the jurisdiction of this Commission. The role of the Commission is to investigate specific complaints about Military Police investigations and/or conduct. In the present case, those complaints arise in the context of separate grievances on the part of the complainants, Shaun and Sheila Fynes, about what the Canadian Forces did and did not do in connection with the death by suicide of their son, Cpl Stuart Langridge. The Fynes brought to the attention of the CFNIS a number of complaints against the CF they asked to be investigated. Their complaints about the CFNIS’ conduct arise from how those complaints against the CF were dealt with, or not dealt with, by the CFNIS. Their complaints about the CFNIS also deal with a number of matters arising from various contacts, communications and other interactions between the Fynes and the CFNIS over a three-year period following Cpl Langridge’s death.

9. It is important to keep in mind the focus of this Commission must at all times be on the complaints about the CFNIS and its members. There is no mandate for the Commission to investigate the substantive complaints against the Canadian Forces underlying the Fynes’ complaints about the CFNIS’ conduct. On the other hand, it is inevitable in the course of considering the thoroughness, accuracy and impartiality of the CFNIS investigations, the Commission must have regard for what it was the Fynes were alleging about the CF. Although those underlying issues are of considerable potential public interest and importance, it cannot be the role of this Commission to offer an opinion as to their merits. All this Commission can do is to review and comment on what the CFNIS did in response and how it conducted itself in the course of its interactions with the complainants. Because this Commission has come to the conclusion a number of matters presented by the complainants to the CFNIS were not properly investigated, it must be emphasized and re-emphasized, this conclusion does not extend to any conclusion at all about the likely outcome had a proper investigation been conducted.

The Complaints

10. Cpl Stuart Langridge was found dead, hanging from a ligature fashioned from his military belt, attached to the chin-up bar in an army barracks room. The CFNIS conducted three separate investigations into matters connected with his death. The first, the 2008 Investigation, was intended to investigate the sudden death and to determine whether there were grounds to suspect foul play. The second, the 2009 Investigation, arose from complaints by the Fynes about a decision to give authority over Cpl Langridge’s funeral to someone other than them. The third, the 2010 Investigation, arose from their allegations that members of the CF were culpably negligent in connection with this death.

11. The complainants allege deficiencies with respect to each of these investigations. They allege some or all of these deficiencies are related to a lack of independence by the CFNIS and a bias on the part of its members in favour of the military and its chain of command. They also allege the deficiencies are related to a lack of skills, professionalism, competence, experience or training on the part of the CFNIS members involved. In addition, they complain about the CFNIS’ failure to disclose their son’s suicide note to them, as well as about a number of matters arising from their interactions with the CFNIS both in their status as the family of a deceased soldier and as the complainants in two of the CFNIS investigations conducted.

The Hearing Process

12. The complaints made by Shaun and Sheila Fynes about the CFNIS investigations following the death of their son, Cpl Stuart Langridge, go to the core of military policing and raise issues of public interest and importance that in the Commission’s view required a full Public Interest Hearing (PIH).

13. The PIH was extensive, involving the testimony of some 90 witnesses and the entering into evidence of over 22,000 pages of documentary material.

14. Given the importance of the issues to both the complainants and the subjects, and given the broader implications, it is understandable that from time to time there were disagreements, including differing positions about matters of process and procedure, which led to competing submissions among counsel for the various parties as well as counsel for the Commission. For the most part, differences were resolved on an amicable and principled basis and overall there was good cooperation on most matters.

15. Some of the process issues were specific to the hearing, but some were of much broader importance, touching on the mandate and jurisdiction of the Commission and as such require special mention.

MPCC Jurisdiction

16. The subjects of the complaint made a number of submissions aimed at narrowing the Commission’s focus in the hearing and in this report. The subjects asserted the Commission is restricted to dealing with allegations of professional misconduct and cannot review systemic or policy issues. They also submitted the Commission can only look into the matters related to the policing function of the Military Police and not to “administrative” matters, and the Commission may not look into or inquire about the conduct of individuals who are not members of the Military Police.

17. While it is correct the Commission’s mandate is focused on the specific complaints made against specific subjects in the context of specific investigations, this does not mean in the process of considering those complaints the Commission is forbidden from considering the broader context in which the matters in question took place, or the impact of policy and systemic issues on the conduct being examined. Further, when a complaint alleges deficiencies in an investigation, it will be necessary for the Commission to consider not only what was done but also what was not done that should have been done. In order to evaluate the thoroughness of an investigation it will be necessary to understand what there was to investigate, including information that could have been available to the Military Police but was not obtained or investigated by them. This might, in the process, raise inferences or questions about the conduct of third parties, but those are, after all, the very matters the CFNIS was asked to investigate.

“Speaking with One Voice”

18. The right of individuals to be represented by counsel of their own choice is undoubted. Nevertheless, the Government’s decision in this case that one set of counsel would represent multiple and disparate individuals and institutions connected with the military and/or government, raises concerns. Department of Justice counsel was put into the position of advocating not only for the interest of its clients the subjects, but also for the interests of government as a whole, the CF and the CFNIS, as well as for the interests of the various CF and CFNIS personnel who were actual or potential witnesses. While there is no necessary conflict amongst all those interests, it seems unsafe to assume at the outset no divergence in interests might subsequently ensue. From the point of view of public perception, there is also a risk of government appearing to use this single representation of multiple interests to enforce conformity of viewpoints where none exists, resulting either in unfairness to the subjects or in unnecessary obstacles to the Commission’s fact-finding mandate.

19. In terms of documentary disclosure, the role of government counsel as both an advocate for the subjects and the “gate keeper” for access to documents raises further complexities, if only on the level of appearances.

20. The Commission is far from alleging any actual irregularities or improprieties in the current hearing, but it does consider there to be a real risk of public scepticism where a single counsel team represents such a multiplicity of interests. The current Treasury Board Policy on Legal Assistance and Indemnification has the effect of making common representation the default position. It would be preferable to avoid potential problems and any potential appearance of irregularity from the outset by providing independent counsel to the subjects of a complaint.

Solicitor-Client Privilege

21. There is no question solicitor-client privilege occupies a unique place in our legal system. The protection from compelled disclosure of matters discussed between a client and his or her lawyer is nearly absolute. It is also true, however, that the law makes it clear the privilege belongs to the client, not the lawyer, and the client is free to waive the privilege as he or she sees fit.

22. In the context of this hearing, the Government asserted the “client” for any communication between a lawyer and a member of the CF, including a member of the CFNIS, is the Minister of National Defence, and only the Minister can claim the privilege or waive it. The Minister made a blanket claim of privilege over all communications between government lawyers and any member of the CF. The impact of this position is that material made available to the CFNIS and relevant to the way it conducted its investigations is not available to the Commission. This can have a significant impact on the ability of the Commission to exercise its mandate to consider the thoroughness of investigations and to evaluate the validity of conclusions reached in those investigations.

23. Accordingly, the Commission asked the Minister to waive privilege with respect to material made available to the CFNIS as part of its investigations or that would have been available had it been requested by the CFNIS. The Commission did not, and would not, ask for any lawyer/client communications dealing with consultations between the subjects of the complaint and their lawyers in connection with this PIH.

24. The Commission’s request for this limited waiver of privilege was turned down by the Minister, who indicated such waivers are extremely rare, and cited jurisprudence affirming solicitor-client privilege is critical to the administration of justice. The Commission is of the view the real question is whether there should be a waiver of privilege where a communication is needed for a full and fair hearing of the evidence and no prejudice will result to a subject of a complaint. It is of the view no legal or policy rationale exists that would prevent disclosure of such material, and urges the Government to reconsider its position with respect to future proceedings.

25. In the current hearing, the refusal to waive privilege did not crucially affect the Commission’s ultimate ability to arrive at conclusions about the investigations in issue. On one issue, however, it did lead to unnecessary withholding of information on a key question. In the context of the 2010 Investigation, the evidence discloses the investigators sought legal advice shortly after their meeting with the complainants. No further investigative work was done and the file was closed without any factual investigation of the complainants’ allegations. Presumably, the legal advice was in some way relevant to the decision to close the file. It may even be the very fact of obtaining legal advice might have been asserted by the subjects as a full defence against allegations of a deficiency in the handling of that investigation. The subjects did not raise any such defence and any resulting prejudice can only accrue to their interests.

26. The Commission was able to conclude the validity of any legal advice obtained would necessarily depend on the facts made available to the lawyers being consulted. Since the complainants disputed the validity of many of the facts and conclusions in the materials gathered by the CFNIS, and in light of the Commission’s own determination there were significant evidentiary gaps in the materials available, absent evidence to the contrary, the Commission was able to conclude the legal opinions obtained could not provide conclusive guidance unless and until the facts upon which that advice was based were corroborated.

27. The fact the Commission was able to conclude, fortunately and somewhat fortuitously, that it was able to deal with the complaints even absent some of the material that would have been available to the CFNIS investigators, does not in any way diminish the concern with regard to the privilege claims. The subjects of the complaint are entitled to defend their interests by whatever legal arguments are available to them. The Government, on the other hand, ought not to be erecting obstacles to the Commission’s fact-finding mandate.

The 2008 Investigation

28. In the aftermath of a sudden death, both the police and the coroner (in Alberta, the Medical Examiner) conduct investigations to determine the cause and manner of death. While this leads to a degree of overlap, the police mandate is to investigate possible offences. A primary question for the police to answer is whether a death is suspicious. In this sense, the lead investigator assigned to the CFNIS investigation of Cpl Langridge’s death was accurate in stating the purpose of the investigation was “to rule out foul play.”

29. The investigative steps undertaken in the 2008 Sudden Death Investigation, however, did little in terms of answering the questions necessary to conclude the investigation. Instead, it was marked by three months’ worth of sporadic activity but little progress towards its ostensible purpose. While the lead investigator was correct in bearing in mind the need to keep an open mind and avoid tunnel vision, this does not justify a reluctance to use the evidence assembled to form hypotheses and then test them against further facts and evidence gathered.

30. The issues with the 2008 Investigation begin with the processing of the death scene.

31. The investigators took their time, methodically compiling a meticulous catalogue of the state of the room and its contents. The time taken to complete this exercise, during the entirety of which Cpl Langridge’s body was left hanging in place, became the basis for a complaint by the Fynes that the investigators showed disrespect by unnecessarily leaving the body hanging and exposed to view by passersby rather than promptly cutting it down and/or covering it. Those complaints cannot be sustained. The time taken to process the scene was within normal parameters and expert evidence establishes it would not have been proper to disturb the body, cut it down or cover it before authorization was given for the body removal service to take it away. The Medical Examiner (ME) had agreed to allow the investigators to complete their work of processing the scene before ordering the body to be removed.

32. Nevertheless, some of the steps taken by the investigators were unnecessary and/or could have been completed after the body was removed. More importantly, the investigators do not appear to have pursued their work with any clear understanding of its purpose. The evidence was processed but not analyzed and no inferences or conclusions were drawn. Seemingly fixated on the instruction to keep an open mind, the investigators dismissed the probative value of the ME’s declaration the scene was consistent with a classic suicide by hanging. They also failed to appreciate the implications of the position of the body, the fact Cpl Langridge’s feet were at all times in contact with the floor, such that he could have stood up at any time to stop the process, the evidence of lividity on the body and the lack of the petichiae on the face, all of which were strongly suggestive of suicide, as was the lack of evidence of a struggle or of any disturbance of the room’s contents.

33. If the investigators were seriously considering the possibility of foul play, they did not conduct any of the expected further investigative procedures to confirm or deny it, including examining the possible entry points for an intruder or looking for fingerprint evidence. Despite elaborate early precautions to preserve the evidentiary integrity of the scene, the lead investigator disturbed possibly relevant evidence and ended by potentially contaminating the scene when he performed a last walkthrough and opened various doors and drawers without wearing gloves.

34. The fate of the suicide note is illustrative. The note was addressed to Cpl Langridge’s family and among other things asked for a simple family funeral. It was photographed and video-taped; its contents were recorded and the note itself was carefully put into a plastic bag, with strict attention to the rules for evidentiary continuity. It was then put away as “evidence”. It was intentionally not released to the family on the basis the investigation was ongoing, a decision that made it impossible for the family to carry out the wishes expressed in the note. Nevertheless, literally nothing was ever done with the note, including no fingerprints or handwriting analysis being undertaken. Eventually, the note was forgotten by the investigators, missing from the list of personal possessions sent to the CF, and the family remained in the dark about its existence for 14 months.

35. The lack of focus and seeming uncertainty of purpose of the investigation are also illustrated by the Investigation Plan (IP). An IP should act as a guide to plan the investigative steps to be taken in order to address the questions needing an answer in order to conclude the investigation. In this case, the IP was simply an unranked and unorganized list of issues, observations, tasks, and notes to self that could be of no use either in organizing investigative steps or in clarifying how they related to the goals of the investigation.

36. One of the matters noted in the IP was “possible negligent actions on behalf of the CF resulting in possible involvement in the death.” A subsequent Quality Assurance (QA) Review by the CFNIS of the 2008 Investigation, criticized the investigators for pursuing the topic of negligence, which the QA Review asserted should have been left for administrative review by a CF Board of Inquiry. That criticism was misguided. Negligence can form the basis for a charge under the Criminal Code or the Code of Service Discipline. Negligence in connection with a sudden death is a proper subject for police investigation and is well within the mandate and jurisdiction of the CFNIS.

37. The problem with the negligence aspect of the 2008 Investigation was not its subject matter but the way in which it was conducted.

38. The investigators became interested in the issue of possible negligence as a result of hearing Cpl Langridge may have been under a suicide watch at the time of his death. They reasoned if Cpl Langridge killed himself despite being under a suicide watch, the failure of the watch to prevent the suicide might constitute negligence. After the first few days, most of the investigative activity in the 2008 Investigation seems primarily focused on whether there was a suicide watch, to the point where that narrow question replaced the correct one, which should have been whether there was evidence of culpable negligence in connection with Cpl Langridge’s death.

39. The limiting assumption that negligence could only arise if there was a suicide watch, prevented the investigators or their supervisors from pursuing information obtained in their interviews that seemed to point to the possibility of negligence on a different basis. They did not notice information that may have suggested, in the circumstances, the failure to mount a suicide watch might have been evidence of potential negligence just as much as mounting a defective one. Focusing exclusively on whether facts confirmed or denied a suicide watch, they did not notice the restrictive conditions imposed on Cpl Langridge may have had some connection with his subsequent death, regardless of what they indicated about the presence or absence of a suicide watch. Instead, without confirmation of a suicide watch from the interviews, the negligence aspect of the investigation simply petered out.

40. Whether in terms of confirming suicide so as to rule out foul play or in terms of investigating possible negligence, what was not done in the 2008 Investigation was as important as what was done. Puzzling decisions were made not to contact Mrs. Fynes or to interview Ms. AFootnote 1, whom the military recognized as Cpl Langridge’s common-law spouse. Both had information highly relevant to both the issue of suicide and of potential negligence, which the investigators failed to obtain.

41. No treating physician and no one involved in dealing with Cpl Langridge’s addictions issues was contacted. No tests were conducted on any of the items seized from the death scene and no follow up was undertaken with respect to the scene or what was found there. No chronology was compiled of Cpl Langridge’s final days.

42. Early on, the investigators conducted warrantless searches of Cpl Langridge’s vehicle and storage locker. Nothing came of these searches, but the testimony of the investigators demonstrated an alarming lack of understanding of the law of search and seizure as it applied in the circumstances.

43. The investigators closed the file shortly after receiving the ME’s confirmation the death was a suicide.

44. The final version of the Case Summary in the 2008 Investigation file removed references to the investigative steps related to the suicide watch issue. The Concluding Remarks in the file stated Cpl Langridge committed suicide, referred to his mental health issues and stated they were caused by or subsequent to his addictions issues. The final version of the Remarks added that the suicide occurred despite attempts by the military to provide Cpl Langridge with structure and support. It is questionable whether, as it was conducted, the investigation was capable of supporting any of those conclusions, other than the death was suicide. Following strenuous objections by the Fynes, the other conclusions were deleted by the CFNIS, for reasons of “compassion” rather than inaccuracy.

45. The 2008 Investigation was unsatisfactory both as a sudden death investigation and as an investigation of possible negligence in Cpl Langridge’s death. While the ultimate conclusion Cpl Langridge’s death was a suicide is clearly correct, little if anything of what the investigators did in the sudden death investigation contributed to that conclusion. On the other hand, while the investigators were correct in identifying potential negligence as a live investigative issue, their understanding of the concept was unnecessarily limited and that portion of their investigation led nowhere.

46. The overall deficiencies in the investigation are attributable to general inexperience in the investigation of domestic sudden deaths, as well as to a general failure of oversight and supervision. The inexperience of those conducting the investigation is not surprising since the CFNIS had only started to conduct domestic sudden death investigations in 2005. Given the relative infrequency of suicides on Defence Establishment property, it is likely such inexperience is a continuing issue.

The Suicide Note

47. After a number of false starts, in January 2009 the CF commenced a Board of Inquiry (BOI) into Cpl Langridge’s death. Toward the end of the process, the President of the BOI noticed a notation in a form accompanying the Province of Alberta Death Certificate referring to a suicide note. The General Occurrence (GO) file for the 2008 CFNIS Investigation contains a copy of the suicide note, but the evidence suggests neither it, nor any mention of it, was included with the redacted version of this file provided to the BOI. Six weeks after first asking about it, the BOI President was provided with a copy of the note and after another full month, he was given permission by his chain of command to contact the Fynes and to disclose the existence and copy of the note to them.

48. Even though the note was addressed to the Fynes and contained a specific request with respect to Cpl Langridge’s funeral, no one had informed them about its existence or its contents until the BOI President called them on May 22, 2009, some 14 months after Cpl Langridge’s death.

49. The Fynes were distraught. Not knowing about the note or its contents, they had been unable to act on Cpl Langridge’s request for a family funeral rather than the full military funeral that took place. They believed the note had been concealed from them in a cruel, callous and disrespectful manner. In the aftermath of the Fynes’ reaction, the CFNIS and its members provided many different, and often incompatible, explanations to the CF, to the Fynes and to the public, which in some cases bore no relationship at all to the facts of the case. It was suggested at various points it was necessary to withhold the note because of CFNIS policy about evidence; it was done in consideration of the best interests of the family; it was done to protect the integrity of the investigation; it had been intended to release the note but this intention was not carried out expeditiously. There was even a suggestion the Fynes themselves were in some way implicated because they did not ask about a note when they spoke to the lead investigator during the investigation. A year later, the Officer Commanding (OC) of the CFNIS Western Region Detachment (WR) was still telling the Fynes there had been a policy at the time not to disclose suicide notes and was providing them with the rationale that it would have been worse for them had the note been disclosed and it were subsequently to have turned out not to be genuine. This insensitive rationale was also provided by other CFNIS witnesses during their testimony before this Commission.

50. The efforts to formulate explanations appear to have been much more strenuous than any efforts to discover what actually happened. None of the suggested explanations was based on information from the investigators themselves and most, if not all, appear based on nothing beyond conjecture. In particular, there was no policy to prevent disclosure of suicide notes. The testimony of the investigators themselves suggests, while there was an initial decision to withhold the original note because the investigation was at an early stage, there was no consideration given to the question of whether the existence of the note should be disclosed to the family. As time passed, the note was simply forgotten and the failure to disclose it had no other basis. When the investigation was concluded, the original note was not returned to the family because there were no adequate processes in place at the Detachment for the return of seized items. When steps were finally taken to return other items, the suicide note was not included. As it had by then long been forgotten, no one noticed its absence. This simple though disturbing explanation does not seem to have been discovered by the CFNIS Chain of Command before the investigators testified in this Commission’s hearing.

51. Very early on, the emphasis in CFNIS communications, both to the Fynes and to the public, shifted from attempts to explain or justify withholding the note to a message there had been a change in CFNIS policy or procedures that would prevent any recurrence. The public was also informed the CFNIS had apologized.

52. The Fynes never accepted the proposition there had been a formal apology made to them for withholding the note. While there may be some semantic issues about what precisely was apologized for, and to whom various apologies were delivered, the evidence reveals there were a number of occasions where the CFNIS and the CF expressed their regret and apologies for what had happened. However, the CFNIS did not apologize immediately, nor take steps to deliver the original note personally to the Fynes once the failure to disclose it was discovered. In fact, when the Fynes first asked for the original note, the Detachment’s initial reaction was to suggest the Fynes make an Access to Information request to obtain a copy, and to advise they did not foresee the original being turned over.

53. The status of the second component of the messaging, about a change in CFNIS procedures to prevent any future recurrence, is more equivocal. The evidence reveals statements about changes in procedures having been enacted were being repeatedly communicated from 2009 onward, even though no explicit written policy about disclosure of suicide notes was in fact adopted before July 2011. The evidence does disclose that during this period before the adoption of a written policy, there had been a change in procedure in the form of an oral directive calling for the family to be informed of the existence of a suicide note as soon as possible and for a copy or the original of the note to be provided to the family or Next of Kin (NOK) as soon as possible. CFNIS HQ also monitored individual cases to ensure suicide notes were not withheld.

54. The actual written policy adopted calls for the NOK to be advised of the existence of a note “as soon as it is practicable” and for the note to be released to them or to the addressee “upon conclusion of the investigation” or “as soon as it is no longer required for the investigation.” Based on the evidence, this new policy is not fundamentally different from the existing practice at the time of Cpl Langridge’s death. It appears the CFNIS considers the failure to disclose Cpl Langridge’s suicide note to have been a mistake in practice rather than a mistake in policy. Nevertheless, the testimony heard by this Commission reveals there was and continues to be a lack of common understanding as to what is meant by disclosure “as soon as practicable” or “when it is no longer needed for the investigation.” Most of the CFNIS witnesses’ views about the appropriate time for disclosure did not change after the “new” policy was adopted. Different witnesses gave differing and contradictory accounts as to their understanding of when, as a practical matter, a suicide note would be disclosed under both the former practice and the new policy. Based on that testimony, it appears the measures put in place are insufficient to prevent a recurrence of what happened to the Fynes. Notwithstanding the written policy, it is far from certain that future suicide notes will be revealed in time for any instructions in them about the deceased soldier’s requests for his or her funeral to be acted on by the family.

The 2009 Investigation

55. In the immediate aftermath of Cpl Langridge’s death, the Fynes assumed they would be planning his funeral. They were soon informed that, in fact, it was Ms. A, as Cpl Langridge’s common-law spouse, who would be making those decisions as Cpl Langridge’s Primary Next of Kin (PNOK). Their Assisting Officer (AO) described their reaction as being “crushed like a grape.” They did, however, acquiesce, believing they had no choice. The actual decisions about the funeral were largely the subject of negotiations between Ms. A and the Fynes.

56. The Fynes subsequently discovered Cpl Langridge had filled out a Personal Emergency Notification (PEN) naming them as Primary and Secondary NOK. This discovery led them to conclude they were unjustly prevented from acting in the capacity Cpl Langridge wished them to act and their anger at the military increased.

57. Through the office of the DND/CF Ombudsman, the Fynes’ complaints were brought to the attention of the CFNIS. The OC CFNIS WR undertook to conduct an investigation, naming himself as lead investigator.

58. Like the Fynes, the OC assumed the PNOK named in the PEN form was the proper person to be recognized by the military as PNOK, including for purposes of funeral planning and decision making. The initial file was opened in December 2009 and a decision to conduct a full investigation was made in February 2010, but otherwise little progress was made for a number of months. The initial investigator working with the OC was transferred before any actual investigative work was undertaken. The investigator appointed to replace him conducted three interviews intended to identify who made the decision to recognize Ms. A as PNOK. He too was then transferred.

59. A third investigator (the “Investigator”) was appointed and the OC largely withdrew from active participation. This Investigator took a totally different tack. He determined the PEN form was on its face not a document intended to create legal rights or obligations and therefore discounted its relevance to the question of who was properly Cpl Langridge’s NOK or PNOK. Based on his own research, he determined there was no relevant CF regulation or order defining NOK or PNOK and instead relied on the “customs of our society” to conclude that NOK equals spouse and spouse includes common-law spouse. Having determined Ms. A was Cpl Langridge’s common-law spouse based on military policies and regulations, he recommended closing the file without further investigation.

60. The Investigator never interviewed either the complainants or Ms. A, preferring to rely on the documentary record in the file. He also did not feel it necessary to pursue the issue of who in the CF had made the PNOK decision, since he concluded it was Cpl Langridge himself who appointed Ms. A as his PNOK when he entered into a common-law relationship with her.

61. There was initial incredulity on the part of the Investigator’s supervisors, including the OC, who asked for further interviews to be conducted with respect to military policies about NOK. Despite repeated views by the ostensible “subject matter experts” who were interviewed, to the effect that these were legal questions requiring legal input, the Investigator’s views prevailed and the file was closed with no further investigation and without legal advice being sought.

62. Throughout the course of his participation in the investigation, the Investigator assumed the Fynes’ complaint and therefore the subject matter of his investigation were simply based on the question of who was NOK. He did not understand the complaint he was investigating dealt with the decision making in connection with Cpl Langridge’s funeral. He testified he only became aware of this aspect of the complaint from watching a news conference held by Mrs. Fynes. He dealt with this as an additional complaint rather than as the actual nub of the complaint leading to the 2009 Investigation. In his view, this “additional” complaint was answered by the fact the Fynes had input into the decisions about Cpl Langridge’s funeral.

63. The issue of who is entitled to make decisions with respect to a military funeral is a complex legal question. It is inconceivable to this Commission that the Investigator, a non-lawyer, attempted to tackle it on the basis of his own research, with no legal advice, and that the OC, the Case Manager and the rest of the supervisory team at CFNIS WR agreed with this approach.

64. The Investigator was mistaken in his understanding of the nature of the Fynes’ complaint. His review of the law and of applicable military policy was incomplete. Many, if not most, of his legal assumptions were arguably incorrect. His conclusion about who was the decision maker is logically puzzling, and his reliance on his own sense of social custom to decide the legal question of Next of Kin cannot be justified.

65. The Fynes’ own understanding of the PEN form as the basis for determining that question may also have been mistaken. However, they were correct in asserting, in focusing on the question of whether Ms. A was Cpl Langridge’s common-law spouse, the 2009 Investigation was not addressing the actual complaint they had made. The Fynes were also correct in complaining the time it took to conduct the 2009 Investigation was excessive. That aspect of the 2009 Investigation, along with the failure to keep the Fynes informed in any meaningful way of what was happening, was also unjustifiable.

66. It may well be, in the end, the Fynes’ complaint was not capable of being sustained. If such is indeed the case, it would not be for the reasons cited by the Investigator and the actual investigative work done would not justify the conclusions reached.

The 2010 Investigation

67. In May 2010, the Fynes met with the OC CFNIS WR in order to discuss, among other things, a complaint they wished to bring alleging negligence on the part the CF Chain of Command responsible for Cpl Langridge’s care. During the course of that extended interview, the Fynes made allegations about the military’s role in Cpl Langridge’s death essentially along the following lines.

68. At the beginning of March 2008, Cpl Langridge was in a civilian hospital following several suicide attempts. He requested to be sent to a treatment facility to help him deal with his addictions issues and the hospital was willing to have him stay there until a transfer could be arranged. Instead, the CF ordered Cpl Langridge back to the base, where, despite the CF’s knowledge of his instability, he was made the subject of restrictive and humiliating conditions. Cpl Langridge was coerced into agreeing to the conditions on the basis he would only be sent for treatment if he could demonstrate compliance with the conditions, even though the CF had already decided he would not be sent. The purpose of the conditions was to goad Cpl Langridge into acting out, so as to justify the CF’s intention to discharge him from the military. Cpl Langridge proved incapable of coping with the conditions and stated he would rather kill himself than return to work under them. Following a brief stay in the hospital, Cpl Langridge was returned to the base. He again asked for the conditions to be relaxed, but was told he must continue to comply with the conditions. Unable to cope, Cpl Langridge committed suicide.

69. The Fynes also alleged the CF was aware of Cpl Langridge’s past suicidal episodes and had a duty to keep him safe as a result. Mrs. Fynes alleged she had been assured Cpl Langridge was being monitored on a 24/7 basis. In their view, either Cpl Langridge was under a suicide watch that was defective or, if he was not, he ought to have been under a proper suicide watch. In either case, the military was negligent.

70. The Fynes believed these facts made out the elements of the Criminal Code offence of criminal negligence. In a formal complaint letter provided during the interview, Mr. Fynes also alluded to Criminal Code offences set out under the rubric of “Failing to Provide the Necessities of Life” and “Duties of Persons Directing Work”.

71. The Fynes also told the investigators they believed there were errors and inaccuracies in both the CFNIS 2008 Investigation record and the CF BOI, which they alleged was biased.

72. During the meeting, the OC made representations the CFNIS would conduct an elaborate investigation that would not take previous investigations – including the BOI – at face value, but rather would re-examine all existing evidence and would interview or re-interview all witnesses. Following the interview, the lead investigator assigned to the file assembled documents, including the BOI report and several items from the 2008 GO file, and requested legal advice.

73. There was no further investigation and as early as mid-August 2010 a decision was made to close the file without further investigation.

74. In order to justify closing the file without conducting any actual investigation, it would have been necessary to determine either the CFNIS had reliable evidence conclusively contradicting the facts necessary to support a criminal or service offence; or, even if the facts were as alleged by the complainants, no offence would be made out. Because of claims of solicitor-client privilege, this Commission is not in a position to know what legal advice was given to the CFNIS or on what such advice was based. Nevertheless, the legal advice could only be as accurate as the facts upon which it was founded and those facts were necessarily limited to the facts in the possession of the CFNIS.

75. In terms of a potential factual basis, the BOI was controversial and its conclusions were questioned even internally in the CF. Quite aside from the OC’s representations it would not be taken at face value, the BOI on its own could not have been relied on to test whether an offence could be made out on the facts. The 2008 Investigation only considered negligence to the extent of attempting to determine whether there was a suicide watch in place. Because of the limited investigation conducted, the information gathered and conclusions reached in the 2008 Investigation were not capable of either refuting or supporting the allegations made by the Fynes. Unless the CFNIS investigators or their legal advisors assumed the 2008 Investigation or the BOI refuted the allegations made by the Fynes, there was no basis to conclude those allegations could be dismissed without further investigation. It would appear to be a self-defeating exercise to conduct a fresh investigation that begins by accepting, without further investigative work, the facts and conclusions disputed by the complainants.

76. The investigator who was subsequently asked to produce a PowerPoint presentation to explain the decision to close the file did his own analysis of the elements of the various offences alleged by the Fynes. His substantive legal analysis of those elements is open to question, but it is in any event unclear what reliable facts were or could have been used to conclude the elements were not capable of being made out on the facts of the case. The presentation itself was limited to the Criminal Code offences set out in the Fynes’ written complaint. A police investigation cannot be circumscribed by the specific charges a complainant may identify. The question for the CFNIS was whether the Fynes’ allegations, if substantiated, were capable of making out either a Criminal Code or a service offence. It was for them, rather than for the complainants, to determine what those offences might potentially be.

77. Various CFNIS witnesses stated they did consider or would eventually have considered service offences as well as Criminal Code offences. There is no record of any such consideration or analysis taking place. The service offences that might potentially have been relevant are NDA s. 124, “negligent performance of a military duty” or s. 129(1) “conduct to the prejudice of good order and discipline”.

78. All of the criminal and service offences potentially applicable, in one way or another include as a foundational element a duty to do or not to do something and conduct in contravention of that duty.

79. The statements made by the Fynes during the May 2010 interview alleged a duty by the CF to keep Cpl Langridge safe, based on its control over him. Additional allegations made during that interview, potentially capable of supporting the existence of a duty or conduct required by law, include the alleged CF knowledge of Cpl Langridge’s suicidal tendencies, the alleged decision to remove him from a place of apparent safety in the hospital and the statements allegedly made to Mrs. Fynes reassuring her Cpl Langridge was being kept safe. The facts as claimed by the Fynes also alleged a failure to fulfill the duty to keep Cpl Langridge safe, either by failing to mount an effective suicide watch or by placing him under conditions they knew or ought to have known would destabilize him, and alleged these acts or omissions contributed to his death.

80. If those allegations were substantiated it is by no means certain a criminal or service offence could not be made out. That is not to say a charge would or should have been laid. The facts referred to by the Fynes were no more than allegations and without substantiation could not be relied on to support a charge. However, until they were investigated, it was not possible to know whether a charge could possibly be warranted.

81. The CFNIS file with respect to the 2010 Investigation should not have been closed without any actual investigation of the allegations made by the Fynes during the May 2010 interview.

82. The Fynes also made allegations during that interview the Commanding Officer in the Regiment had committed an offence by failing to institute a suicide prevention protocol and by failing to convene a Summary Investigation (SI) following each of Cpl Langridge’s suicide attempts. The CFNIS did not investigate either allegation. Certainly, in the case of the alleged failure to institute a suicide prevention protocol, there was no basis to dismiss the allegation summarily.

83. In their rush to close the file, the CFNIS members never attempted to do the very thing they promised to do, namely to uncover the truth of what had happened to Cpl Langridge, while apparently doing the very things they promised not to do, notably taking previous investigations at face value and using them to justify dismissing the Fynes’ allegations.

84. It is understandable the investigators would want to be cautious with the allegations made by the Fynes. They were by no means ordinary allegations and a decision that criminal or service offence charges relating to negligence could be laid on their basis may well have been without precedent. However, that does not justify dismissing them out of hand without further investigation. Just because a set of facts has never happened before, or has not formed the basis of a charge before, does not mean it cannot meet the elements of an offence. Precedent is not a requirement when a charge is applied to a novel set of facts.

85. While it is not possible to conclude the failure to investigate demonstrates CFNIS bias or lack of independence, that failure may indicate a lack of imagination and an inability to conceive of the possibility the military may have borne some responsibility for Cpl Langridge’s death. In that respect, this Commission is in no position to opine about any potential outcome of a proper investigation into the allegations. It can conclude, however, such an investigation ought to have taken place and the Fynes’ allegations that the CFNIS failed to properly investigate potential criminal or service offences alleged to have been committed by the CF Chain of Command in connection with Cpl Langridge’s death are substantiated.

CFNIS Interactions with the Fynes

86. From the outset, many of the Fynes’ complaints and much of their dissatisfaction can be seen as related to the way the CFNIS interacted and communicated with them.

87. The investigators in the 2008 Investigation appeared to have considered the Fynes extraneous to their investigation. The only contact with the Fynes during that investigation was initiated by the Fynes on another issue. There was certainly no effort to elicit relevant information or to brief the Fynes about the progress or results of the investigation.

88. The shocking failure to inform the Fynes about the existence or contents of the suicide note was, as the CFNIS later recognized, inexcusable. In many ways, it laid the ground work for many of the complaints that led to this Commission’s public hearing.

89. The CFNIS response to the discovery of the suicide note was geared more to finding a plausible explanation to convey to the CF and the public, than to providing accurate information or to try to make amends to the Fynes. On this matter as well, the Fynes appeared to have been an afterthought. Immediately upon discovering the suicide note had not been disclosed, the CFNIS ought to have personally delivered the note to the Fynes, provided an immediate official apology and made a concerted effort to find out exactly what happened so as to provide a meaningful explanation to the Fynes. They did none of these things. The apology they did provide a month later was the result of the CFNIS CO accidently calling the Fynes’ number in the mistaken belief he was calling their AO.

90. During the course of the awkward accidental conversation with the Fynes, the CO undertook to ensure the Fynes would be provided with a report about the 2008 Investigation. Whatever improvement ensued in the relations with the Fynes as a result of this commitment was quickly dissipated by the delivery of a heavily censored copy of the GO file, amounting to one-third of its actual size, which deleted all officer notes, witness interviews and documentation about the evidence collected. Although the Fynes eventually were given a less expurgated, though still incomplete, copy of the file, the entire saga managed to make things worse rather than better and led to complaints, substantiated by this Commission, that information was improperly severed without legal or policy justification.

91. In late November 2009, the CFNIS finally did provide an in-person briefing to the Fynes about the 2008 Investigation. The briefing was conducted by the OC CFNIS WR, who had no personal involvement in the 2008 Investigation, though he did play an important role in the discussions surrounding the discovery of the suicide note. During the briefing, the Fynes raised many of the issues about the 2008 Investigation that later came to form one of the bases for their complaint to this Commission. Though there is no evidence of any intention to mislead, the OC did not provide any specifics about the investigation and some of the explanations and answers given to the Fynes in response to their questions were inaccurate or unrelated to the facts of the case.

92. Although the National Defence Act establishes a mandatory process for the Military Police to report any complaint they receive to the CFPM and to this Commission, the OC treated the Fynes’ concerns as requests for information rather than as complaints to be acted upon. Although he undertook to provide answers to all unanswered questions, less than half of the questions raised and left unanswered during the course of the briefing were in fact dealt with in follow-up. In his testimony before this Commission, the OC cited his own assessment as to the merits (or lack of merit) of the Fynes’ complaints to justify not having reported or referred them, notwithstanding the Fynes’ expressed dissatisfaction with the explanations provided. This circular reasoning, by which a failure to investigate is justified by a prejudgment of the merits of what is sought to be investigated, is a recurring and unjustifiable theme in the CFNIS approach to complaints made by the Fynes.

93. Many of the questions left unanswered by the November 2009 briefing and some that were answered, but not to the Fynes’ satisfaction, were raised again over a year later in a letter addressed to the officer designated by the CF to coordinate contacts with them. Many of the responses then provided by the CFNIS were similar to those given in the course of the November 2009 briefing, focusing on general information unrelated to the facts of the case. Some were factually inaccurate. The answers appeared aimed at justifying the CFNIS’ handling of the case rather than providing factual information on what was done. While the failure to provide accurate information was not intentional, the underlying continued failure to make appropriate efforts to gather responsive information was unacceptable.

94. Shortly after the November 2009 briefing, the CFNIS opened an investigative file with respect to the Fynes’ complaints about the Regiment designating Ms. A to make decisions about Cpl Langridge’s funeral. The OC and a second investigator met with the Fynes in March 2010 to discuss the investigation. In May 2010, another interview was held. The Fynes presented additional complaints, which led to the opening of a separate investigative file into their allegations of CF negligence in connection with Cpl Langridge’s death.

95. During the course of the two interviews the OC made numerous representations about how the respective investigations would be conducted and gave specific undertakings to update the Fynes about the investigations through regular contact and to provide them justifications for any conclusions reached. The actual investigations were not conducted in accordance with the representations made, and no substantive updates or explanations were provided to the Fynes. The Fynes were not contacted at all for lengthy periods.

96. Representations about how an investigation will unfold are generally not advisable. When such representations are made, they cannot be treated as unbreakable commitments. Circumstances change, new information is uncovered, preliminary conclusions are revisited and necessary adjustments will be made. Decisions about the conduct of police investigations should be dictated by the needs of the investigation rather than by any prior commitments made to complainants. However, when such commitments are made and changes subsequently occur, the complainants should be notified and provided with an explanation.

97. In this case, contrary to the OC’s representations, both the 2009 and 2010 Investigations were largely based on existing documents rather than, as promised, on interviewing or re-interviewing of witnesses to establish the facts. Despite previous explanations the focus of the 2009 Investigation would be to establish who made the decision to recognize Ms. A as PNOK and on what basis, the 2009 Investigation veered off into a confirmation that Ms. A was Cpl Langridge’s common-law spouse. Despite assurances that previous conclusions would be revisited and statements made in previous witness interviews would be tested by direct questioning, the BOI, SI and 2008 Investigation reports and documents appear to have been taken at face value with no further testing or probing. Despite descriptions of elaborate investigative techniques and considerable human resources to be applied to the 2010 Investigation, no actual investigation at all was conducted.

98. There is good reason to question the substantive merits of each of these decisions, but none of them was prohibited simply because of the OC’s representations to the contrary. What was not permissible in the circumstances, however, was the utter abandonment of the undertaking to keep the Fynes updated and informed. Based on the testimony of the OC, the failure to honour these commitments was not deliberate but rather the result of inattention and occurred, at least for part of the time frame involved, in the context of serious issues affecting his family. While that may to some extent explain the failure to honour the explicit commitment to provide meaningful updates, it does not excuse it. The Fynes, justifiably, concluded they were once again being ignored and abandoned.

99. A separate unjustifiable departure from the commitments given involves the failure to provide a coherent and comprehensible explanation for the conclusions ultimately reached in each investigation. In the May 2010 interview, the OC gave a clear and unqualified promise if he were to conclude a charge was not warranted, “I will have the justification for that statement.” The original plan for informing the Fynes of the outcome of the two investigations was to provide them with an oral briefing based on a PowerPoint presentation. Although the decision to close the 2010 file without conducting any further investigation was made as early as mid-August 2010, the Fynes were given no indication of that decision and the final oral briefing for both investigations was scheduled for February 2011. Because the Fynes requested the briefing to be conducted at their lawyer’s office and in his presence, the oral briefing was cancelled and instead, the Fynes were provided in May 2011 with a three-page letter informing them of the decision no charges were warranted with respect to the subject matter of either investigation.

100. The letter itself provides no justification for those conclusions other than to state they were reached as a result of “two detailed and comprehensive investigations.” With respect to the 2009 Investigation, the letter does state the investigation determined Ms. A was Cpl Langridge’s common-law spouse, but offers no further explanation as to how this answered the Fynes’ allegations she was wrongly appointed as PNOK for purposes of making decisions about Cpl Langridge’s funeral. With respect to the 2010 Investigation, the letter provides no explanation at all.

101. The Fynes’ request to have the briefing in the presence of their lawyer may have caused understandable discomfort for the CFNIS, but it did not relieve the OC of compliance with his promise to provide a justification for a decision that charges were not warranted. The statements in the three-page letter do not constitute a meaningful explanation, let alone justification, of that conclusion. Not only does the letter fail to provide any explanation of the investigative steps taken and how they led to the conclusions reached, it does not provide even a hint that the steps taken were entirely inconsistent with the representations previously made to the Fynes. Worse still, the reference to “two detailed and comprehensive investigations” is, at least with respect to the 2010 Investigation, potentially misleading given it involved no actual investigation of the facts whatsoever.

102. Even without the promise to provide justification for any decision that charges were not warranted, the Fynes should have been provided with a proper explanation of what was done in the investigations, including the radical departure from the previous representations. The promise to provide a justification only makes this failure worse, as does the entirely unnecessary length of time to complete each investigation as compared with the actual steps taken, including specifically the unexplained delay in providing a final briefing.

103. From the beginning of the 2008 Investigation right through to the written briefing three years later, the Fynes were not treated by the CFNIS with the respect and consideration they were entitled to receive. They were often ignored and the information provided to them was at best inadequate and at worst potentially misleading. While the CFNIS members involved did not intentionally seek to deceive the Fynes, their interactions with them made it impossible to establish a relationship of confidence and trust.

CFNIS Independence and Impartiality

104. The most serious group of allegations made in the Fynes’ complaint challenges the ability of the CFNIS to conduct independent and impartial investigations. This Commission has found each of the investigations conducted by the CFNIS was flawed in a number of respects. The Fynes go one step further and allege the reason the investigations were defective was that the CFNIS, lacking independence from the CF, was biased in favour of the military and its interests. They claim actual influence was exerted through various interactions and coordinated activities between the CF and the CFNIS, and also allege individual members were motivated by a desire to “protect the uniform”. If sustained, these claims would go to the heart of the ability of the CFNIS to discharge its mandate to investigate serious and sensitive offences alleged to have been committed in the CF.

105. The importance of police independence is clear and obvious. Without independence from external interference, a danger arises of a “police state” in which political or government actors can direct police to investigate enemies or refrain from investigating friends. On the other hand, structures must exist to hold police accountable so as to avoid the danger of a different sort of “police state” in which the police exercise arbitrary and unconstrainable powers. The dangers of improper influence from above are heightened for internal police forces, like the CFNIS, who do not have a separate structure or corporate identity and ultimately answer to the CF chain of command. The potential for sensitive issues of independence to arise is especially present when the CFNIS is called on to investigate allegations of wrongdoing related to actions or decisions made or supported by the CF chain of command as opposed to isolated acts of wrong-doing by an individual CF member. The allegations of wrongdoing leveled against the CF and its members in the 2009 and 2010 Investigations, as well as the allegations of cover up with respect to the handling of the 2008 Investigation file, fall precisely into this category.

106. Many of the complainants’ allegations of bias and lack of independence appear to assume the very fact an investigation was defective or its conclusions were unsound is itself proof of an improper purpose. In so doing, the complainants mistake outcome for intent. The Commission found no evidence of any improper purpose or of any outside CF influence in the way the investigations were conducted. The vast majority of the problems with the investigations are the result of inexperience, inadequate supervision, faulty assumptions and human error, with no demonstrated relationship to bias or lack of independence.

107. As a factual matter, none of the complainants’ allegations of bias and lack of independence can be substantiated. Indeed some of the events complained of did not occur as they allege. Nevertheless, police independence and freedom from bias are not only important in terms of actual independence and actual freedom from bias. Because of the importance of maintaining public confidence in the police, appearances do matter. While the evidence does not substantiate the existence of any actual bias or lack of police independence, there are a number of instances and issues that put in question the appearance of independence.

108. With respect to independence, a particularly important issue is the relationship between CFNIS investigations, particularly the 2009 and 2010 Investigations, and internal administrative investigations conducted by the CF into many of the same issues.

109. The CFNIS 2009 Investigation addressed many of the same issues as the SI convened by the CF to look into the administration of Cpl Langridge’s estate. The SI was explicitly stated to have been convened “in anticipation of litigation” and could be understood to be intended to help the CF defend its interest against a threatened lawsuit by the Fynes. The OC of the Detachment, who was also lead investigator for the 2009 Investigation, recognized a potential for the overlap in subject matter and in witness list to have a negative impact on the CFNIS investigation and asked for the SI to be deferred. It is unknown why the CF declined to allow the CFNIS investigation to go first, but there is no evidence of any wrongdoing or improper intent in that decision. Nevertheless, the failure to stop the SI could create an impression the CF investigation was considered more important, regardless of its impact on the CFNIS investigation into alleged service offences. Furthermore, once the SI was complete, the CFNIS did access its report. It was the unanimous testimony of all CFNIS personnel involved that the SI had no impact on the 2009 Investigation. Nevertheless, especially in light of the failure to conduct interviews with key fact witnesses, it is not clear the CFNIS investigation was sufficiently robust to refute an unfortunate possible impression the CFNIS deferred to the CF, not only in terms of timing but also in terms of conclusions.

110. The CF also conducted a BOI into the circumstances of Cpl Langridge’s death. The Fynes were especially critical of the BOI and how it was conducted, and requested a separate police investigation be conducted into their allegations of CF negligence in connection with their son’s death. This became the basis of the 2010 Investigation. In this case as well, CFNIS investigators accessed the BOI report, which contains a number of controversial conclusions and findings of fact. They did not obtain its annexes containing the evidence on which the BOI relied. The testimony is clear it would not have been proper for the 2010 investigators to base their own conclusions on those of the BOI without conducting their own assessment of the evidence. The decision to close the 2010 file was made on the basis of an investigative assessment that did not involve the CFNIS conducting any new interviews or factual investigations. There is no positive evidence the CFNIS relied on the BOI’s factual findings. However, not all CFNIS witnesses seemed to have a clear understanding such reliance would be problematic and, in the context of the limited investigative activity in the 2010 Investigation, at least an appearance might be created that would not bolster public confidence in CFNIS independence.

111. There is no evidence to support the Fynes’ contention of improper discussions or information exchanges between the CF and CFNIS. Nevertheless, the CFNIS decision to communicate with the Fynes through a CF officer designated to coordinate the CF relationship with them was not helpful in bolstering the appearance of independence, nor was the CFNIS’ participation in media briefings and in Media Response Lines coordinated by the CF. Special care needs to be taken to avoid any impression the CFNIS and DND are “speaking with one voice” or the military is in control of information being provided to the public about CFNIS investigations.

112. The CFNIS decision to cancel a planned verbal briefing for the Fynes, when they requested it be conducted in the presence of the lawyer representing them in a potential lawsuit against the CF, raises concerns. The evidence is equivocal as to whether, as the Fynes believed, the cancellation was motivated by a CFNIS desire to protect the CF’s litigation interests, with one member involved testifying his concerns related to his role as a CF member rather than as a CFNIS investigator. CFNIS members should not be wearing their CF hats in their interactions with complainants.

113. There is no evidence the redactions to the 2008 CFNIS GO file originally produced to the Fynes were made with an intent to cover up deficiencies in that investigation. However, it is concerning that many of the ultimate redaction decisions were not made by the CFNIS, but rather by a separate DND department. That process, still in existence today, needs to be reviewed and amended.

114. Ultimately the evidence revealed, whatever the deficiencies in any of the investigations, the CFNIS members involved all sought to complete their tasks to best of their ability and with no intention to cover anything up or to protect the CF.

115. CFNIS members receive strong indoctrination and training on the need to conduct robust investigations into individual behaviour by CF members, regardless of rank. It is not as clear that the importance of vigorous investigations into allegations attacking CF institutional conduct and decisions is equally deeply engrained. In order to ensure allegations are brought forward with confidence, it is necessary to demonstrate any such allegations will be fully investigated and CF conduct will be critically examined. In the present case, the investigations may not have been sufficiently robust or rigorous to avoid fueling suspicions and concerns about police independence and impartiality such as those raised by the Fynes.

The Notice of Action

“Notice of Action” as an Aspect of the Complaints Resolution Process

116. A “Notice of Action” is a distinctive and integral aspect of the process set out by statute for dealing with complaints made to the MPCC, never the more importantly than when the Commission decides to hold a Public Interest Hearing.

117. Following completion of a Public Interest Hearing, the Commission prepares an Interim Report, including its Findings and Recommendations. This Interim Report is sent to the Minister of National Defence, the Chief of the Defence Staff, the Judge Advocate General and the Canadian Forces Provost Marshal (CFPM). The National Defence Act then requires the CFPM to prepare a Notice of Action setting out the Military Police responses to the Commission’s Findings and Recommendations. The CFPM is to set out any actions taken or planned with respect to the complaint. Where the Military Police declines to act on a Finding or Recommendation, reasons must be set out.

118. Once it has received the Notice of Action, the Commission prepares its Final Report, including a discussion of and responses to the Notice of Action.

119. The importance of the Notice of Action is manifest. The purpose of the independent oversight established by the National Defence Act in the form of the MPCC complaints resolution process is to identify deficiencies in practices and procedures; to promote remediation of such deficiencies; to ensure police accountability; and, in light of the extraordinary powers granted to the police, to safeguard public confidence that the conduct of the Military Police is being properly regulated and overseen. These values, and especially the value of promoting public confidence, require to the maximum extent possible, transparency in the oversight regime. That is the rationale for the availability in appropriate cases, of the MPCC Public Interest Hearing process.

120. The Commission believes that this transparency must extend to the entire Public Interest Hearing process from its inception through to the publication of the Commission’s Final Report.

121. In the Commission’s view, requiring the Military Police to prepare a Notice of Action before the Commission produces its Final Report is intended to ensure that the Commission, the parties and the public at large may be aware not only of the deficiencies pointed out by the Commission and what the Commission believes should be done about them, but also, and crucially, whether the Military Police accepts these Findings and how, if at all, it proposes to implement the Recommendations. Without such information and the Commission’s ability to publicize and comment on it, the principle of accountability is compromised and so is the transparency that is a prerequisite for public confidence in the process.

The Notice of Action in This Matter

122. In the current case, a Notice of Action was delivered to the Commission some seven months after the Commission provided the Military Police with its Interim Report.

123. The Commission has serious concerns regarding the content of this Notice of Action.

124. There is no requirement that the Military Police accept all – or indeed any – of the Findings and Recommendations set out in an Interim Report prepared by the Commission. What is required is for the Military Police to identify which Findings and Recommendations it will act on, which it rejects or will not implement, and the reasons for any rejections. The Commission can then respond with its final evaluation and readers of the Final Report, including government, the parties and the public, can reach their own conclusions as to the sufficiency of the proposed responses. If concerns remain, there can then be informed debate and discussion within the democratic process.

125. In the current Notice of Action, with only one exception, the recommendations explicitly accepted relate to relatively minor and technical matters, and even there, steps identified to implement the recommendations are at times vague.

126. There is a slightly larger number of recommendations directly rejected by the Military Police. These include some of what the Commission views as the most important of its recommendations, including recommendations related to:

127. The Commission is not satisfied that the reasons set out in the Notice of Action justify rejecting these recommendations.

Non-committal responses

128. There is a troubling third category of response in the Notice of Action. This category consists of non-committal responses that do not explicitly reject Findings and Recommendations but also do not accept them either explicitly or by necessary implication.

129. In terms of responses to the Commission’s Recommendations, the number receiving such non-committal responses exceeds the combined number of Recommendations either explicitly accepted or explicitly rejected. When it comes to responses to the Commission’s Findings, every response in the Notice of Action but one falls into this category.

130. As responses to the Commission’s Recommendations, these non-committal comments most often involve vague references to future policy reviews in which the Recommendations in question will be considered. As responses to the Commission’s Findings, the non-committal comments acknowledge that the Findings have been made but contain no indication of whether the deficiencies set out by the Commission are acknowledged and accepted. Sometimes the responses take the form of statements essentially indicating an intention to seek a second opinion, presumably in confidence, from another police force.

131. In the Commission’s estimation, all of these non-committal responses amount to rejections of the Findings and Recommendations in question. If they were to be seen otherwise, the Military Police would in effect be entitled to ignore any Finding or Recommendation it chose to address in non-committal terms and neither the Commission nor the public would ever know what if anything was done about the identified deficiencies. The entire issue would be removed from public view. This would fly in the face of transparency, could potentially avoid accountability and would essentially nullify the process of independent oversight.

132. Properly categorizing these non-committal responses as rejections underlines the fact that no reasons are given for not accepting the Findings and Recommendations in question.

Attempt to prevent publication of the Notice of Action

133. The Commission has prepared a more detailed and substantive review of the responses in the Notice of Action in this matter. In the ordinary course, the Commission would publish this analysis as a chapter in its Final Report and would attach the Notice of Action as an appendix to the Report.

134. In the present case, however, four weeks after transmitting the Notice of Action, the Military Police delivered a letter to the Commission instructing the Commission not to publish the Notice of Action, something the Commission had invariably done without issue in past Public Interest cases. This new policy initiative was implemented by refusing to remove the designation “Protected B” that had been marked on the Notice of Action.

135. “Protected B” is an internal Government of Canada designation intended to prevent the publication of sensitive personal, private or business information whose publication could result in “grave injury”. The Military Police also marked the letter containing the instruction not to publish the Notice of Action, as itself “Protected B.”

136. In the letter setting out the new policy initiative, the Military Police suggested an approach for the Commission to deal with the Notice of Action in light of its “Protected B” designation. The Commission considered the suggested approach to be self-contradictory, inconsistent in principle with transparency and with accountability, and unworkable in practice. In response to the Commission’s objections, the Military Police subsequently offered to remove the “Protected B” designation from the Notice of Action on condition that the Commission agree not to append the Notice of Action to its Final Report. This condition is unacceptable. The Commission cannot agree to suppress publication of a document it considers a central part of the Public Interest Hearing process. Because the Commission could not agree to the self-censorship being proposed, the “Protected B” designations on the Notice of Action and related correspondence remain in place.

137. The Commission believes the parties and the public are entitled to see the Notice of Action. It also believes the use of the “Protected B” designation by means of which the Military Police has sought to censor the Commission’s Final Report is wrong in law. However, much as it disagrees with this use of the “Protected B” designation, the Commission does not intend to flout it by publishing the Notice of Action or referring to the specific information it contains.

138. The Commission has therefore launched an Application requesting the Federal Court to declare that the Military Police cannot prohibit the Commission from publishing the Notice of Action and that the designation “Protected B” has been improperly applied to the Notice of Action and related correspondence in this case.

139. Pending the Court’s decision on the Application, the Commission has blacked out the chapter in this Final Report containing substantive analysis of the Notice of Action as well as the appendix containing the text of the Notice of Action and the related correspondence. Instead, the Commission has added a brief chapter containing a high level discussion of the Notice of Action, without specific reference to its wording. Once the Court delivers its final decision, the Commission will lift the redactions in a manner and to an extent consistent with the Court’s reasons.

140. The Commission considers the attempt to prevent publication of the Notice of Action to be as inconsistent with the principles of accountability and transparency as the non-committal responses in the Notice of Action, if not more so.


141. The Commission, the parties and the public have a right to know whether the Military Police acknowledges the deficiencies set out by the Commission in its Findings and to know whether and how the Military Police is committed to implement the Commission’s remedial recommendations, or the reasons why it is declining to do so. The Commission’s Findings and Recommendations are not transient expressions of opinion that the Military Police is entitled to peruse and at its option ignore. They cannot simply be dismissed with a non-committal shrug. The Notice of Action is not an element in a private confidential conversation between the Commission and the Military Police. It is a statutorily mandated requirement. The Commission understands it to be an essential part of the information to which the public, not to mention the parties, are entitled in the context of the Public Interest Hearing process. There is no functional reason why the Notice of Action should be cloaked in secrecy or removed from public scrutiny.

142. The purpose of independent oversight of the police is to ensure accountability, encourage remediation of identified deficiencies and promote public confidence in the effectiveness, objectivity and transparency of the oversight regime. The effective refusals in the Notice of Action to engage with the Commission’s Findings and Recommendations and the attempt by the Military Police to prevent its publication, are difficult to square with those purposes. They raise troubling questions as to the willingness of the Military Police to submit to effective independent oversight.

II. The Hearing Process

History and Outline of Proceedings

1. On January 18, 2011, the Commission received a complaint from Mr. Shaun Fynes on behalf of himself and his wife, Mrs. Sheila Fynes, seeking a review of the investigations conducted by the CFNIS following the suicide of their son, Cpl Stuart Langridge.Footnote 2 Mr. Fynes alleged the CFNIS lacked sufficient independence and the investigation of Cpl Langridge’s death was biased. He also complained about alleged errors and deficiencies in connection with the CFNIS investigations conducted following the death, including alleged suppression of Cpl Langridge’s suicide note for over a year.

2. Mr. Fynes expressed concern that an investigation opened in 2009 to look into allegations members of Cpl Langridge’s Regiment did not properly designate his “primary next of kin” remained incomplete more than a year later. He further complained that in 2010, he had requested the CFNIS investigate the possibility of criminal negligence in connection with Cpl Langridge’s death, but to date there had been little progress beyond a legal review of the request and a seeking of direction from superiors. Mr. Fynes also pointed to an alleged failure of the CFNIS to communicate with him and his wife about the investigations.

3. On April 29, 2011, the Chair issued a decision to conduct a public interest investigation into the Fynes’ complaint.Footnote 3 The decision was made in recognition of the serious allegations about, among other things, the independence and objectivity of the CFNIS in conducting the 2008 investigation and forming conclusions about the death of Cpl Langridge, and about the CFNIS’ ability to adequately and independently conduct the 2009 and 2010 investigations.

4. These allegations go to the core of military policing. Such issues could raise questions about the ability of CFNIS members to fulfill their duties and potentially erode public confidence in their investigations. It was also important for the Commission to conduct an investigation to contribute to a restored confidence in the process for the complainants, as the Fynes indicated they felt marginalized and misled.

5. The complainants had not specifically identified the subjects of the complaint, so it became necessary for the Commission to do so after reviewing the investigative files and interviewing the complainants. Additionally, the complainants indicated they did not believe their initial complaint and subsequent correspondence and conversations captured the totality of their allegations about the 2008 investigation, and noted they might also have further allegations once they were advised of the results of the 2009 and 2010 investigations. As such, an interview with the complainants also allowed for clarification of the allegations.Footnote 4

6. Based on the information gathered during the public interest investigation, the Commission identified 13 subjects of the complaint and disclosed to them a list of formal allegations.Footnote 5

7. On September 6, 2011, the Chair issued a decision to hold a public interest hearing.Footnote 6 The Commission made it clear from the outset the public interest hearing would require an investigation into systemic matters such as the policies, practices and organization of the Military Police.Footnote 7 The allegations in the complaint put into question the very ability of the CFNIS to conduct independent investigations into the behaviour of members of the CF, particularly where members within the chain of command might be involved.

8. If there were conscious or unconscious biases preventing the CFNIS from uncovering and exposing information potentially detrimental to the CF, or if there was insufficient independence from the CF and its interests preventing CFNIS members from making adequate decisions concerning the issues to be investigated or appropriately working with complainants, this would cast doubt on the ability of the CFNIS ever to carry out its core functions. The allegations went beyond bias to raise specific concerns about incompetence and/or a lack of requisite experience on the part of the CFNIS investigators. An open, public hearing to address the allegations in a transparent manner and hear what would necessarily be extensive evidence and submissions was deemed necessary and in the public’s interest.

9. The Fynes Public Interest Hearing commenced on October 19, 2011, with an initial case conference.Footnote 8 The case conference was called to identify counsel for the parties, set a hearing schedule, and hear a motion from the complainants seeking that the Commission recommend the Government of Canada provide public funding for their legal representation.

10. On September 26, 2011, Col (Ret’d) Michel W. Drapeau, counsel for the complainants, filed a written motion formally requesting that the Commission make a recommendation to the Treasury Board of Canada to grant public funding to the complainants in order for them to retain legal representation for the PIH.Footnote 9 Col (Ret’d) Drapeau argued legal representation was necessary for the complainants to participate fully as parties in the PIH, noting they did not have the financial resources to afford representation without incurring severe hardship.Footnote 10 Col (Ret’d) Drapeau proposed to act at a reduced rate. An accompanying affidavit from the complainants set out their circumstances and means.Footnote 11

11. The complainants’ request for public funding was opposed by the Government through submissions made in writing by the Department of Justice (DOJ) counsel to the Government of Canada.Footnote 12 This position was surprising. Understandably, Government resources are not unlimited and public funding for counsel for complainants at MPCC public interest hearings should be considered exceptional rather than the norm. However, the fact Government’s legal advisor took a position on whether or not funding was warranted may seem incongruous in circumstances where Government counsel were also representing the subjects of the complaint before the Commission, and where the Government would have to make the ultimate decision about whether to accept a funding recommendation from the Commission, if one was issued.

12. On October 26, 2011, the Commission issued a recommendation to the Government of Canada to grant funding for the complainants’ legal representation, at the reduced hourly rates proposed by Col (Ret’d) Drapeau.Footnote 13 Pursuant to section 250.44 of the National Defence Act, the complainants are parties to a PIH held by the Commission.Footnote 14 Pursuant to the Act and the Rules of Procedure for Hearings before the Military Police Complaints CommissionFootnote 15 they are entitled, as much as the subjects of the complaint, to participate fully in the hearing including cross-examining witnesses, presenting evidence and making submissions, including final submissions. The Commission found that, in order for the status of parties to be meaningful, it is inevitable in some complex cases such as this one, the complainants will need some form of representation at the hearing.

13. The Minister of National Defence issued a decision to grant public funding for the complainants’ legal representation on March 16, 2012.Footnote 16 The decision may have been delayed to some extent by confusion regarding the responsible agency. The Commission’s funding recommendation was issued to The Honourable Tony Clement, President of the Treasury Board of Canada. In January 2012, Mr. Clement advised the Commission he had forwarded the recommendation to the Minister of National Defence as he felt it was more appropriate for it to be dealt with by the Minister under his powers and discretion.Footnote 17 The interval between the Commission’s recommendation and the Minister’s funding decision had the unfortunate result of forcing Col (Ret’d) Drapeau to remove himself, for the time being, as solicitor of record and preventing him from preparing for the imminent commencement of the hearing.

14. Following the October 2011 case conference, the Commission received evidentiary materials and disclosed that evidence to the parties in preparation for witness testimony. Although document production did not always proceed smoothly or without incident, ultimately sufficient documentation was identified and made available to the Commission to allow it to conduct the PIH and carry out its mandate. On March 27, 2012, the Commission entered into evidence six collections of documents containing a large volume of material provided to the Commission by the complainants and by the Government, and which had previously been disclosed accordingly.Footnote 18 As further documents were identified and redactions reassessed, new documents and revised versions of existing documents were added to the evidentiary record. By the conclusion of the hearing, the Commission had entered a total of 1699 documents into evidence, adding up to over 22,000 pages of material.

15. The PIH heard the testimony of its first witness on March 27, 2012. The Fynes Public Interest Hearing heard evidence from 90 witnesses over 60 days of testimony, generating over 12,500 transcript pages. The last witness testified on October 10, 2012.

16. Closing submissions and reply submissions from the parties were filed on January 2 and January 8, 2013 respectively, and oral submissions were heard January 9, 2013.

17. On October 12, 2012, Col (Ret’d) Drapeau formally requested supplemental funding in anticipation of the extensive work required to prepare written closing submissions, make oral submissions at the hearing, and prepare written reply submissions.Footnote 19 The Commission issued a funding recommendation on October 30, 2012, to grant supplemental legal funding at the reduced hourly rates again proposed by Col (Ret’d) Drapeau.Footnote 20 On February 14, 2013, the Minister of National Defence issued a decision to grant supplemental funding for the complainants’ legal representation in recognition of the increased length of the hearing, the increased number of witnesses, and the extensive documentary evidence filed.Footnote 21

18. In keeping with the Commission’s commitment to conduct open and fair hearings in the public view, no part of the hearing was held in camera. In only one instance was a publication ban imposed on the contents of the hearing, and this concerned graphic video recordings produced by the CFNIS investigators depicting the scene of Cpl Langridge’s suicide and their initial work at the scene, as well as that of the ME Investigator.Footnote 22 The video was viewed at the request of the complainants. Members of the media were permitted to be present during this evidence but were not permitted to record or broadcast images or audio of its contents. The publication ban is permanent.

19. In addition to the critical importance of full and timely disclosure from the Government and the parties of all materials relevant to the matters under investigation, the Commission’s ability to meet its mandate also greatly benefits when the Government takes a cooperative approach to information-gathering functions like witness interviews. Similarly, when a flexible approach is taken with complex legal issues, significant impasses can be resolved. All those who were involved in the PIH faced significant challenges and all, including Commission counsel, at times made errors in their sincere but unrealistic attempt to meet ambitious deadlines intended to give the public, and especially the parties, the timely answers they deserved.

20. Although a number of obstacles and process issues arose in the course of this complex and extensive public interest hearing, in many cases these were ultimately overcome through cooperation between the Commission, the parties, and their counsel. The procedural challenges encountered often – but not always – resulted from positions taken by the Government institutions involved, especially with respect to legal privilege and other impediments to disclosure.

21. This by no means implies any bad faith or misconduct on the part of the Government counsel who appeared before this PIH. All counsel clearly sought to carry out their instructions in a manner that recognized their ethical and professional obligations. Wherever responsibility for some of the problems outlined in this chapter might lie, it should not be seen to rest with counsel who represented their clients diligently under often difficult circumstances.

22. Ultimately, and despite the difficulties and setbacks, the most important objectives of the Commission were accomplished with the cooperation of all parties and counsel involved. In the end, it was possible to hold the public interest hearing in the open and provide meaningful findings and recommendations, which can be openly shared with the complainants, the subjects, the Government of Canada, and the Canadian public.

The Interim Report and the Notice of Action

23. On May 1, 2014, the Commission delivered the Interim Report to the Minister of National Defence, the Chief of the Defence Staff, the Judge Advocate General, and the Canadian Forces Provost Marshal (CFPM).Footnote 23 Four months later, on September 5, 2014, the Commission wrote to the CFPM to inquire as to when the Commission could expect to receive the Notice of Action.Footnote 24 On September 16, 2014, the Chief of Staff of the Canadian Forces Military Police Group (CF MP Gp) replied that the Notice of Action was ready, but that a delay of about one month was anticipated before it could be sent to the Commission, because the CFPM wished to brief the Senior Chain of Command regarding the Notice of Action before its distribution.Footnote 25 The Commission was advised that the Notice of Action would be forwarded following the briefing of the senior leadership.

24. On November 4, 2014, the Commission received an e-mail message from the CF MP Gp advising that it would be approximately six more weeks before the Notice of Action would be ready to be sent to the Commission, as the briefing to the Senior Chain of Command had been rescheduled to the last week of November 2014.Footnote 26

25. On December 10, 2014, the Commission was advised of still another delay in the delivery of the Notice of Action, meaning that the Notice of Action would not be delivered in mid-December as expected.Footnote 27 In an e-mail message, the CF MP Gp advised the Commission that further to the briefing already provided to the Chief of the Defence Staff about the Interim Report and the Notice of Action, the Minister also wished to be briefed. The message explained that as the Commission provides its Interim Report to these statutory recipients, it was to be expected they would wish to be briefed as to the status of the file before the Notice of Action was provided to the Commission. The CF MP Gp did not provide additional information as to when the Commission could now expect to receive the Notice of Action, but indicated that once the briefing to the Minister was scheduled, the Commission would be advised.Footnote 28

26. On December 11, 2014, the Commission responded, expressing concern about the unacceptable delay in providing the Notice of Action.Footnote 29 At this point, more than seven months had passed since the delivery of the Interim Report.

27. Shortly after, the CFPM provided the Commission with a Notice of Action. The Notice of Action was received on December 16, 2014 and was dated December 3, 2014.

28. The Notice of Action was marked “Protected B,” a level of an internal government designation intended to protect sensitive personal, private, or business information that could result in grave or severe injury if compromised or released.Footnote 30

29. On December 22, 2014, the Commission wrote to the CFPM to acknowledge receipt of the Notice of Action. At that time, the Commission requested that the “Protected B” designation be removed so that the Notice of Action could be included in the Commission’s Final Report, as had been done in previous cases.Footnote 31

30. On January 15, 2015, the Commission received a letter from the CF MP Gp indicating that the Notice of Action could not be included in the Commission’s Final Report or otherwise published and that it would remain designated “Protected B”. The letter itself was also marked “Protected B”. In this correspondence, the Military Police suggested an approach to deal with the Notice of Action in light of this designation, but the Commission considered this approach to be both unacceptable in principle and unworkable in practice.

31. Over the course of the following weeks, the Commission exchanged correspondence with the Military Police to express its strong objection to the attempt to prevent the publication of the Notice of Action, and to seek clarification of the reasons for this unprecedented position. As most of the correspondence received about this matter was marked “Protected B”, the details of the exchanges are not discussed here.

32. On February 11, 2015, the Military Police transmitted its final decision on the matter to the Commission, maintaining its refusal to permit the publication of the Notice of Action.Footnote 32 In this correspondence, the CFPM agreed to provide an undesignated version of the Notice of Action to the Commission, but only on the condition that the Commission provide assurances the Notice of Action would not be appended to the Commission’s Final Report. The Commission could not agree to these conditions, and advised the CFPM on February 12, 2015, that it would not provide the requested assurances.Footnote 33

33. The Commission has launched legal proceedings requesting the Federal Court to declare that the Military Police cannot prevent the Commission from publishing the Notice of Action and that the designation “Protected B” has been improperly applied to the Notice of Action and related correspondence in this case. Pending the Court’s decision in this matter, the Commission is prevented from publishing the Notice of Action and correspondence related to its designation, or from referring to the specific information they contain. The Commission has therefore redacted the chapter in this report containing a substantive analysis of the Notice of Action and the appendix attaching the text of the Notice of Action and related correspondence. Once a final decision is rendered by the Court, the Commission will lift these redactions in a manner and to an extent consistent with the Court’s reasons.

The Commission’s Mandate

34. The Commission provides independent civilian oversight to the Military Police. The Commission is mandated to review conduct complaints (meaning a complaint about the conduct of a member of the military police), and interference complaints (meaning a complaint about interference with a military police investigation), which have been referred to it.Footnote 34 Conduct complaints refer to complaints about the conduct of MP members in the performance of their policing duties or functions. These include the conduct of an investigation, the handling of evidence, responding to a complaint, the enforcement of laws, and the arrest or custody of a person.Footnote 35

35. Created by statute, the Commission has had a number of powers conferred upon it to enable it to carry out its functions efficiently, fairly, and independently. The Chair can decide to commence a public interest investigation or hearing if it is “advisable in the public interest” to do so.Footnote 36 This decision is discretionary. The Commission can commence an investigation even if the originating complaint has been withdrawn. The Chair has the ability to set rules for the conduct of investigations and hearings and for the performance of the Commission’s other duties and functions.Footnote 37 The Commission has the power to summon witnesses and compel them to provide sworn evidence, as well as to produce any documents or things under their control, which the Commission considers necessary for its investigation.Footnote 38

36. Subject to certain exceptions, the Commission operates under relaxed rules of evidence (like many administrative bodies) and can receive and accept evidence and information even if it would not be admissible in a court of law (for example, because of rules against hearsay).Footnote 39 The Commission also has a legislated duty to “[…] deal with all matters before it as informally and expeditiously as the circumstances and the considerations of fairness permit.”Footnote 40

37. The Commission’s conclusions are non-binding and its reports are not legally enforceable, but the Military Police leadership must provide written reasons for declining to act on the Commission’s findings and recommendations. As such, the nature of the Commission’s work is akin to a public inquiry, with its influence “[…] being a matter of moral or political suasion through transparency and public accountability, rather than executive or adjudicative authority.”Footnote 41 The Commission is legally and administratively separate from the CF and the Department of National Defence and is not subject to direction from the Minister in respect of its operational mandate. The Commission operates at arms’ length from the Government and does not form part of the Crown. The Commission’s legal counsel is staffed independently of the DOJ, whose lawyers provide the bulk of legal services to Government agencies.Footnote 42

Submissions about MPCC Jurisdiction

38. In their final submissions, the subjects of the complaint made a number of assertions concerning the MPCC’s jurisdiction. Notably, the subjects submit that: the MPCC can only make findings about allegations of professional misconduct; it should not review systems or policy issues; and:

[…] Nor did Parliament contemplate that this Commission would become a vehicle by which the conduct of the CF generally, or anyone within the CF aside from the MP, would be investigated. The mandate of this Commission cannot be used as a springboard to investigate or criticize the conduct of non-MP members of the CF or the Government of Canada […]Footnote 43

39. The Commission accepts the general principle that its oversight mandate is focussed on the specific complaints made against specific subjects. However, when the complaint alleges deficiencies in an investigation, that mandate requires it to examine whether or not investigators were diligent, thorough, objective, and competent during their investigation(s). This means the Commission’s mandated function, as envisaged by Parliament, to monitor and assess the day-to-day decisions of the Military Police, requires it to examine what the Military Police members examined or ought to have examined.

40. This does not constitute an attempt to expand or exceed its jurisdiction, as claimed by counsel for the subjects. To the contrary, in order to discharge its mandate, the Commission must be able to understand the information available to the Military Police and – most importantly – information which could have been available to the Military Police but was not obtained or investigated by them. To contend the Commission is precluded in these circumstances from examining what the Military Police members uncovered or ought to have uncovered in their investigation of a death, a potential crime, or a service offence would be an artificial and inappropriate constraint.

41. The final submissions of the subjects also warn the Commission against investigating, making findings, or making recommendations relating to the administration of the Military Police. The subjects note that sections 2(1) and 2(2) of the Complaints about the Conduct of Members of the Military Police Regulations, provide a definition of the military police duties and functions that may be the subject of a complaint.Footnote 44 Under section 2(2) of the regulations, when an MP member performs a duty or function relating to “administration, training or military operations that result from established military custom or practice,” these are not policing duties or functions. The closing submissions of the subjects describe such administrative matters as:

Duties or functions related to administration are those unrelated to core policing and that a MP officer performs in his capacity as a member of the CF. They are, therefore, excluded from the “policing duties and functions” that may be subject of a complaint and more properly considered matters of “administration” based on common sense and interpretation of analogous case law.Footnote 45

42. For this reason, counsel for the subjects submit, matters such as the development of media lines and communications strategies and “establishing reporting priorities; development of policies and procedures as well as application of ATIP legislation in relation to disclosure” are excluded from the Commission’s oversight jurisdiction.Footnote 46

43. The Commission accepts, as a general principle, there are matters related to what the Military Police do that are not connected with their policing function but rather arise in the context of their status as an administrative unit within the CF. However, this does not mean, as submitted by counsel for the subjects, certain Military Police duties and functions are categorically prohibited from consideration. A CFNIS member simply performing an administrative duty may not be subject to a conduct complaint, but a CFNIS member whose conduct in relation to an investigation or other core policing function is alleged to be deficient will be subject to a complaint to the MPCC even if part of the complaint pertains to how administrative matters impacted the investigation. Investigating and making findings and recommendations with respect to MP conduct in relation to an investigation is explicitly within the Commission’s jurisdiction.

44. While the subjects’ final submissions strenuously maintain the topic of media releases and communications strategies are outside of the Commission’s jurisdiction to investigate, one of the Fynes’ central complaints is that the CFNIS lacked independence in its approach to the investigations it undertook. In so far as the content of media releases or the interaction between CF and CFNIS communication strategies either confirms or rebuts these allegations, these topics are well within the Commission’s jurisdiction to investigate and to make findings and recommendations as appropriate.

45. Further, the interactions of the CFNIS members with the complainants form part of their policing function to be reviewed by the Commission and were directly raised in the Fynes’ complaint. To the extent the complainants sought to obtain Cpl Langridge’s file from the CFNIS, it is within the Commission’s mandate to address the issues that arose in the disclosure of the file to the complainants.

46. Similarly, if the evidence demonstrates a shortcoming in an investigative step or other procedure related to a gap or deficiency in Military Police policy or training, it is also clearly within the Commission’s jurisdiction to point out the deficiency and recommend corrective measures.

47. To draw a line between what Military Police and CFNIS members do in the course of an occurrence or investigation and the many interconnected activities capable of impacting on what they do and how they do it, is to propose an artificial and unrealistic distinction. Sections 2(1) and 2(2) of the Complaints about the Conduct of Members of the Military Police Regulations are not “watertight compartments.”Footnote 47

48. With specific respect to allegations about CFNIS independence, the subjects submit, “[t]his Commission has no free standing jurisdiction to conduct a review of the structure and means by which the CF has chosen to provide police oversight for the force.”Footnote 48 The Commission does not accept the terms in which this argument is framed. Systemic issues touching upon CF oversight and Military Police independence can affect the competence of investigations and may lead to improperly conducted investigations. As such, these issues are directly within the Commission’s mandate. Where specific allegations are made about improperly conducted investigations, including allegations that the investigators in question are biased or lack sufficient independence, it is incumbent upon the Commission to examine the conduct of the investigation wherever it leads. The concepts of police bias and tunnel vision are well-understood phenomena. Even an unconscious bias or a perceived lack of independence can seriously undermine the outcome of a police investigation and the public’s trust in the institution.

49. The subjects further submit:

[T]his Commission must be equally careful to ensure that its process is not subverted or its mandate exceeded by the broad and sweeping complaints against the CF at large which permeated this hearing. The vast majority of the witnesses who appeared before this Commission were not Subjects of this complaint, nor were they MPs. Many of them are the target of very serious accusations by the complainants, including accusations that they have made professional errors and or committed criminal offences. It is not the role of this Commission to investigate, pursue or comment on the behaviour of other government actors.Footnote 49 [Emphasis added]

50. This description of the Commission’s role is inaccurate. The focus of the Commission’s examination is to consider the thoroughness of the police investigations. If the Commission is presented with complaints about misconduct and/or inadequacies in connection with the thoroughness of an investigation or the adequacy of its conclusions, these complaints must be examined. It cannot be known whether an investigation was thorough and comprehensive unless one looks into what there was to investigate. Conclusions reached might, in the process, raise inferences or questions about the conduct of third parties, but these were, after all, the very questions the CFNIS was tasked to investigate. The Commission’s ability to determine for itself what the subjects knew or had the means of knowing, and to summon witnesses from the CF, the DND, or even other government departments in the course of its investigation into a complaint, should be beyond dispute.Footnote 50

51. Finally, the subjects submit:

This Commission has no jurisdiction to make findings or recommendations regarding the means by which the CF has chosen, as an institution, to provide legal advice to the NIS. Nor does this Commission have the jurisdiction to make findings about the conduct of individual JAG lawyers who have been subpoenaed to appear as witnesses before this Commission and have been the subject of serious professional allegations by the Fynes and their counsel.Footnote 51

52. The Commission reiterates the view its oversight of Military Police investigations requires an examination of the facts and information available to investigators. Where investigators rely upon legal advice provided to them, or on legal advice provided to other members regarding the conduct being investigated, it is appropriate for the Commission to attempt to understand the circumstances of these communications. Where a deficiency in the advice (such as a mistake of law) impacts the conduct or findings of an investigation based on that legal advice, the finding may be relevant to an assessment of the reasonableness of the police investigation and may explain the reason for the outcome of investigations subject to a complaint. It should be noted this report has made no such findings on the facts as revealed by testimony and by documents made available to the Commission. This result in no way diminishes the legitimacy of the inquiry.

Speaking with One Voice

53. The Commission acknowledges the high standards of professionalism demonstrated by counsel for the complainants and the subjects throughout a lengthy, complex, and occasionally contentious hearing process.

54. In particular, the comments here are not intended to reflect on the personal conduct of the individual lawyers in the Department of Justice and the CF acting on behalf of the subjects and the Government in the PIH. The Commission stresses that counsel conducted themselves throughout the proceedings with integrity in often stressful circumstances to discharge what, to the Commission, appears to be an almost impossible assignment given the disparate interests of their “unified” client.

55. It should nevertheless be noted, the Government’s decision that one set of counsel would represent multiple and disparate individuals and institutions connected with the Military and/or Government raises a number of potential concerns.

56. Professor Kent Roach testified about the representation of Military Police at public inquiries and considered the topic in a related paper submitted to the Commission. He discussed the possibility a conflict of interest may arguably arise where interference with Military Police independence has been alleged, and yet those complained about are represented by lawyers who also represent the CF and the Government.Footnote 52 The independence problem is compounded by a Government policy sometimes referred to as “speaking with one voice,” about which the Hon. John Major remarked critically in the Final Report of the Commission of Inquiry into the Investigation of the Bombing of Air India Flight 182:

There is no doubt that agencies, no less than individuals, are entitled to representation by counsel who will present their actions and represent their interests in their best light. Where one set of counsel is appointed to do this for a variety of agencies with historically divergent perspectives and understandings, the task becomes unmanageable and risks trivializing the real differences that separate the agencies and compromising the benefits that might be expected from the separate representation of competing viewpoints.Footnote 53

57. In these proceedings, the “one voice” approach meant, as a practical matter, a single legal team composed of DOJ and other Government or Military counsel represented throughout the PIH the interests of:

58. The DOJ played a central role in acting for the MP, the CF, and the DND in responding to requests for documentary disclosure. This meant the DOJ was responsible for directing searches for documents in the possession of its various clients and making decisions about redactions and privilege claims prior to disclosure. The DOJ disclosed these documents in coordination with the CFPM Legal Advisor. This arrangement effectively puts the DOJ in the position of acting both as an advocate for its clients and as “gatekeeper” on behalf of the Government as a whole in the process of disclosing documents.

59. While it is possible all these interests align and all these parties share a common perspective on the facts and issues raised during the hearing, the apparent decision, as a matter of policy, to proceed on the assumption all these separate voices will be harmonized into a single consistent perspective carries a risk. This unified representation risks creating an impression of unfairness, whether to the complainants or to the subjects themselves, and appearing to raise unnecessary obstacles in the Commission’s fact-finding mandate.

60. Early in the proceedings, Commission counsel voiced concerns to members of the DOJ legal team about the potential impact on fairness, or at least the appearance of fairness, in these proceedings.Footnote 55 One practical concern arose from the possibility, in the context of its representation of one set of interests, the legal team might obtain information from sources like pre-hearing interviews, which would otherwise not be available to other interests being represented if not for the joint representation. Given the legal presumption that facts within the knowledge of one member of a law firm - let alone one member of a legal team - become facts within the knowledge of all members, and given the ethical obligation of counsel to share potentially relevant information with their client, a perception of unfairness might well arise. It was therefore suggested consideration be given to establishing ethical screens designed to insulate the different working groups of Government counsel from one another. This would have allowed all parties and interests to be represented by DOJ or other Government counsel with no possible appearance that otherwise unavailable information was being shared. These concerns were acknowledged but dismissed by Government counsel, who noted the Treasury Board’s Policy on Legal Assistance and IndemnificationFootnote 56 did not contemplate such undertakings or ethical walls for Government counsel, and maintained such measures did not appear necessary or appropriate in this case.Footnote 57

61. The Government’s decision to speak with a single voice runs the risk of appearing to enforce conformity of viewpoints where such conformity might not otherwise be expected to exist. Concerns could arise about the possibility that a particular interpretation of evidence or a theory of the case reflecting the perspective of one or more institutional interests might be advanced in preference to an approach more directly reflective of the interests or views of one or more of the subjects.

62. To be clear, it is not being suggested any such circumstance actually did arise in the present hearing. Neither the Commission nor the public has any right to inquire about conversations between any persons or institutions being collectively represented and the lawyers who represent them, so all that is left are possibilities and appearances. What matters is that the possibility of such circumstances is inherent in the policy of having Government institutions, fact witnesses and all the subjects of a complaint being represented by a single counsel team. This possibility can lead to an appearance of irregularity, which is damaging to the process even when, in factual terms, there may be absolutely no impropriety.

63. Public confidence in the integrity of the complaints process depends on the fairness, transparency and legitimacy of the Public Interest Hearing process. To stress again, while the Commission has no reason to believe anyone acted in any way other than appropriately, appearances and perceptions count. There is a real risk of public scepticism in circumstances where a single counsel team represents such a multiplicity of interests. Such scepticism can be particularly unfortunate where it may raise doubts about the ability or willingness of a subject of a complaint to raise defences and explanations which could reflect negatively on Government institutions like the Military or other witnesses being represented by the same legal team.

64. To be sure, clients must be free to select counsel of their choice to represent them, and nothing in these comments should be understood as seeking to deny that right. The difficulty is, the Treasury Board Policy on Legal Assistance and Indemnification – cited by the counsel team as a reason for declining to establish ethical screens that would clarify who was speaking for which client – also has the appearance of acting as a constraint on the subjects’ and witnesses’ actual ability to retain counsel of choice.

65. As a practical matter, this policy places the subjects in a difficult position. They are forced to choose between accepting representation by DOJ counsel paid for by the Government, or objecting to such an arrangement and going through the long and arduous process of obtaining independent representation (or opting to retain private and independent counsel at their own expense). It would be preferable to avoid the potential problems completely from the outset by providing independent counsel to the subjects to protect their interests with no possibility of a perception of potential divided loyalty. In the past, the DOJ’s Canadian Forces Legal Advisor appears to have recognized this problem by appointing independent counsel for the subjects of PIHs.Footnote 58 On a going forward basis, it would be preferable to follow that process by providing the subjects with independent counsel at the outset of a PIH.

Fact-finding and Effective Oversight

66. To conduct effective oversight of the Military Police in accordance with its mandate, the Commission requires access to facts potentially relevant to a complaint. Those facts may be found in documents or in the oral testimony of witnesses. For hearings to be conducted effectively, it is necessary for the potentially relevant information to be available to Commission counsel and the parties sufficiently in advance of the actual testimony to allow for meaningful preparation both by Commission counsel and the parties, including the complainants. In the PIH process, potential relevance is determined by reference to the issues arising from the complaint submitted to the Commission. The qualifier “potential” relevance is significant because it is not possible to determine actual relevance before evidence is collected and examined. Sometimes, when witnesses or subjects decline pre-hearing interviews, actual relevance cannot be determined until actual testimony is heard.

67. Where the complaint includes allegations of errors and inadequacies in investigations conducted by the CFNIS, potentially relevant information includes, at a minimum, the information that was available or could have been available to the investigators, along with the complete record of what was done to gather and draw conclusions from that information.

68. At the outset, it is necessary to acknowledge, in the present case, the information gathering exercise necessary to support meaningful fact-finding was both extensive and intensive. Much of the burden for collecting and processing the information fell on the CFNIS, on various branches of the CF and on their counsel. Given the volume of material, the complexity of some of the evidence, the potential for controversy arising from some of the legal issues and the time pressures inherent in the process, in may have been inevitable some mishaps would occur and there would be occasions of disagreement about what information should or could be made available.

69. Given this context, it is important to acknowledge the efforts of the CF, the CFNIS and their counsel team to comply with the information gathering needs of the Commission and to work with Commission counsel – and where appropriate counsel for the complainants – in a spirit of cooperative problem-solving, which ultimately led to most issues finding a reasonable resolution.

70. Nevertheless, the process was not always a smooth one.

Documentary Disclosure

71. The Commission appreciates the extensive and notable cooperation of all involved in the massive undertaking of responding to document requests for a large and complex PIH. Assembly of the immense collection of documents forming the evidentiary record was only possible because of the cooperation and hard work of the parties and their counsel, as well as of the Commission’s own counsel and staff.

72. The Commission understands the enormity of the task and the fact mistakes are inevitable, but disclosure issues, when they do arise, prejudice the ability of the Commission to do its work. The emergence of a number of disclosure issues on the one hand highlights problem areas in the hearing process, and on the other hand illustrates the possibility to resolve such issues with open discussions and concerted efforts. The hope is the incidents discussed below will be used as lessons to prevent, or at least to minimize, the impact of disclosure problems for future hearings.

73. When the Commission conducts a hearing, the NDA confers on it the power to compel witnesses to appear and give evidence and also to produce any documents under their control the Commission considers necessary to the full investigation and consideration of the matters before it.Footnote 59 Quite properly and helpfully, the Government legal team responsible for disclosure also was instructed to disclose to the Commission, upon request, all the records it would be entitled to receive as if the Commission had actually issued a summons.Footnote 60

74. Shortly after the decision to conduct a PIH was issued, Commission counsel requested from the CFPM a number of documents identified as being relevant to the complaint, in addition to the GO files for the three investigations already produced earlier.Footnote 61 The initial request covered documents at CFNIS WR and CFNIS HQ relating to Cpl Langridge’s death, interactions with the complainants, the 2008, 2009, and 2010 investigations, or the issues raised by the complainants. The initial request also sought documents relating to any meetings where the complainants’ case was discussed and any Military Police member was present, as well as information concerning the investigative training of CFNIS members in general, and the training specifically received by the 13 subjects in particular.

75. As Commission counsel reviewed documents and began to conduct pre-hearing interviews, follow-up disclosure requests were issued. In February 2012, Commission counsel wrote to the CFPM Legal Advisor requesting that potential witnesses represented by DOJ counsel search their records to identify relevant documents in their possession not already provided to the Commission.Footnote 62 This request was made upon the realization witnesses at pre-hearing interviews referred to and acknowledged the existence of relevant documents the Commission had not seen previously, putting Commission counsel in the position of having to review them only after the interviews or, in a few cases, shortly beforehand.

76. The pace of document production and the completeness of disclosure were not always problem-free. In particular, there were instances of last-minute disclosure of large collections of documents sent on the eve of testimony, and also late disclosure of documents that would have been exceptionally relevant for witnesses who had already testified. At the commencement of the hearing, for example, the Commission received a very large production of documents from the Government. Commission counsel raised concerns at that time about the difficulty such last-minute productions would impose.

77. In another instance, just prior to the testimony of Dr. Mohr, a psychologist employed by the CF, and Mr. Perkins, a Base Addictions Counsellor, roughly 100 pages of new documents relevant to that testimony were produced at the last moment.Footnote 63 This belated production occurred despite numerous specific requests for these documents and repeated confirmation all relevant documents had been produced. On this occasion, DOJ counsel stressed the late disclosure had not been intentional. The story of these documents requires some explanation, notably because their eventual production was preceded by numerous requests and by repeated confirmations all relevant documents had been produced. This raises serious concerns about the adequacy of document searches conducted.

78. Commission counsel requested disclosure of Cpl Langridge’s complete medical file in January 2012 following the pre-hearing interview with Dr. Mohr when Commission counsel realized the records might not be complete.Footnote 64 A first version of the file was produced in early February.Footnote 65 On February 23, 2012, Commission counsel made a specific request for any notes about a CFB Edmonton Garrison Clinic or Mental Health Clinic case conference about Cpl Langridge held on or about March 7, 2008.Footnote 66 Commission counsel were subsequently told no such notes were found.Footnote 67

79. On March 16, 2012, Commission counsel made a specific request for Cpl Langridge’s complete mental health file and records because it appeared the records in the Commission’s possession were still incomplete. Further mental health records were provided on March 29, and the Commission made a request for confirmation the records were now complete and included records for Cpl Langridge’s addictions counselling.Footnote 68 However, late in the afternoon on the day before Dr. Mohr and Mr. Perkins were scheduled to testify, new BAC records were received by the Commission – including the previously requested note specifically referring to a March 13, 2008 Base Clinic case conference about Cpl Langridge. This was the first record received of a conference held two days before Cpl Langridge’s death. These documents were highly relevant to the evidence of Mr. Perkins, one of the BACs in question, and to that of Dr. Mohr. Furthermore, one of the documents previously produced with respect to Dr. Mohr’s testimony turned out to be the wrong document, and the correct document was only produced the morning of her testimony. This document was several hundred pages in length.Footnote 69

80. These documents would also have been highly relevant to witnesses who had already testified. Commission counsel reserved the right to bring some witnesses back to testify about the documents,Footnote 70 although, fortunately, this did not prove necessary.

81. DOJ lead counsel acknowledged it was neither desirable nor acceptable that documents were being provided on such a late basis. She noted the legal team for the Government had made a number of inquiries to ensure the complete medical records were produced.Footnote 71 The team believed the complete medical records had been produced to the Commission as of March 30, but through an oversight, additional documents existed, which were not produced to the Commission. This was only discovered days before the scheduled testimony.Footnote 72 Further, the lengthy document was identified by the witness as incorrect and in need of replacement only the night before her testimony, and this was corrected as soon as DOJ counsel became aware of it. DOJ lead counsel made it clear she believed a thorough search had been made, and the appropriate priority had been given to the document requests. She promised to personally make the necessary queries to ensure all search efforts were made and do everything within her power to ensure this did not happen again.Footnote 73

82. The Commission accepts DOJ counsel’s bona fides in this matter. However, this does not diminish the frustration and inconvenience caused to the Commission and all parties by the inadequate research conducted on behalf of the CF.

83. On another occasion, the Commission received 200 additional pages of CFNIS materials on June 8, 2012, just two business days before the testimony of Maj Bolduc, the DCO CFNIS during the relevant investigations. The materials included communications from Sgt Mitchell to Maj Dandurand and were clearly captured by the Commission’s September 2011 request for disclosure “of all notes, memorandums and correspondence (including internal)” at CFNIS HQ and Western Region concerning interactions with the complainants or related to Cpl Langridge’s death.Footnote 74 The late disclosure was made more vexing in view of a February 2012 letter from Government counsel, which made assurances all documents responding to this request had already been provided in December 2011.Footnote 75

84. In yet another instance, in February 2012, Commission counsel requested any documents or information concerning all changes or revisions made following the Fynes case to Military Police policies and procedures with respect to the disclosure of suicide notes.Footnote 76 Two documents were received in reply: an October 2010 revision to a CFNIS SOP, and a July 2011 revision to that policy.Footnote 77 Following a witness interview in April 2012, Commission counsel sent a further disclosure request seeking confirmation of the date when changes relating to the procedures for the disclosure of suicide notes were made, as well as any and all records of interim policies or directives prior to those changes taking effect.Footnote 78 On April 23, 2012, DOJ counsel advised that LCol Sansterre changed the policy by means of quarterly OC conferences and monthly conference calls in and around July 2009. Commission counsel were advised, “[t]here are no additional written documents related to these communications.”Footnote 79 However, on the day of LCol Sansterre’s testimony to discuss the policy, additional written records of the OC conferences and conference calls were provided to the Commission.Footnote 80 Then, in the June 8, 2012, document production, and after LCol Sansterre had already testified on these issues, further records directly relevant to this request were delivered.Footnote 81

85. These incidents suggest a flaw in the means by which documents are searched and identified, and possibly a deficiency in the understanding of the relevance of these documents on the part of those in possession of them.Footnote 82 The frustrating disclosure problems were discussed on the record at the hearing on June 11, 2012.

86. A further instance of late disclosure involves the production of the subjects’ documents in the summer of 2012.Footnote 83 Many of these documents were clearly covered by the initial September 2011 request,Footnote 84 and they were directly relevant to the conduct of the CFNIS investigations and related activities. The documents included such basic information as the status reports for the investigations and should have been produced well before August 2012. The documents also included Sgt Bigelow’s notebook, which was never scanned into SAMPIS and would have been invaluable to the Commission and to the parties during the testimony of the fact witnesses heard between March and June 2012.

87. The delay is particularly remarkable considering subjects’ counsel were initially insistent on having all testimony completed in the spring of 2012,Footnote 85 which it turns out was a time prior to when these documents were ultimately produced.

88. These incidents provide just a few snapshots of an occasionally troubled disclosure process throughout the PIH. While there is no suggestion any individual acted improperly or any of the disclosure delays were intentional, the Commission was and remains concerned, since late production of documents has a serious impact on its ability, and the parties’ abilities, to prepare for witness testimony.Footnote 86

89. Whether there is a strict legal right to receive documents in advance of a witness’ testimony, receiving documents on the eve or the morning of such testimony means a scramble to assimilate new information and the possibility of missing implications or nuances, which only become clear with sufficient time for review or comparison to other evidence. This impact is even greater when a particularly relevant document is produced for witnesses who have already testified. Ultimately, the truth-seeking function of the Commission is impaired when relevant and important information does not come to light in time. It is inevitable errors or oversights will occur during the process of reviewing and producing many thousands of documents, but disclosure problems such as these can raise doubts about the completeness of searches and, in particular, the reliance which can be placed upon assurances that all relevant documents have been produced.Footnote 87

90. In light of these concerns, the Commission urges the greatest diligence be exercised in responding to document disclosure requests, so complete and comprehensive searches are undertaken in a timely manner. The Commission urges Government counsel to obtain the necessary assurances to confirm these searches have been completed before advising the Commission all requested documents have been produced or no such documents exist.

91. Beyond the timing and thoroughness of disclosure, the Commission, at times, also met with resistance to its disclosure requests. This merits attention because of the potential this sort of reaction has to impact negatively on the Commission’s ability to function. In one instance, counsel for the CFPM and counsel for the DND/CF legal advisor challenged the relevance of the materials being requested and the Commission’s jurisdiction to request them.Footnote 88 As such, the Commission was asked to provide further information “[…] regarding the relevance of the following information to the conduct of the military police subjects at issue in this matter […]”.Footnote 89 To name a few, the documents said to be of doubtful relevance included the mental health file materials requested from Dr. Mohr, documents concerning a possible suicide watch for Cpl Langridge in December 2007, records of suicide prevention training, March 2008 Base Clinic case conference records, and documents related to the personnel file review of Cpl Langridge.Footnote 90

92. The Commission agrees with the position taken by Commission counsel these comments appear to suggest it is the role of the DOJ and/or its clients to pass judgment on what is and is not relevant to the Commission’s investigation in responding to document requests.Footnote 91

93. For the reasons explained above in discussing the Commission’s jurisdiction, the issue of whether or not materials requested by the MPCC were reviewed by the MP is irrelevant to whether or not those documents should be produced to the Commission. Similarly, the topics the Military Police chose to investigate cannot constrain the topics relevant to the Commission: the Commission’s role is to determine the topics and materials the members should have investigated. It should be noted a similar position was previously advanced by the DOJ in Garrick et al. v. Amnesty International Canada before the Federal Court of Canada, where it was decidedly rejected by de Montigny J., who wrote:

[…] it is for the Commission, not the Government, to determine ultimately what documents are relevant to its inquiry. If it were otherwise, the Commission would be at the mercy of the body it is supposed to investigate. This was clearly not the intent of Parliament.Footnote 92

94. In this instance, the relevance of materials did not appear to be understood by those in charge of gathering and producing them. Because the Commission must rely on the searches conducted by those from whom it requests materials, this disconnect between their understanding of relevance and Commission counsel’s understanding is of obvious concern.

95. The Commission was also advised there were three boxes of documents concerning Cpl Langridge obtained from searches throughout DND and the CF, and while the view was expressed it was unlikely these documents were relevant, Commission counsel were invited to attend in person to review the documents.Footnote 93

96. Despite the initial opinion by the CFPM Legal Advisor and the CF/DND Legal Advisor as to the dubious relevance of the documents, the in-person review by Commission legal counsel of the three boxes of material generated a request for over 1600 pages of material. Some of the documents were likely duplicates of items already in the Commission’s possession, but the materials also yielded significant new evidence. The large volume of materials ultimately produced as a result of the review made it clear there are good reasons for the Commission and its counsel to be the judge of what is relevant to a hearing.

Witness Interviews

97. When the Commission decides to hold a PIH to investigate a complaint, the information available through documents is supplemented by oral witness testimony.

98. The Commission has the power to compel the appearance of witnesses by summons but also sought the cooperation of witnesses in advance of their testimony by inviting them to participate in pre-hearing interviews. Such interviews are of great assistance to the Commission in gathering new information and gaining insight into witnesses’ knowledge and recollections prior to their testimony. The interviews are also helpful to the Commission in determining whether or not calling a witness to appear at a hearing is, in fact, necessary. The names of people may appear on documents, which thereby suggest they have relevant information, but an interview may establish they have scant involvement in the matter or their evidence would not add materially relevant information. Pre-hearing interviews also can contribute to efficient use of time and resources by enabling Commission counsel to focus the witness’ examination-in-chief at the hearing on the most relevant topics about which the witness can assist the Commission. In addition, conducting pre-hearing interviews allows Commission counsel to provide more disclosure to the parties, at least about the expected areas to be covered with the witnesses, which in turn assists the parties in preparing for the hearing.

99. In order to facilitate cooperation and gain information from as many witnesses as possible, the Commission agreed with a DOJ proposalFootnote 94 that the pre-hearing interviews with witnesses who were represented by Department of Justice counsel (such as CF members and Crown employees) would be conducted on a confidential “off-the-record” basis.Footnote 95 The agreement meant witness interviews would not be recorded or transcribed (apart from notes taken by Commission counsel), and the content of the interviews would not be used to cross-examine or impeach the witnesses during their testimony. For each witness who participated in a pre-hearing interview, a “will-say” statement outlining the general topics anticipated during a witness’ testimony was disclosed to the parties. These terms were also applied to unrepresented witnesses and witnesses represented by other counsel.

100. While perhaps not ideal in terms of efficiency, the confidential pre-hearing interview format agreed to may be an inevitable cost of securing witness interviews in advance of their testimony and encouraging candour in those interviews. The trade-off is, the closed nature of the interviews does not necessarily engender public confidence in the transparency of the process.

101. Despite the Commission’s agreement to confidential off-the-record interviews to facilitate witness cooperation, not all witnesses agreed to participate in pre-hearing interviews. The Commission proposed that the subjects of the complaint be interviewed under similar terms as the non-subject pre-hearing interviews. As was their undoubted right, the subjects of the complaint did not agree to be interviewed in advance of the hearing.Footnote 96 In addition, several MP and JAG witnesses also declined to participate in pre-hearing interviews.Footnote 97 PO2 Gazzellone and Maj Bolduc, both non-subject CFNIS witnesses, refused to participate in a pre-hearing interview, as did LCdr Thomson, LCol King, Maj Fowler, LCol MacGregor and Maj Reichert, from the Office of the Judge Advocate General. DOJ counsel requested the identity of witnesses who refused to be interviewed be kept confidential. The Commission did not agree with this request.Footnote 98


102. Redactions are portions of documents expurgated by Government on the basis they are not producible to the public as a result of either a common law privilege or a statutory provision.

103. Documents may be redacted by Government agencies to remove personal information, to sever information protected by national security concerns (such as those enumerated by section 38 of the Canada Evidence Act),Footnote 99 or to prevent the disclosure of confidential communications afforded special protection by legal privileges (like solicitor-client privilege). When redactions are made carefully and judiciously, an appropriate balance can be struck between protecting sensitive information where disclosure could cause harm, and respecting the public’s right to be informed and hold the Government accountable.

104. The Commission urges the exercise of great diligence to ensure any and all redactions applied by the Government legal team to documents prior to disclosure are well-founded and appropriately confined in order to guarantee the broadest disclosure possible.Footnote 100 In this case, while there were a few instances in which redactions seemed excessive, the majority of the redaction issues encountered during the PIH were resolved through discussions between counsel and through the cooperation of counsel in reconsidering redaction decisions.

105. It should also be noted that a major portion of the redactions, which were imposed because of litigation privilege, were correspondingly lifted when the complainants discontinued their civil litigation claim against the Government.Footnote 101 Other redaction issues were resolved through creative compromises. Others still were never resolved.

106. The most vexing redaction problems occurred in the context of the ongoing issue of claims for solicitor-client privilege, which were made on a blanket basis. Because this issue took on a special importance and involved not just the redaction of documents but also extended to oral testimony as well, it is dealt with separately.

Solicitor-Client Privilege

107. A sporadically recurring issue creating significant friction involved the reflexive and absolutist invocation on the part of DOJ counsel of solicitor-client privilege on behalf of the Minister of National Defence with respect to information which, at the time, appeared centrally relevant to the mandate of the Commission.

108. At the outset, it is important to acknowledge the central importance of the doctrine of solicitor-client privilege. Solicitor-client privilege applies to any confidential communications between a client and his or her lawyer made with respect to seeking or providing legal advice.Footnote 102 The privilege is a class privilege, meaning it presumptively applies in every case of such communications, and anyone seeking to have privileged information admitted has the burden of demonstrating why the communication should not be privileged.Footnote 103 There are only a few limited exceptions where the privilege will not apply or will be overridden by a court, such as in the case of legal advice intended to facilitate the commission of a crime or fraud or where the privilege would block evidence that might be the only way for an accused person to establish innocence.Footnote 104

109. The validity of the privilege and its special place in the legal system are not in issue. The functional reason for the extraordinary protection of solicitor-client privilege in our legal system is rooted in the need to protect client confidences in the context of the administration of justice in an adversarial system.

110. A client whose confidential communications to counsel could be exposed and disclosed against his or her will would be reluctant to seek legal advice or to be represented by legal counsel. The privilege promotes candour between clients and their legal advisors, enables individuals and institutions in need of advice to make fully informed decisions about how to conduct their affairs and facilitates access to the justice system. Although the protection of solicitor-client communications from disclosure is nearly absolute, the privilege belongs to the client (not the lawyer) and the client is free to waive that privilege if he or she sees fit regardless of anyone’s wishes, including those of the lawyer.Footnote 105

111. There are three principal issues comprising the Commission’s critical concerns with the solicitor-client privilege claims raised in this hearing.

112. The first issue pertains to advice received by the CFNIS subjects about the investigations. This would include, most importantly, advice potentially underlying the decision to conclude the 2010 investigation without conducting any witness interviews.

113. In the context of these hearings, it is important to bear in mind no suggestion has been made that the subjects ought to be required to waive privilege over any communication seeking legal advice regarding their own interests or their legal rights and certainly not with respect to any advice sought or received in connection with their status as subjects of the complaint. The ability of the subjects to rely on solicitor-client privilege in protecting their interests should not be second-guessed and, in any case, it would be difficult to justify overriding the claim or asking the subjects themselves to waive the privilege.

114. However, the subjects may themselves, in some cases, wish to waive privilege claims in order to explain their actions. It must be said here, should the subjects have wished to rely on legal advice received in order to explain or justify their actions, DOJ counsel would have been placed in a difficult position, considering their CF and DND clients’ position against any such waiver of privilege.

115. Treating the Minister as the sole client for the purpose of solicitor-client privilege could create significant problems for the individuals who actually sought or benefitted from the legal advice and whose interests are directly at stake in a PIH. The subjects appear to be effectively bound to insist upon such solicitor-client privilege claims advanced by their DOJ counsel because their counsel jointly represents the Minister and other Government clients. Because the Commission is properly not entitled to inquire as to any conversations between the subjects and their counsel, it – like the public – can only go on appearances. Because it cannot be known precisely whose interests are being advanced as among the many represented by DOJ counsel, when privilege claims are made, uncertainty may remain about the possibility, in some instances, the subjects’ ability to answer the allegations made against them might have been prejudiced.

116. Given the fact it is absolutely clear this type of information will often be central to the Commission’s mandate during a public interest hearing, consideration may need to be given to the development of a solution to allow the Commission to review the information without making it public and to fully and fairly assess the subjects’ conduct in the proper context.

117. The second issue of concern relates to solicitor-client privilege claims over advice received by CF members during the course of the events under investigation and which was known to CFNIS members, or should have become known, in the course of a thorough investigation. What was sought in this hearing was access to information about a number of CF decisions relevant to the Fynes’ complaints that may have involved legal considerations. Among these decisions were the CF decision not to mount a suicide watch and its decision to recognize Ms. A as Cpl Langridge’s Primary Next of Kin (PNOK). Each of these decisions was clearly and centrally relevant to the police investigations being complained about, and any legal considerations would be similarly relevant to the Commission’s assessment of the reasonableness of the investigations themselves. Most of the information being sought was either before the investigators in the course of their investigation or could have been available to them.

118. In the present case, the Minister claimed a broad and categorical privilege with respect to any legal information whatsoever either in the documents – where it was redacted – or in the oral evidence.

119. The Commission acknowledges and appreciates the general argument that, if solicitor-client privilege was routinely waived or pierced, this could have a negative impact on the Government’s ability to have candid discussions with its advisors.Footnote 106 However, the Commission sought limited waiver from the CF and the Government of Canada exclusively, and it is the position taken by the CF and the Government that causes concern. Some of the privileged materials were provided directly to CFNIS investigators by counsel as legal advice, while others were disclosed as documents containing legal advice previously obtained by members of the Regiment. In both cases, a perverse outcome seems likely when the Commission is categorically denied the same documents and communications as were freely disclosed to CFNIS members.

120. The third issue involves questionable privilege claims made during the testimony of counsel working for the office of the JAG when asked for their individual views about what the law was. The breadth of the objection is illustrated in the testimony of Maj Rodney Fowler in relation to the Commission’s efforts to understand the CF perspective on the legal principles governing the administration of deceased soldiers’ estates – a question at the heart of the Fynes’ complaints about the 2009 investigation. Here, the position of DOJ counsel appeared to be that even asking the witness the meaning of “next of kin,” as understood at the time by the CF in connection with the administration CF members’ service estates, would violate solicitor-client privilege.

121. DOJ Counsel went further and also contended that even asking the witness to provide basic factual information about whether or not Assisting Officers were entitled to approach his office for legal advice constituted an improper “indirect” attempt to adduce privileged information concerning what advice was given and to whom.Footnote 107 The DOJ and JAG view appeared to be that answering these questions would run the risk of improperly disclosing any legal advice that had ever been given on the topic within the JAG branch. This was exemplified by Maj Fowler’s repeated assertion that answering questions about legal matters within his expertise would cause him to “have to opine” on a legal issue, which fell within the JAG mandate to advise the CF,Footnote 108 and thus he could not answer “because it would disclose a solicitor-client confidence.”Footnote 109

122. On May 23, 2012, the Commission heard submissions on the issue of whether it had jurisdiction to make rulings on questions of solicitor-client privilege. DOJ counsel made extensive submissions on this point but, given the scope of the motion being argued, was not in a position to make submissions on the validity of the objections she made during Maj Fowler’s testimony. She requested, in the event the Commission determined it did have jurisdiction to make rulings on solicitor-client privilege, submissions then be heard on the propriety of the objections.Footnote 110

123. The Commission ultimately did not make any determinations on this question and, accordingly, has not heard submissions on the validity of the claims themselves. As such, there may be good reasons justifying invoking solicitor-client privilege claims in this matter, of which the Commission is unaware. However, the Commission continues to have great difficulty with these claims at face value. Surely, solicitor-client privilege cannot apply to the CF’s understanding of the law it was applying. It cannot be the case the CF was entitled to administer military estates on the basis of legal interpretations, which were or could be kept from the public, thereby creating the impression the CF was entitled to administer a “secret law” concerning military estates touching real lives and real families.

124. In the Commission’s opinion, there is no genuine conflict between a lawyer’s duty to maintain the privilege over confidential communications with clients concerning legal advice and the lawyer’s freedom to make a general public statement about his or her view of the state of the law. However, even if such a conflict did exist, this is precisely the sort of information that should be waived because it goes to the heart of the decisions made and conclusions reached by the CFNIS investigators. In cases where CFNIS investigators rely in good faith on legal information during the conduct of their investigations, they ought to be able to rely on this legal information in presenting their response to allegations made against them before this Commission. Whether or not such reliance did occur in the course of the various CFNIS investigations in this matter, the principle is an important one.

125. The positions taken in support of the broad privilege claims being asserted seem far removed from the generally understood purposes thought to underlie the privilege. Most importantly, insofar as they block access to information, which was or arguably should have been looked into during the course of the investigations being complained about, these sweeping claims seem in direct conflict with the Commission’s oversight mandate. If the Commission is to evaluate the thoroughness and technical competence of the investigations, it ought to have access to the information that was or should have been before the investigators.

126. In keeping with the spirit of public comments made by the Minister of National Defence reiterating the Government’s commitment to full cooperation with the Commission, the Commission sent a letter to the Minister on June 18, 2012, seeking a pragmatic compromise to the impasse.Footnote 111 The Commission recognized the law authorizes the Minister, as the ultimate “client” and holder of the privilege on behalf of the Government of Canada, to waive the privilege either on a blanket basis or with respect to specifically identified communications. Rather than contending with the legal framework for the privilege claims, which involved certain very broad claims and could result in protracted adversarial proceedings, the Commission instead wrote to the Minister of National Defence requesting he exercise his discretion to waive the solicitor-client privilege claims on a limited basis.Footnote 112

127. In the past, the Minister has recognized the utility of this doctrine, and indeed granted a waiver in respect of a legal opinion related to a case before the Commission in order to facilitate the Commission’s exercise of its mandate in a public interest investigation.Footnote 113

128. The waiver sought for the current PIH would have applied only to specific communications going to the heart of the subject matter the PIH was meant to investigate. Because of potential prejudice to the subjects possibly arising from their inability to discuss the legal advice they reviewed or relied upon, the Commission also specifically requested the Minister consider waiving any claim of privilege with respect to information that might be helpful for the subjects of the complaint to explain their actions.Footnote 114

129. On June 21, 2012, the Commission received the reply from The Honourable Peter MacKay, then Minister of National Defence. The Minister declined to waive any of the claims of solicitor-client privilege and explained, the state of the law made any such waiver extremely rare. He based this conclusion on jurisprudence affirming solicitor-client privilege as critical to the administration of justice in Canada, citing a Supreme Court of Canada decision declaring that solicitor-client privilege must remain “[…] as close to absolute as possible”Footnote 115 as supporting stringent norms to ensure its protection. The Minister concluded the Commission’s request that he waive the claims of solicitor-client privilege

[…] is neither warranted nor advisable in this case. Such a waiver would not accord with the state of the law in Canada or with the nearly absolute practice in maintaining confidentiality over communications between clients and legal advisors.Footnote 116

130. While the Commission remains of the view that there was clearly no legal impediment preventing the Minister, who claims the sole status of “client”, from waiving the privilege, as a client may do so at any time and for any reason, the Commission also recognizes it was within the Minister’s discretion to decide to refuse the limited waiver request. However, where it is the Minister who claims the sole status of “client” for purposes of waiver, the real question in connection with any given communication that may be capable of attracting solicitor-client privilege is: should there be a waiver of the privilege if it is needed for a full and fair hearing of the evidence and no prejudice will result? A refusal to waive solicitor-client privilege can deprive the Commission and the parties of extensive information central to the mandate of the MPCC.

131. In the event of an impasse such as arose in this hearing, the recourse, whether directly or by way of judicial review, would be to refer questions about the Commission’s jurisdiction and about the propriety of solicitor-client privilege claims to the Federal Court of Canada. Any such recourse would significantly delay the progress of a PIH – likely for many months – and would incur great cost to the Commission, to the parties, and to the Government to resolve. Such a detour inevitably would impede the Commission from being able to discharge its statutory mandate, which includes a requirement to “deal with all matters before it as informally and expeditiously as the circumstances and considerations of fairness permit.”Footnote 117

132. As it turns out, subsequent testimony put the importance of some of the legal information being sought into a somewhat different perspective. Sgt Shannon testified he did not seek legal advice in connection with the 2009 investigation and conducted his own legal research about the Next of Kin issue.Footnote 118 In terms of the briefing he prepared for the chain of command concerning the conclusions of 2010 investigation, it is not known whether Sgt Shannon relied on the existing legal opinion obtained by MCpl Mitchell with respect to the potential offences involved. To the extent any external legal analysis or external opinion played any role in the earlier decision to close the file without conducting any investigation, such opinion could only have been based on the information that had been gathered for the file. The Commission has found this information was incomplete and contained many factual errors.Footnote 119 With respect to the 2008 investigation, the evidence indicates the investigators who did look or could have looked into the evidence never turned their minds to the issue of the authority of the CF to conduct a suicide watch or to any legalities that would have been relevant to such a decision. As well, they never interviewed any of the individuals who might have directly received legal advice on these matters.Footnote 120

133. All these factors reduced, although they did not eliminate, the importance of the content of any legal information received by the CF or by the CFNIS, in assessing the three CFNIS investigations.

134. In the final analysis, the Commission was able to discharge its oversight function with the Fynes’ complaints adequately, even without the legal information originally sought. That is a fortunate and somewhat fortuitous outcome, though it does not in any way diminish the concern with regard to the privilege claims. It would still have been preferable for a more complete examination of the issues, particularly in respect to the 2010 investigation, for the Commission to have the information. The information requested was relevant and material to the Commission’s mandate and remains so. In future cases, a similar blanket refusal by the Minister to waive privilege could have an even more serious impact on the Commission’s work.

135. The Commission continues to believe the Minister ought to consider waiver requests on a case-by-case basis and, unless there is actual prejudice, privilege ought to be waived so as to allow the Commission to discharge its oversight mandate. Where, as may sometimes be the case, the perceived risks associated with a waiver are too great, the possibility of allowing the Commission to receive the information without disclosing it publicly in order to discharge its mandate should not be discounted. The “limited waiver” of privilege is certainly well understood in Canadian law, in that disclosure of a privileged communication for one purpose does not mean it can then be used for any other purpose.Footnote 121 Similarly, it is possible to disclose a privileged document under strict conditions and preserve the intention not to waive privilege.

136. Recent legislative developments make it clear that a limited waiver regime is entirely consistent with the great value placed on protecting solicitor-client privilege on the one hand, and police oversight functions on the other. This Commission, which was created by the National Defence Act, is modeled after the Commission for Public Complaints Against the RCMP, which was created by the Royal Canadian Mounted Police Act.Footnote 122 The Commission notes that the RCMP Act has recently been amended by Bill C-42Footnote 123 to permit the Commission for Public Complaints Against the RCMP to access information covered by solicitor-client privilege as well as other privilege claims.Footnote 124 When the amendments come into force, ss. 45.4(2) and (3) will provide that:

(2) Despite any privilege that exists and may be claimed, the Commission is entitled to have access to privileged information under the control, or in the possession, of the Force if that information is relevant and necessary to the matter before the Commission when it is conducting a review under section 45.34 or 45.35 or is conducting an investigation, review or hearing under Part VII.

(3) The entitlement to access includes the right to examine all or any part of a record and, subject to the Commissioner’s approval, to be given a copy of all or any part of a record.Footnote 125 [Emphasis added]

137. Pursuant to s. 45.41 of the amended RCMP Act, should the Commissioner of the RCMP refuse to grant the Commission for Public Complaints Against the RCMP access to the privileged information, a conciliation mechanism can be employed under which, at the Commission’s request, the Minister will appoint a conciliator (such as a former judge of the superior court of a province or of the Federal Court).Footnote 126 The conciliator will then review the privileged information and provide observations regarding the information and its relevance and necessity to the matter before the Commission. If after these observations are received an agreement concerning the privileged information cannot be reached, the parties may apply for judicial review.

138. The Commission for Public Complaints Against the RCMP will not have unfettered access to privileged information, nor is the privilege waived by virtue of accessing the privileged information. Pursuant to s. 45.43 of the amended RCMP Act, the Commission for Public Complaints Against the RCMP may not use the privileged information for any other purpose than the matter for which the access was granted, and under s. 45.47(2) may not disclose that information to anyone other than certain persons (such as the Minister, or the Attorney General if the information is required for criminal proceedings).Footnote 127 Additionally, the new s. 45.44(2) provides that whenever the Commission for Public Complaints Against the RCMP prepares a document or report for distribution, this document must first be reviewed by the Commissioner to ensure it does not contain privileged information before it can be published or distributed. Although this is a somewhat complicated and even convoluted system for reviewing solicitor-client privileged information, the amendments are an explicit recognition that a functional and pragmatic mechanism of limited waiver that facilitates the work of a police oversight body is at least possible.

BOI & SI Statements and Answers

139. It should be self-evident by now that the Commission’s oversight mandate requires it to be able to receive and review whatever information was available to investigators in any matter the Commission has been charged with investigating. For this reason, another evidentiary hurdle for the PIH was the strict, letter-of-the-law insistence by Government counsel on the absolute inadmissibility of statements and answers given by witnesses during a BOI or SI even though this information was provided to the CFNIS investigators.

140. In the course of the 2009 Investigation, MCpl Mitchell obtained from LFWA a draft report of the BOI examining the circumstances of Cpl Langridge’s death, which included extensive findings based on the evidence heard at the BOI.Footnote 128 The findings and supporting facts were expressly tied to the testimony of particular witnesses. MCpl Mitchell also received from LFWA the report and annexes to the SI conducted concerning the administrative actions taken by the Unit after Cpl Langridge’s death.Footnote 129 These materials comprised over 575 pages and, among other things, contained the questions Maj Chenette (who conducted the SI) provided to a large number of LDSH witnesses concerning the events following the death and the answers they provided.Footnote 130

141. The documents obtained by the CFNIS were of clear relevance to the 2009 and 2010 investigations, given they provided a wealth of information on the subjects of those very cases. The documents were scanned into SAMPIS and investigators assigned to these files reviewed them. Accordingly, the BOI report and SI report and annexes were clearly relevant and important to the Commission’s work.

142. Section 250.41(2) of the National Defence Act prohibits the Commission from receiving or accepting certain evidence:

  1. any evidence or other information that would be inadmissible in a court of law by reason of any privilege under the law of evidence;
  2. any answer given or statement made before a board of inquiry or summary investigation;
  3. any answer or statement that tends to criminate the witness or subject the witness to any proceeding or penalty and that was in response to a question at a hearing under this Division into another complaint;
  4. any answer given or statement made before a court of law or tribunal; or
  5. any answer given or statement made while attempting to resolve a conduct complaint informally under subsection 250.27(1).Footnote 131 [Emphasis added]

143. The DOJ took the position none of the information provided by witnesses in the BOI or SI was admissible because of section 250.41(2) of the NDA. All such information was redacted, meaning large portions of the 2009 GO file were essentially just blacked-out pages. Commission counsel argued the NDA provision did not prohibit admitting the information for the limited purpose of demonstrating what information was available to the CFNIS members during their investigations, even if the statements themselves could not be used as evidence of what a witness actually said for the purpose of making findings. For a time, the matter came to an impasse.

144. A compromise was ultimately reached to admit some of the information in question through the use of agreed-upon summaries. One document included a list of the questions asked to witnesses during the SI.Footnote 132 DOJ counsel agreed with Commission counsel these should not be redacted, as they were not inadmissible under any NDA provision. The questions were admitted verbatim except where the question could identify the answers provided by a specific witness. The questions were important because of the possibility the conduct of the SI, which took place before any CFNIS investigation into the same issues, may have contaminated certain witnesses by the nature of those questions.Footnote 133 The second document contained a general summary of the information the SI witnesses provided.Footnote 134 Any information capable of identifying which witness provided what information was reworded or omitted. Neither Commission counsel nor the DOJ regarded the compromise as derogating from or contradicting their respective conflicting positions about the appropriate interpretation of section 250.41(2) of the National Defence Act.

145. Significant compromises were made in connection with this global summary. However, while the resulting documents did not wholly satisfy anyone, the compromise prevented delays and allowed important and relevant information to be received.

146. The reading of the restriction in NDA section 250.41(2)(b) proposed by the DOJ once again has the effect of depriving the Commission of the ability to examine the very materials the CFNIS had access to during the investigations. More specifically, the Commission is prevented even from examining the documents for the purpose of assessing what information the CFNIS had in its possession (rather than for the truth of its contents). Here, too, the Commission’s mandate to informally and expeditiously deal with the matters before it is relevant,Footnote 135 since the proposed interpretation of the section can add significant length, complexity and expense to a PIH (for example, by operating as a de facto “best evidence rule” requiring the expense of hearing testimony from witnesses even when their evidence is uncontroversial). The prohibitions also mean a significant tool for testing the reliability and credibility of a witness is impeded, to the detriment of the Commission’s ability and duty to uncover the truth.

147. Notwithstanding these problematic aspects of the prohibitions in the NDA, the compromise reached in this hearing demonstrates the benefits of a collaborative problem solving approach, which mitigates some of the potentially detrimental impact of the provision. The Commission is hopeful compromise will be employed more often and, in future hearings, the Government can adopt a more relaxed approach to recognize the distinction between accepting statements for the truth of their contents and the fact the statements were made.

Specific Document Management Problems Arising from SAMPIS

148. The Commission faced a number of document management problems specifically related to the uniqueness and idiosyncrasies of SAMPIS, the electronic military police information database into which investigative materials are compiled and stored.Footnote 136 SAMPIS is a police records management system developed by the firm Versaterm, and is a customized version of a commercial system licensed to police services across North America.Footnote 137

149. These problems related to SAMPIS are distinct from the issues of production discussed earlier in this chapter. They may recur in future PIH proceedings unless dealt with specifically. A significant amount of time and attention was spent at the hearing in an attempt to understand the problems and, in some instances, answers were still lacking despite best efforts by all involved to get to the root of the issues.

Multiple versions of GO files

150. On June 26, 2012, the Commission heard evidence from a panel of witnesses called to testify about SAMPIS and the management and disclosure of GO files (the GO files panel”).Footnote 138 Although the opinion of members of the GO files panel was that the SAMPIS system is “very reliable,”Footnote 139 problems undoubtedly remain. The evidence of the GO files panel made it clear, between the quirks of SAMPIS and simple human error, (which, despite the clear diligence of the CFPM liaison officer to the MPCC and all those responsible for ATIP severances and disclosure, may be inevitable) SAMPIS may produce unpredictable results. Due to the systemic nature of this issue, it can be expected the disclosure of potentially incomplete and/or inconsistent versions of GO files is likely to reoccur in future complaints. Unless dealt with, this problem will continue to make it difficult for the Commission to have confidence in the completeness of disclosure and for the Commission and the parties to adequately apprehend and assess the facts within an investigation.

151. The fundamental problem is the fact there are a number of scenarios in which pages may not print when disclosing a GO file, and there is no guarantee these omissions will be caught by those reviewing the files prior to disclosing them to the Commission. At least some of these scenarios impacted the documents provided to the Commission. Throughout the proceedings, the Commission received multiple versions of the General Occurrence Files for the investigations in question. It became apparent there were differences in the page count between the redacted and unredacted versions of the GO files, and these differences were not explainable simply because redactions were made.Footnote 140 The issues were eventually remedied through follow-up disclosure.Footnote 141

152. The Commission sought explanations for the different versions of the GO files for the three investigations produced to the Commission and to the complainants.Footnote 142 The issue was not that pages were consciously withheld, but rather that they were unaccountably missing in the disclosure.

153. The Commission’s concern is to ensure the hearing record fully reflects all of the documents included in the electronic system and available to the Military Police members involved in the investigation.Footnote 143 Consequently, the Commission sought evidence regarding the workings of SAMPIS, as well as explanations concerning the discrepancies and information about any measures put into place by the Military Police to ensure the problem of incomplete disclosure or missing pages did not reoccur.

154. According to the process in place for disclosure, when a request for a GO file is received, the CFPM liaison officer to the MPCC first contacts the relevant Military Police Unit to ensure all records connected to that file have been scanned.Footnote 144 A “release” is then generated in the system. For MPCC disclosure, everything but information protected by solicitor-client privilege is to be included. Because the SAMPIS release function for disclosure automatically selects all items in the GO file for the release, privileged materials must be visually identified and manually de-selected by the operator.Footnote 145 This means that in the ordinary course, the expectation is all the materials that can be disclosed to the Commission should be included in the disclosure release.Footnote 146

155. There are, nevertheless, some problems created by the process with respect to privileged materials. Where information is marked as solicitor-client privileged by the individual who created an entry, but in actuality contains a mixture of privileged and non-privileged material, the Commission is concerned that entire entry may, inadvertently, not be printed. The evidence of the panel is that a whole text box would be de-selected if the entire content pertained to a legal assessment.Footnote 147 This gives rise to the possibility of errors in judgment resulting in entire entries not being produced, even though only portions should in fact have been removed. Additionally, when text boxes or other documents containing a legal opinion are redacted manually, it is clear something has been severed,Footnote 148 but in other cases, entries marked as privileged are de-selected for printing, meaning there will be no indication in the disclosed file that a document exists but was not included.Footnote 149

156. Although each entry marked as privileged is examined by the liaison officer to determine whether something has been identified improperly – or has not been identified as being privileged when it should have been – each entry is not necessarily examined by legally trained individuals to determine whether privilege claims can or should be made.Footnote 150

157. Many of the other problems with GO file production are the result of SAMPIS idiosyncrasies. Entries in a GO file often include documents scanned or added into the file.Footnote 151 This is where the system’s quirks arise. In many cases, the scanned or added documents will be missing from the final printout or PDF file disclosed.Footnote 152 Generally, the printout will include a notation indicating the pages are missing, and the operator can then print them manually.Footnote 153 However, in some cases, depending on how the document was initially attached to the file, there will be no indication in the printout the missing document existed.Footnote 154

158. What this means is, depending on a number of factors, printouts of the GO file are often incomplete, at least initially. There seems to be no easy way to ensure the integrity of the contents of the disclosed file. Discovering and restoring any missing documents involves additional steps, including a review of the entire GO file for references to files or recordings that are missing.Footnote 155 The GO files panel testified many of the discrepancies in the different versions of the GO files provided to the Commission were likely a consequence of these issues, combined with a possible failure to manually incorporate some of the missing images.Footnote 156 Nevertheless, some of the discrepancies simply could not be explained.Footnote 157

159. It is difficult to reconcile differences between GO file releases because of the way SAMPIS organizes the output. When generating a release, SAMPIS determines the order in which the documents will be printed and assigns page numbers.Footnote 158 However, the page numbers are only set out in relative terms based on the pages sent to the printer and not based on the total number of pages in the GO file. This means a given document could appear on a different page in each release and, if for any reason a folder is not selected for printing or pages do not print, there will be no skipping of page numbers to indicate any portion of the file is missing.

160. In the end, the inquiries made mean the Commission is, overall, now satisfied all of the GO file materials for the three investigations at issue in this case have been produced. The oversights that led to the failure to produce all pages initially are not surprising, given the large number of pages involved and a page reconciliation process vulnerable to human error. However, they emphasize the discouraging prospect that these problems are likely to be recurring, if not systemic. Through no fault of the individuals involved, the evidence of the GO file panel has revealed the unfortunate reality that the disclosure process is inefficient and error-prone.

161. It is of great concern there are so many opportunities for entire pages not to be disclosed despite the good faith efforts and diligence of the individuals involved. In this vein, although it is clear the SAMPIS problems were not the product of bad faith or any intent to hide information, the weaknesses in the system left the complainants with the impression the CFNIS was keeping a “double set of files”Footnote 159 because there were such large and unexplainable discrepancies between what was found on the same pages of the different versions of the GO files they received.Footnote 160 Efforts to resolve these issues would help to prevent any future impression by victims, complainants or families that the CFNIS is trying to hide information.

SAMPIS and “related dates”

162. A further SAMPIS issue, which can influence the integrity of the evidence received by the Commission, involves the dates reflected in GO file entries. The evidence of the GO file panel is a SAMPIS entry generally has more than one date assigned to it.Footnote 161 For example, an investigator may take a statement from a witness but not enter the statement into SAMPIS until several weeks later. The SAMPIS entry itself would be internally date-stamped with the current date, but the user might also assign to the entry the date the statement was originally taken. However, when the GO file is printed, only the user-assigned date is displayed.Footnote 162 It appears at the top of the GO File entry, below the author’s name, under the heading “Related date.”Footnote 163

163. The problem that arises is the entry gives no indication to anyone reviewing the GO file of the date when the entry was made. Only the assigned “related date” is known. This means, from the perspective of an individual reading a disclosed GO file, an entry may appear to be more contemporaneous than it is. During the testimony of MS McLaughlin, for example, he was asked to look at his typed “Investigative activity” entry concerning a meeting with the DND and CF Ombudsman Investigator, Mr. Patrick Martel. The “related date” field for this entry reads Friday, December 18, 2009, the date when the meeting took place.Footnote 164 MS McLaughlin could no longer recall when this entry was typed.Footnote 165 From SAMPIS metadata provided to the Commission, it was learned the entry was created on January 15, 2010.Footnote 166 This was nearly a month after the meeting.

164. MS McLaughlin prepared this entry from memory and without the benefit of notes.Footnote 167 The significance of this span of time is the fact his recollection of the meeting differs from Mr. Martel on some significant points – in particular, MS McLaughlin’s entry specifically stated Mr. Martel identified Capt Lubiniecki as negligent in appointing the wrong next of kin,Footnote 168 while Mr. Martel adamantly denies this.Footnote 169 The fact it is impossible to know simply by looking at the GO file entry when this synopsis was written means one might mistakenly assume the individual creating the document had done so nearly immediately after the events described, and thus with a fresh recollection of what transpired.

165. If it were necessary to resolve competing versions of evidence, it is possible greater weight would be assigned to the documentary evidence (or the testimony derived from it if used to refresh a witness’ recollection) based on this mistaken assumption, as compared to the weight that might be assigned if one learned an entry was written some time after the events discussed and without the assistance of notes or a recording. To be clear, there is no suggestion MS McLaughlin acted improperly in any way. The point is the Commission, as a review body, (or a trial judge in the case of a criminal prosecution) might inadvertently be misled when such entries are disclosed and the police member has no personal recollection of when the entry was typed.

166. Similarly, MS McLaughlin prepared a complaint synopsis for the 2009 GO file after he and Maj Dandurand met with the complainants. MS McLaughlin believed he created this entry “[…] almost immediately after or the following day”Footnote 170 after the meeting, which was held November 28, 2009. The entry also has the “related date” heading of November 28, 2009. However, based on the SAMPIS metadata information provided to the Commission in an affidavit from Mr. Beaulieu (the Military Police National Records Centre Manager, SAMPIS administrator, and a participant in the GO files panel), the complaint synopsis was actually created on January 12, 2010, a month and a half after the meeting with the Fynes.Footnote 171

167. In assessing the reliability or weight to be assigned to an entry made into the GO file, it is very relevant for the Commission to know how long after the events the entry was made and what materials were used to prepare it. Because of the way the system prints the entries, the Commission is not in a position to easily know whether entries are contemporaneous or whether more questions need to be asked about what materials were used to refresh memory. A Military Police witness could seek to refresh his or her memory of events based on a document he or she sincerely (but mistakenly) believes had been written contemporaneously, and, without making onerous additional enquiries, there would be no indication of the true date it was created.

168. The idiosyncrasies in the design and functioning of SAMPIS raise serious concerns about the integrity and accuracy of SAMPIS files being disclosed to the courts, this Commission or other third parties. Consideration should be given to working with the designer of the underlying software in order to address these concerns.

III. Narrative

Early Years and History of Career in Military

1. Stuart Langridge was born in Surrey, British Columbia on March 26, 1979.Footnote 172 His mother and biological father were divorced when Stuart was five years old. His mother, Sheila, met Shaun Fynes when Stuart was six, and they subsequently married. Mr. Fynes was continuously in Stuart’s life from then on, so he had the benefit of a two-parent family for most of his life. He also had two brothers with whom he was close as a child.Footnote 173

2. Stuart’s early childhood was described by Mr. and Mrs. Fynes as happy. He was an energetic little boy with an infectious laugh.Footnote 174 He was fond of the outdoors, playing soccer and learned to ski at an early age.Footnote 175 He also took part in karate, football and Scouts.

3. Stuart’s involvement with the military began early in his life.Footnote 176 He had always wanted to be in the militaryFootnote 177 and, on his twelfth birthday, Mr. Fynes took Stuart to the local armoury where he joined the Irish Fusiliers Army Cadets.Footnote 178 Mrs. Fynes said, “From that point on, Stuart was in a green uniform more often than not.”Footnote 179 Mr. Fynes encouraged him to join the reserves as soon as he was ableFootnote 180 and he enrolled on February 4, 1997.Footnote 181 When he was 21, he transferred directly from the reserves to become a full time member in the army. He was posted to the Lord Strathcona’s Horse (Royal Canadians) in Edmonton on June 1, 2000.Footnote 182

4. During his employment in the regular force, Cpl Langridge’s occupation was as a crewman.Footnote 183 A crewman is an armoured soldier who operates and maintains armoured fighting vehicles including their weapon systems and communications equipment.Footnote 184 Cpl Langridge deployed overseas twice. From October 1, 2002, until April 1, 2003, he was deployed on Operation Palladium in the former Yugoslavia where he was a Coyote (armoured reconnaissance vehicle) driver in an infantry battle group.Footnote 185 From August 9, 2004, to February 10, 2005, Cpl Langridge was deployed on Operation Athena in Kabul, Afghanistan.Footnote 186 On that mission, he worked as a Coyote gunner on a reconnaissance squadron.Footnote 187 He was also deployed from August 14 to November 1, 2003, as part of Operation Peregrine assisting the British Columbia government in its efforts to fight forest fires.Footnote 188

5. Cpl Langridge did very well as a soldier. At the time of his re-engagement with the military in December 2005, Cpl Langridge was described by his troop leader as having “performed extremely well” in his prior employment with the CF, as being “dedicated, loyal and motivated” and a “definite asset to the CF.”Footnote 189 In his last personnel evaluation report for the period ending March 31, 2007, Cpl Langridge’s supervisor wrote he was “a very reliable soldier who completed all tasks given to him on time and to a high standard” and he “consistently approached his duties with a vigour and professionalism that sets an example for junior soldiers.”Footnote 190 In the last training course he took in March 2007, even though he did not complete it due to medical concerns, the course officer described Cpl Langridge as “demonstrat[ing] above average leadership potential,” “having an extremely positive attitude” and stated, “his overall performance was excellent.”Footnote 191

March 2007 to June 2007: Cpl Langridge’s Declining Health and Its Consequences

6. Prior to March 2007, Cpl Langridge was generally a fit and healthy young man.Footnote 192 He was described in his personnel evaluation for the period ending March 31, 2006, as “a physically fit soldier, [who] has a warrior’s attitude and continuously places in the top of the Sqn during [the] Sqn fitness competitions and attempted the gruelling Ex MOUNTAIN MAN competition.”Footnote 193

7. In terms of pre-existing medical concerns, he did have a history of complaints regarding chest discomfort since at least 2001.Footnote 194 Also, he attended an appointment at the Base Mental Health Clinic in December 2003, following his deployment to the former Yugoslavia, after he received less than optimal ratings on his enhanced post-deployment screening report.Footnote 195 In particular, he had medium risk scores on psychosocial stressors and alcohol problems in addition to a high risk score on the somatization index.Footnote 196 Somatization is the conversion of anxiety into physical symptoms. However, Cpl Langridge did not complete the assessment process at the clinic and no diagnosis was made.Footnote 197 In July 2005, following his deployment to Afghanistan, Cpl Langridge was assessed once again and found to be at low risk of problem drinking and to be experiencing no depression, suicidality, panic attacks or generalized anxiety.Footnote 198 However, it was noted he was experiencing major sleep disturbance.Footnote 199 No follow-up appointments were made.Footnote 200

8. In the latter months of 2006, and prior to the onset of his serious medical issues, Cpl Langridge was employed by the Headquarters Squadron.Footnote 201 The role of Headquarters Squadron is to provide support, both in the field and in garrison, to the other squadrons who are the tactical troops that operate the combat vehicles.Footnote 202 Headquarters Squadron employs CF members who, for example, are cooks, or clerks or maintain the military vehicles.Footnote 203 Cpl Langridge worked in the regimental kit shop, a store where soldiers could purchase equipment (e.g., boots, gloves, knives) and sundries such as cigarettes and snack food.Footnote 204 His work in the kit shop appears to have been intended to give him a break from the tour schedule.Footnote 205

9. At this time, Cpl Langridge was also in a stable, long-term relationship with Ms. A. They had met in October 2005Footnote 206 and, by May of the following year, she had moved in with him.Footnote 207 Ms. A described the early stages of their relationship as “fantastic,” and Cpl Langridge as being someone who “loved to have fun,” “a happy guy” and he “loved being in the military.”Footnote 208

10. The onset of Cpl Langridge’s serious medical problems seems to have coincided with the Primary Leadership Qualification (PLQ) Course he attended in March 2007. Successful completion of the course would have led to a promotion for Cpl Langridge, as the aim of the PLQ course is “to qualify personnel to perform the duties of a MCpl within the Land Environment.”Footnote 209

11. Cpl Langridge left on the fourth day of the 34-day PLQ course due to “medical reasons”Footnote 210 which included “sharp pains in the chest.”Footnote 211 When he visited the Base Clinic upon his return from the PLQ, Cpl Langridge complained of, among other things, chest pain which he said he had been experiencing for over a year.Footnote 212 On subsequent visits to the clinic over the following weeks, Cpl Langridge’s doctor, Dr. Sivaprakash Rajoo, determined the pain was likely caused by anxiety – Cpl Langridge complained he had been “under alot [sic] of stress lately” – and placed him on medication for anxiety and later, also on antidepressants.Footnote 213 Cpl Langridge’s health began to deteriorate rapidly as he complained of insomnia and night sweats as well as decreased energy and concentration.Footnote 214 Cpl Langridge also revealed he had been binge drinking because it decreased his pain and anxiety and it made him happy.Footnote 215 By May 30, 2007, Dr. Rajoo had written in the clinical notes, “may need to consider PTSD.”Footnote 216

12. On June 12, 2007, Cpl Langridge received a referral to a psychiatrist to be assessed for PTSD versus major depressive disorder.Footnote 217 Dr. Rajoo wrote in his referral that Cpl Langridge suffered from depression and anxiety and failed to improve on medication. He also mentioned Cpl Langridge’s underlying alcohol and substance abuse disorder.Footnote 218 As described in testimony, Dr. Rajoo, and later, Cpl Langridge’s psychiatrist, Dr. Leo Elwell, considered his two illnesses to be co-morbid and to require concurrent treatment.Footnote 219

13. Sometime in May 2007, Cpl Langridge was transferred from the kit shop to B Squadron (a tank squadron) to prepare for deployment to Afghanistan.Footnote 220 It is standard procedure for any soldier deploying to an operational theatre to undergo safety-sensitive drug screeningFootnote 221 and Cpl Langridge was given a safety-sensitive drug test.Footnote 222 On June 8, 2007, the Regiment was notified Cpl Langridge’s test was positive for cocaine.Footnote 223

14. As a consequence of the positive test, Cpl Langridge was no longer able to deploy overseas.Footnote 224 He was transferred back to the kit shopFootnote 225 because, at the time, Headquarters Squadron did not deploy overseas.Footnote 226 There was some suggestion by Cpl Jon Rohmer, a good friend of Cpl Langridge, that Cpl Langridge had purposely failed the test to avoid going on tour.Footnote 227

15. In general, soldiers within the Regiment preferred to be employed within a squadron operating armoured vehicles than within Headquarters Squadron.Footnote 228 From at least one of his own comments, it appears Cpl Langridge felt assignment to Headquarters Squadron carried a stigma. He told staff at a hospital, where he was later admitted, he was humiliated to have to work in the kit shop because he had been deemed unfit for the field.Footnote 229 Cpl Langridge’s first Base Addictions Counselor (BAC), Mr. Don Perkins, confirmed other soldiers looked “very dimly” at those who had to be taken off tour because of a failed drug test, and soldiers not able to go on tour are “the black sheep of the family because you are not holding up your end. […] If you get dropped out, other people are going to have to pick up your slack.”Footnote 230

16. The failed drug test also led the Commanding Officer of LDSH, LCol Pascal Demers, to recommend Cpl Langridge complete counselling and probation.Footnote 231 As explained in testimony by Capt Mark Lubiniecki, the Unit Adjutant, it was common practice if a solider tested positive for drugs prior to deploying overseas to give that individual an opportunity for rehabilitation, referred to as counselling and probation. The rehabilitation would take place over a 12-month period during which the solider would seek medical treatment and be tested randomly for drug use. If, at any time during the 12-month period, the soldier failed a drug test, a recommendation would be made for release from the CF.Footnote 232

17. Cpl Langridge formally denied the use of cocaine on October 17, 2007.Footnote 233 There was a limited internal review of the test results completed on January 4, 2008, which confirmed the initial positive finding for cocaine.Footnote 234 On January14, 2008, Cpl Langridge requested the sample be re-tested by an independent civilian lab,Footnote 235 which delayed the start of the counselling and probation period.Footnote 236 At the time of his death, there is no evidence the secondary testing had been completed, and Cpl Langridge had not yet been placed on counseling and probation.Footnote 237

18. Cpl Langridge was first referred to the BAC in his May 28 and 29, 2007, appointments with Dr. Rajoo.Footnote 238 He met with Don Perkins, an addictions counsellor, over three sessions and, in his June 13, 2007 assessment, Mr. Perkins wrote there was a high probability Cpl Langridge suffered from substance dependence.Footnote 239 Mr. Perkins testified it was his recollection he presented Cpl Langridge with the option of attending residential treatment but, at that point, Cpl Langridge was not interested.Footnote 240 Instead, Cpl Langridge agreed to attend a week-long Secondary Substance Intervention Workshop.Footnote 241

19. Cpl Langridge had not yet been seen by anyone at the Base Mental Health ClinicFootnote 242 when he attempted suicide for the first time on June 22, 2007. He tried to overdose on his prescription medication as well as other medications.Footnote 243 He took the pills following an argument with Ms. A when she found cocaine in their home. When Ms. A returned home the next day, she testified Cpl Langridge told her he had not been feeling well, so he took extra pills. She testified she found pills all over the house but was not certain whether he had actually taken all the pills or had just made a mess and the attempt demonstrated he was trying to ask for help.Footnote 244

20. Following this apparent suicide attempt, Cpl Langridge attended the first day of the substance intervention workshop on June 25, 2007.Footnote 245 The aim of the program was to educate the attendees on their alcohol and drug use and where it might lead.Footnote 246 Cpl Langridge refused to return after the first day because he was “uncomfortable with the ‘huggy feely’ stuff and did not wish to disclose any information to the other participants.”Footnote 247

21. That evening, Cpl Langridge attempted suicide for the second time in three days. He drove to a field, began to drink heavily, and ran flexible piping from the exhaust of his vehicle into the passenger compartment. He was found by friends after he sent text messages asking them to comfort Ms. A.Footnote 248

22. As a result of this second suicide attempt, Cpl Langridge was admitted to a civilian hospital for a short-term stay. His diagnosis upon discharge two days later was he suffered from an alcohol induced mood disorder and severe stress.Footnote 249

July 2007 to November 2007: Medical and Mental Health Evaluations

23. Following his second suicide attempt, Cpl Langridge took a period of sick leave and then summer vacation leave.Footnote 250 Cpl Langridge followed up with members of Mental Health Services and the Base Medical Clinic.Footnote 251 He also agreed to try one-on-one addictions counselling although he attended only three more meetings with Mr. Perkins.Footnote 252

24. In mid-July 2007,Footnote 253 Cpl Langridge was transferred from working in the kit shop to working for the Stables NCO, MCpl William Fitzpatrick.Footnote 254 The job involved taking care of the computer lab and other tasks assigned as part of the RSM’s detail such as polishing brass, collecting garbage, changing oil pans and cleaning the mess.Footnote 255 Cpl Langridge described his work as “not a good job,” “boring,” “sucks,” and “nothing to do.”Footnote 256 MCpl Fitzpatrick confirmed in his testimony there was not a lot of work for Cpl Langridge and he wasn’t busy.Footnote 257

25. On August 7, 2007, Cpl Langridge had an appointment with Dr. Rajoo, at which he was assessed for the appropriateness of being placed on a TCAT or “temporary category”.Footnote 258 A TCAT is for soldiers not able to perform to the minimum set of standards for their military trade because of a medical condition.Footnote 259 When the medical condition is resolved, the soldier is removed from the temporary category and can return to their trade and full duties.Footnote 260 In Cpl Langridge’s case, Dr. Rajoo placed him on a TCAT for six months.Footnote 261 Among other things, the TCAT alerted the Unit the CF member would be given extra appointments and seen more frequently by physicians.Footnote 262 A TCAT is also a step in the process for getting a medical release from the military.Footnote 263 There is evidence Cpl Langridge intermittently expressed interest in pursuing a medical release throughout the last year of his life.Footnote 264

26. Dr. Rajoo also imposed medical employment limitations (MEL) on Cpl Langridge. MELs describe particular limitations on how a member can be employed by the unit because of a medical concern. They have to be honoured by the military Chain of Command without alteration.Footnote 265 The MELs for Cpl Langridge indicated he was “unfit [for] military operational environment,” he was not permitted to use weapons or practice at ranges and he needed regular specialist follow-up.Footnote 266 In practice, this meant he could be at the base working half days or full days doing routine jobs, but could not go out into the field.Footnote 267

27. In August 2007, Cpl Langridge was assessed by a base psychologist, Dr. William Lai, who conducted a clinical interview, administered psychometric testing and reviewed Cpl Langridge’s medical file.Footnote 268 During the clinical interview, Cpl Langridge complained of feeling depressed most of the time and, when he was stressed, having difficulties breathing, blurred vision, dizziness, light-headedness, and chest and intestinal discomfort. He also said he was having “horrifying” nightmares, two or three times a week, though he did not believe they were related to his tours of duty.Footnote 269 Dr. Lai made the following provisional diagnosis in his draft psychological assessment report:Footnote 270


Axis I: […] Major Depressive Disorder, Single Episode, Severe without psychotic features. […] Posttraumatic Stress Disorder – chronic, moderate […] Alcohol abuse.

Axis II: Deferred

Axis III: Chest pains; gastrointestinal problems; knee problems

Axis IV: Potential conflicts with common-law and coworkers; concerns regarding health of mother and brother

Axis V: Current GAF 45: some self-harm ideation, serious impairment in social and occupational functioning.Footnote 271 [Emphasis added]

28. In a case conference note dated August 23, 2007, Dr. Lai observed the psychometric testing results pointed to PTSD, but no specific traumatic incident or event had been identified and identification of such an event was required for a diagnosis of PTSD.Footnote 272 Dr. Lai testified it was “likely” Cpl Langridge had PTSDFootnote 273 based on the information he had at this point, but further exploration was necessary to determine if a full PTSD diagnosis was justified.Footnote 274 Several follow-up appointments were made with Cpl Langridge in an attempt to complete the psychological assessment, but, in the end, the assessment was never finalized.Footnote 275

29. Cpl Langridge’s relationship with Ms. A had also been deteriorating since the onset of his health and addiction issues. According to Ms. A, Cpl Langridge began to change in 2006, with more pronounced changes occurring in 2007.Footnote 276 Over time, the state of their relationship became more volatile, marked by good days and bad days, as Cpl Langridge’s health and substance abuse issues became increasingly serious.Footnote 277 Cpl Langridge told his health care providers in the spring of 2007 he had numerous arguments with Ms. A because of his drinking,Footnote 278 and in October 2007, he told them he was having problems at home.Footnote 279 In his interviews with Dr. Lai, Cpl Langridge stated Ms. A was someone who was easily “worked up,” had “lots of anxiety” and had given him an “ultimatum,” demanding he stop drinking. However, Cpl Langridge also said he was determined to keep and improve the relationship with Ms. A, and he wanted to marry her at some point.Footnote 280

30. Cpl Langridge attempted suicide for a third time on October 29, 2007. He took an unknown quantity of prescription medication at home and was taken to emergency.Footnote 281 On his discharge the following day, he was diagnosed as suffering from an alcohol-induced mood disorder as well as alcohol abuse.Footnote 282

31. Following his discharge, Cpl Langridge again met with members of Mental Health Services and members of the Base Clinic.Footnote 283 His symptoms continued unabated with clinical notes stating he had nervous pains in his chest, was stressed out, tired, confused and would wake up screaming and drenched in sweat.Footnote 284

32. On November 15, 2007, Cpl Langridge had an appointment with Dr. Elwell.Footnote 285 During the appointment, Dr. Elwell conducted a clinical interview.Footnote 286 His diagnosis was Cpl Langridge suffered from generalized anxiety disorder, major depressive disorder and alcohol abuse but most likely not PTSD. He also identified quite strong personality traits and moderate to severe stressors in Cpl Langridge’s life.Footnote 287 He treated Cpl Langridge by adjusting his medicationsFootnote 288 and suggesting individual therapy sessions.Footnote 289 Dr. Elwell scheduled a follow-up appointment with Cpl Langridge on February 19, 2008, but Cpl Langridge was in Alberta Hospital Edmonton at the time of the appointment.Footnote 290 The appointment was not rescheduled.Footnote 291

December 2007 to January 2008: Common-law Declaration and Residential Treatment Program

33. Cpl Langridge continued to visit the Base Clinic regularly and also attended individual counselling sessions with a mental health nurse three times through November and December 2007.Footnote 292 During his meeting with Mr. Perkins on November 21, 2007, Cpl Langridge requested to attend a residential treatment program.Footnote 293 Because of his deteriorating condition, Mrs. Fynes and Ms. A had staged an intervention that same month aimed at getting him to reduce or stop his substance abuse.Footnote 294 Cpl Langridge acknowledged his loss of control to Mr. Perkins, stating, once he started drinking, he was unable to stop.Footnote 295 Arrangements were made for Cpl Langridge to attend a residential treatment program starting early in January 2008.Footnote 296

34. On December 7, 2007, on one of the happier days of their relationship,Footnote 297 Cpl Langridge and Ms. A signed a CF common-law statutory declaration.Footnote 298 Ms. A testified Cpl Langridge had been asking her to sign the declaration since July.Footnote 299 The declaration required they make an appointment and attend at the base, provide identification as well as proof they had lived together for a year and then sign the declaration before a CF officer.Footnote 300 The declaration stated Cpl Langridge and Ms. A “undertake to hold each other out as husband and wife.”Footnote 301 The declaration entitled Ms. A to the benefits the military offered spouses, for example medical insurance and travel assistance.Footnote 302 Most importantly, Ms. A agreed to sign the declaration because it would allow her to attend the spousal program at the Edgewood residential treatment centre.Footnote 303 Ms. A testified, “it would allow me to attend treatment at Edgewood with him, something that was really important because Stuart had committed to me that I could be a part of his treatment from start to finish.”Footnote 304

35. Shortly after Christmas, Cpl Langridge went on a cocaine bingeFootnote 305 and, in the opinion of Mr. Perkins, he scared himself. At Cpl Langridge’s request, Mr. Perkins was able to move the residential treatment start date up by a week. Cpl Langridge had given his ID, car keys and credit cards to Ms. A, and Mr. Perkins noted Cpl Langridge was “motivated to get help.”Footnote 306

36. The extent to which Cpl Langridge acknowledged his use of alcohol and drugs varied widely, but when he was admitted to residential treatment, he disclosed he had been bingeing on alcohol two to five times a week for several years. He also stated he had been using approximately two grams of cocaine daily for at least four months. In addition, he acknowledged smoking marijuana daily for twelve years.Footnote 307

37. Cpl Langridge arrived at the Edgewood Treatment Centre in Nanaimo, B.C., on January 4, 2008, but only remained in treatment for six days.Footnote 308 He withdrew from treatment after leaving group therapy sessions.Footnote 309 This led Ms. A to take some of her belongings, leave their shared townhouse and go to her parents’ condominium before Cpl Langridge arrived back in Edmonton.Footnote 310

January 2008 to March 2008: Cpl Langridge’s Precipitous Decline

38. Cpl Langridge’s substance abuse problems continued following his early departure from Edgewood. Upon his return to the Regiment, Cpl Langridge did not see Mr. Perkins again.Footnote 311 A medically ordered drug test on January 22, 2008, returned a positive result for marijuana.Footnote 312 He tested positive for cocaine and marijuana in hospital on February 2, 2008, after his fourth suicide attempt.Footnote 313 He tested positive again for cocaine and marijuana on March 7, 2008.Footnote 314 Though he did at various times in the last weeks of his life attempt to reduce his substance use, and he did seek and desire treatment, Cpl Langridge’s struggle with addictions evidently persisted until his death.

39. Cpl Langridge was also undoubtedly upset over the state of his relationship with Ms. A, telling his clinicians he was finding it hard to cope with his girlfriend leaving him, and that he was going through a divorce.Footnote 315 However, despite their falling-out, Cpl Langridge and Ms. A continued to have contact. When things were good, Ms. A would return to live in the townhouse with Cpl Langridge, but when things were bad, she would take some clothes and go to her parents’ home.Footnote 316 In clinical notes from the time, Cpl Langridge described Ms. A as calling him constantly and stated not much had changed except they were not living together.Footnote 317 Also, despite Cpl Langridge’s early departure from residential treatment and despite the volatile nature of their relationship at the time, Ms. A still attended the spousal program at Edgewood. She testified the program delved into issues of co-dependency and, because of its personal emotional content, was “probably one of the most difficult things I have ever done in my entire life.”Footnote 318

40. After his return from Edgewood, Cpl Langridge was, at his request, moved to work in a reconnaissance squadron.Footnote 319 Cpl Langridge asked for an opportunity to work alongside his peers and demonstrate they could have confidence in himFootnote 320 – he wanted to be “an effective soldier of the Strathconas.”Footnote 321 The move was short lived, lasting less than a week.Footnote 322 There was conflicting testimony about whether the move did not work out because the squadron commander did not feel Cpl Langridge was being a productive soldier,Footnote 323 or because Cpl Langridge felt mentally he was just not in the right space and the reconnaissance squadron was not the best place for him to be.Footnote 324 Whatever the reason, Cpl Langridge was moved back to Headquarters Squadron working for MCpl Fitzpatrick.Footnote 325 Cpl Langridge continued to work in this job until his death.

41. Cpl Langridge’s health also deteriorated even further.Footnote 326 The clinical notes indicate he told his mental health nurse he “often thinks about hurting himself in the evenings so he won’t have to go back to work.”Footnote 327

42. Cpl Langridge’s fourth known suicide attempt was on January 31, 2008, when he tried to hang himself at home.Footnote 328 He went to the Base Clinic the next morning where he was observed to be “tearful, curled in a fetal position, no eye contact, active suicidal ideation with plan and means.”Footnote 329 He was admitted to the RAH for a short-term stay with an admitting diagnosis of “bizarre paranoid behaviour.”Footnote 330 While in hospital, he attempted suicide for a fifth time on February 3, 2008, by attempting to strangle himself.Footnote 331 Cpl Langridge was discharged, apparently against medical advice, the next day.Footnote 332 His diagnosis was noted as alcohol and cocaine induced mood disorder, alcohol and cocaine abuse, borderline personality disorder and antisocial traits, as well as severe stressors.Footnote 333

43. Mrs. Fynes testified she believed Cpl Langridge would finally be getting proper help after his hospital suicide attempt, and she was therefore astounded to arrive at the RAH on February 4 and find Cpl Langridge ready to leave. She described seeing a red mark on Cpl Langridge’s neck from the ligature.Footnote 334 She had a low view of the treatment offered by the RAH, describing it as “a catch and release program” where “people arrive drunk or stoned or whatever and they dry them out and then they kick them out. Three days and you’re done.”Footnote 335 Records from the RAH indicated the discharge was against medical advice because Cpl Langridge wanted to leave but “Mother not willing to take [Cpl Langridge] home [with] her or take responsibility for him.”Footnote 336 Mrs. Fynes testified she did not want Cpl Langridge to leave the hospital, and felt the hospital was kicking him out.Footnote 337 She told the Commission, “[i]f they wanted him to stay, then he wouldn’t have been leaving.”Footnote 338 However, Cpl Langridge insisted on leaving.Footnote 339 Mrs. Fynes testified she then accompanied Cpl Langridge back to the Health Unit and to the Padre’s care.Footnote 340 The padre and some members of the Base Mental Health Team were concerned that Cpl Langridge was not in fact stable,Footnote 341 and Mrs. Fynes recalled they made arrangements to have another soldier stay with Cpl Langridge for his safety.Footnote 342 On February 5, 2008, just a day after his discharge, Cpl Langridge drove himself to the Alberta Hospital Edmonton and was admitted for a 30-day stay on an involuntary basis.Footnote 343

44. After he was admitted to hospital, Ms. A and his friend, Cpl Rohmer, went to the townhouse where Cpl Langridge had been living. Ms. A described finding pills, drugs, empty beer cans and liquor bottles all over the house. More disturbingly, she also testified she found the bathtub half full of water with “knives everywhere” as well as “between three and five nooses made out of different things that he had obviously attempted to hang himself with” in the basement.Footnote 344

45. In mid-February 2008, this townhouse, which Cpl Langridge and Ms. A had been sharing during their relationship, was given up and the lease was terminated.Footnote 345 It was Ms. A’s testimony the lease had to be broken because they could no longer afford to pay the rent,Footnote 346 while Mrs. Fynes testified Cpl Langridge wanted to move back onto the base.Footnote 347 Ms. A removed all of her belongings,Footnote 348 and Mrs. Fynes, with the help of the Base Padre and several other soldiers, removed Cpl Langridge’s belongings, which were placed in storage at the base.Footnote 349

The Military’s Knowledge of Cpl Langridge’s Condition

46. The Regiment was not privy to the specifics of Cpl Langridge’s medical condition as his health deteriorated. The medical authorities share very little with the chain of command.Footnote 350 The chain of command received notification of medical employment limitations and medical leave, but the military medical system does not seek approval of the military chain of command to send CF members on treatment.Footnote 351

47. The military chain of command would have been aware of Cpl Langridge’s reduced work schedule as a result of his deteriorating health. Cpl Langridge was frequently on sick leave or working a reduced schedule. When his health allowed him to work, he was almost always working only half days and, with a few exceptions, only three days a week.Footnote 352 In his testimony, Dr. Rajoo agreed Cpl Langridge needed to either be off work or on a reduced schedule in order to get better.Footnote 353 While the clinical notes are not completely clear, it appears there was no period of time after May 30, 2007 – nine months prior to his eventual suicide – in which Cpl Langridge was healthy enough to be able to work more than four consecutive full days in a row.Footnote 354

48. There was also evidence members of the Regiment chain of command may have been aware of all but the first of Cpl Langridge’s suicide attempts.

49. The chain of command was undoubtedly aware of Cpl Langridge’s second suicide attempt. Cpl Langridge’s friends who received his text message and who found him in his Jeep were CF members and, after receiving the text message, they contacted the MP as well as their supervisor, who in turn contacted the chain of command.Footnote 355 The attempt resulted in a military administrative investigation (i.e., a Summary Investigation) into facts and causes. The Summary Investigation contained recommendations regarding how the Regiment could assist in Cpl Langridge’s ongoing treatment and recovery.Footnote 356

50. With respect to his third suicide attempt, there was military involvement in getting Cpl Langridge to hospital. On the morning of October 29, 2007, Sgt Anick Murrin, who was the sheriff for LDSH,Footnote 357 was asked by RSM Douglas Ross to attend at Cpl Langridge’s residence.Footnote 358 Cpl Langridge had not shown up for work or for a scheduled medical appointment that morning, meaning he was AWOL.Footnote 359 Clinical notes state he had phoned the Unit to tell them he would not be going to work because Ms. A had left him.Footnote 360 Sgt Murrin found him asleep at his home. After initially being roused, Cpl Langridge seemed unable to wake up, so Sgt Murrin contacted the Base Clinic and was told he should go to a civilian hospital.Footnote 361 She called 911 and waited with him until the ambulance came and transported him to hospital.Footnote 362 She advised the LDSH RSM, CWO Ross, of the situation.Footnote 363 In her testimony, Sgt Murrin was adamant she had not been responding to a suicide attempt and did not believe Cpl Langridge was suicidal.Footnote 364 However, Cpl Langridge’s military Unit was aware he had been admitted to the RAH psychiatric unit and even advised the Base Clinic.Footnote 365

51. Cpl Langridge attempted suicide for a fourth time at the end of January 2008 and again in hospital, a few days later, in early February 2008. Capt William Hubbard, the chaplain for the Regiment, testified Ms. A called him and made him aware of the attempt in January 2008 and, as a result, Cpl Langridge had been taken to hospital.Footnote 366 It was Capt Hubbard’s evidence he personally spoke to members of the regimental chain of command and made them aware of this attempt.Footnote 367 There was conflicting evidence from the members of the chain of command about what (if any) information they received from Capt Hubbard.Footnote 368 Capt Lubiniecki did not recall being informed of the January attempt but confirmed having been told of the subsequent attempt made while Cpl Langridge was in hospital.Footnote 369

Cpl Langridge’s Last Days

52. From February 5 to March 5, 2008, Cpl Langridge was hospitalized as a patient of the Alberta Hospital Edmonton (AHE) in the acute adult psychiatric unit.Footnote 370 His admission to hospital was the culmination of several suicide attempts over the course of the prior ten months (including a suicide attempt only days before while at the Royal Alexandra Hospital),Footnote 371 continuing drug and alcohol abuse, and serious, unresolved mental health issues. While he went to the hospital voluntarily, he was admitted for a 30-day stay on an involuntary basis because his behaviour was unpredictable.Footnote 372 He was admitted in a state of anxiety and suicidal depression.Footnote 373

53. While in hospital, Cpl Langridge’s progress was mixed. He did join the programming offered by the hospitalFootnote 374 – for example the Substance Abuse Recovery Group,Footnote 375 AAFootnote 376 and Narcotics AnonymousFootnote 377– but his attendance at programming was not consistent nor was he particularly engaged.Footnote 378 He sometimes accessed drugs while in care,Footnote 379 using his privileges to leave the grounds to visit his drug dealer.Footnote 380 About halfway through his stay, he confessed to staff he was continuing to use cocaine and, when coming down off the drug, he had increased feelings of suicidality.Footnote 381 In the early hours of February 19, 2008, Cpl Langridge either contemplated suicide or actually attempted to hang himself with a belt, but then approached hospital staff for help.Footnote 382 He stated he wanted to quit drugs, but his addiction made it very difficult.Footnote 383 As a result, he was placed under close observation,Footnote 384 meaning he could not leave the unit and a nurse had to check on him every 15 minutes.Footnote 385 However, when the restrictions were removed,Footnote 386 there was some suspicion his drug use began again,Footnote 387 and Cpl Langridge was again placed on close supervision until his departure from hospital.Footnote 388 His treating psychiatrist, Dr. Bernard Sowa, testified that while there had been some issues with Cpl Langridge, this was not unexpected in terms of his treatmentFootnote 389 and progress was made in terms of his mood and anger settling down.Footnote 390

54. While Cpl Langridge was in hospital, a psychology report was completed on the basis of clinical interviews and psychometric testing. The conclusion of the report stated:

Stuart’s history and presentation is consistent with posttraumatic stress disorder with situationally based panic attacks (i.e. going to work for the military). Currently, he is also struggling with a major depressive disorder and traits of social anxiety. Stuart also displays traits of borderline and narcissistic personality. At this time, he has very poor coping abilities relying primarily on drug and alcohol abuse with minimal insight into his psychological difficulties.Footnote 391 [Emphasis added]

55. Dr. Lori Harper, the clinical psychologist who oversaw the psychology resident who completed the report, said Cpl Langridge presented with symptoms consistent with post-traumatic stress disorder and it could not be ruled out as a diagnosis.Footnote 392 Similar to the findings of Dr. Lai from August 2007, no traumatic event was identified by Cpl Langridge, though he did allude to one, so no definitive diagnosis of PTSD could be made.Footnote 393

56. Mrs. Fynes was present for the early part of Cpl Langridge’s treatment at the AHE. She testified that “Stuart did really well for the first few days and he was starting to make plans about what was going to happen next.”Footnote 394 He said he felt safe in the hospital, and expressed interest in moving back to the base. But shortly after that, he seemed almost too happy. Mrs. Fynes felt something was “[o]ut of context, it didn’t fit. […] I remember driving back to the hotel thinking, “There’s something wrong here.”Footnote 395 She phoned the ward and told a nurse she suspected Stuart had accessed some drugs because his mood and behaviour had changed quickly. Although reluctant to believe this could happen in the AHE, the nurse arranged for testing and cocaine was detected in his system.Footnote 396

57. During his stay in hospital, Ms. A and Cpl Langridge continued to have steady contact. Ms. A had assisted him over the phone to get to the AHE and stayed on the phone with him while he waited to be admitted.Footnote 397 Ms. A testified she visited Cpl Langridge as much as possible during this hospitalization. However, there were also occasions when Cpl Langridge specifically asked medical staff to not allow Ms. A to visit.Footnote 398

58. Towards the end of his hospitalization, Cpl Langridge expressed interest in attending an addiction rehabilitation (rehab) program.Footnote 399 This was a course of action supported by Dr. Sowa who stated in testimony, “this is someone who definitely need[ed] treatment for his addictions problems,” and was encouraged by Cpl Langridge’s show of initiative.Footnote 400 This was also a course of action endorsed in the psychology report, which recommended, “although Stuart’s insight is somewhat limited, he may benefit from inpatient drug treatment, such as the services available at AADAC or Henwood.”Footnote 401 Twice Cpl Langridge contacted Leo Etienne, a CF BAC, to ask if he could remain in hospital voluntarily when his 30-day committal ended, and proceed directly to a residential rehabilitation program.Footnote 402 Cpl Langridge contacted the base because, as a member of the military, he had certain responsibilities in terms of accounting for his whereabouts with the CF.Footnote 403 Furthermore, the CF would be paying the cost of the rehab program.Footnote 404 Mr. Etienne told Cpl Langridge a case conference would be held with the CF treatment team at the base to make recommendations on his continued care.Footnote 405

59. The military treatment team wanted Cpl Langridge to come back to base for a period of time prior to attending a rehab program. Cpl Langridge told Dr. Sowa he was required to spend two weeks at the base following his discharge.Footnote 406 Dr. Sowa contacted the base and confirmed this was the case.Footnote 407 This return to the Unit was referred to in the notes from the Base Clinic as a ‘trial of good behaviour’ to see if [he was] capable of going to [an] addiction treatment centre.”Footnote 408 According to base medical personnel, the concern was Cpl Langridge had been continuing to access drugs while in hospital and needed to be stable and “a little bit clean” prior to being sent for addictions treatment.Footnote 409 The thinking was Cpl Langridge was suitable for outpatient management and would attend individual and group counselling while at the Base.Footnote 410 In testimony, base medical personnel maintained there was no suggestion Cpl Langridge would not be sent for residential rehab eventually, though he first had to be stable, able to follow some routine, and willing to participate in the program.Footnote 411

60. Cpl Langridge expressed considerable anxiety about returning to the Regiment, telling nursing staff he was scared to leave the hospital.Footnote 412 Dr. Sowa described the events preceding Cpl Langridge’s release from hospital in the discharge summary as follows:

Our plan was to keep him in the hospital until he could be discharged directly to the military. [Cpl Langridge] certainly was not certifiable at the end of the first certificates. He agreed to stay in hospital as a voluntary patient until arrangements could be made for him to return to a drug rehabilitation program.

Unfortunately the military called as to inform us […] that they actually […] 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 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.Footnote 413 [Emphasis added]

61. While Dr. Sowa had no medical objection to Cpl Langridge leaving the hospital, he did state he did not initiate any return of Cpl Langridge to the base.Footnote 414 The plan had been for Cpl Langridge to remain voluntarily in hospital. It was Dr. Sowa’s recollection there was a message from the base saying essentially, “We want him” and “We have our program here.”Footnote 415 There is also evidence Cpl Langridge believed he had no choice but to leave the hospital and return to the base if he wanted to attend the treatment program he sought.Footnote 416 Despite Cpl Langridge’s wish to stay in hospital voluntarily and transfer directly to a residential treatment program,Footnote 417 his clinician’s support for this optionFootnote 418 and his anxiety about leaving the hospital,Footnote 419 Cpl Langridge returned to the CF base on the morning of Wednesday, March 5, 2008.Footnote 420

62. Very little is known about the actual arrangements made by the CF for Cpl Langridge upon his return to base, despite the fact Dr. Elwell, Cpl Langridge’s treating psychiatrist on the base, stated in testimony, “we were technically on the hook to watch after him.”Footnote 421 There is conflicting evidence as to where he lived upon returning, even though he was assigned a barracks room on the base.Footnote 422 Ms. A testified he had the option of coming to live with her in her parents’ condo, but he instead returned to the base because he had been told he had to by the military.Footnote 423 It is not known whether Cpl Langridge was required to work, though the clinical notes from the hospital indicate he was told by his BAC he would not be starting work immediately and would instead be attending substance abuse groups.Footnote 424

63. Due to Cpl Langridge’s instability, some effort was made to arrange what some CF members referred to as a “suicide watch.”Footnote 425 This consisted of compiling a list of names of CF members who would be available to “watch” Cpl Langridge on an around the clock basis.Footnote 426 However, the list and potential watch were never implemented, in part because Cpl Langridge reportedly objected to such supervision.Footnote 427 It was also called off because Maj Earl Jared, who was the Officer Commanding of Headquarters Squadron where Cpl Langridge worked, did not agree with the measure.Footnote 428 Despite this, both Mrs. Fynes and Ms. A, stated they received assurances from Cpl Langridge’s BACs that Cpl Langridge would be watched by someone 24 hours a day.Footnote 429

64. Other details regarding what was expected of Cpl Langridge or the treatment plan put in place to stabilize him are not known. What is known is Cpl Langridge had four scheduled appointments at the Base Mental Health Unit in the two days following his return from the hospital, though he did not show up for three of those appointments.Footnote 430 There is evidence he did see BAC Dennis Strilchuk between three and five times during the period he was out of the hospital, and was provided individual counseling.Footnote 431 Cpl Langridge’s last meeting with Mr. Strilchuk was Friday, March 7, 2008, two days following his release from the hospital. Mr. Strilchuk noted Cpl Langridge had been “totally non-compliant” in following restrictions which had been placed on him and Cpl Langridge was sent to his unit for close supervision.”Footnote 432 Cpl Langridge admitted to medical personnel he had been consuming alcohol and using other drugs since he was released.Footnote 433 In light of these developments, Mr. Strilchuk stated he would no longer work with Cpl Langridge and felt he could no longer help him.Footnote 434

65. Following his last meeting with Cpl Langridge, Mr. Strilchuk referred him to the Base Surgeon, Capt Richard Hannah, who met him the same morning. Cpl Langridge was upset. He complained to Capt Hannah about restrictive conditions that had been placed on him.Footnote 435 There are no details in the documentary record about the conditions Cpl Langridge was complaining about. He told Capt Hannah he wanted to return to the AHE for treatment; Capt Hannah contacted the AHE and learned that the AHE was “full” and not accepting referrals.Footnote 436 Cpl Langridge refused to go to the RAH instead. Consultation between Capt Hannah, members of the mental health clinic and members of the Regiment, in particular the Regimental Sergeant Major CWO Ross, resulted in a series of medical employment limitations and, in the words of CWO Ross, “control measures” being “imposed” on Cpl Langridge.Footnote 437 The “control measures” included a requirement to live at the Regimental Duty Centre, to sleep in the defaulters’ room, to keep the door to that room open at all times, a 2100 hrs curfew, a requirement to sign in with the Duty Officer every two hours daily and to provide a phone number where he could be reached if he left the Harvey Building (where the Duty Centre was located).Footnote 438 Cpl Langridge was also required to attend all medical appointments, abstain from alcohol and drugs, work Monday to Friday from 0800 hrs to 1630 hrs (which was half an hour beyond what other soldiers had to workFootnote 439) and wear his uniform during the normal duty hours.Footnote 440

66. According to CWO Ross, the intent behind the conditions was to provide Cpl Langridge with structure and not as punishment, although CWO Ross stated the extra work was “just because I wanted to do that, to be quite honest.”Footnote 441 If Cpl Langridge failed to comply, he could be charged under military law, as the conditions were considered to be orders.Footnote 442 The defaulters’ room, where Cpl Langridge was required to sleep, was for CF members receiving punishment and, as part of the punishment, they were required to follow a specific and strict work and reporting schedule for a period of time.Footnote 443 Though Cpl Langridge’s conditions were, in some respects, similar to those imposed on defaulters, Capt Hannah and CWO Ross both stated Cpl Langridge was not a defaulter.Footnote 444

67. Both CWO Ross and Capt Hannah stated the conditions were agreed to by Cpl Langridge and were, in fact, welcomed by him.Footnote 445 The conditions were supposed to provide him with the structure necessary to get back to being a solider.Footnote 446 There was no time limit on how long the conditions would apply. Rather, the conditions were to be in place until Cpl Langridge “showed he could handle himself.”Footnote 447

68. If Cpl Langridge initially agreed to the conditions, this agreement was short-lived as he very soon came to find them upsetting, onerous and restrictive. On Tuesday, March 11, 2008, less than a week after his return from the AHE, Cpl Langridge visited the Base Clinic complaining he felt like he had been thrown back into the deep end and had no idea where his life was going.Footnote 448 He stated the conditions placed on him were too hard, and he wanted them changed.Footnote 449 However, he was advised he “must return to his unit and continue to work and see how he does” and if he was doing okay, there would be consideration of a residential treatment program.Footnote 450 When faced with returning to his Unit, Cpl Langridge stated to the clinic physician he was suicidal and he would rather kill himself than return to his unit.”Footnote 451 He was taken to emergency at the Royal Alexandra Hospital where it was noted he was depressed, anxious and suicidal.Footnote 452 In particular, he is quoted as saying he “can’t take army stuff anymore.”Footnote 453 He complained he had not slept in two days, his anxiety was increased, his mood was low and he had been using drugs more frequently.Footnote 454 He was placed under close observation.Footnote 455 Cpl Langridge told Royal Alexandra staff he wanted to return to Alberta Hospital Edmonton because, during his time there, he benefited from the treatment he received.Footnote 456 Cpl Langridge remained at the Royal Alexandra for only two days, until Thursday, March 13, 2008, when he signed himself out of hospital against his treating physician’s advice.Footnote 457

69. In the days preceding his death, there is evidence Cpl Langridge had been giving away his personal belongings.Footnote 458 There is also evidence he continued to seek to have his “restrictions lessened,”Footnote 459 in particular to have the two-hour mandatory check-in increased to three hours.Footnote 460 CWO Ross refused to change the condition, instructing Cpl Langridge he needed to show he could handle himself first.Footnote 461 Nevertheless, according to CWO Ross, there had been no issues with Cpl Langridge complying with the conditions before March 11, 2008,Footnote 462 and Capt Lubiniecki, the Regimental Adjutant, maintained the chain of command “were happy with [Cpl Langridge’s] performance and the way he was conducting himself up to that point.”Footnote 463

70. It remains unknown to what extent Cpl Langridge had actually been complying with the conditions or to what extent he was monitored and supervised. Even though CWO Ross stated the duty staff were fully aware of the conditions,Footnote 464 the evidence suggests they were not. According to Sgt Trent Hiscock, who was the Duty Officer on the day of Cpl Langridge’s death, the only conditions actually written out and passed on from Duty Officer to Duty Officer were in a handwritten note stating the Duty Driver would drive Cpl Langridge to all his appointments and drop him off.Footnote 465 The rest of the conditions were passed on verbally and not all the conditions were known by the Duty Staff.Footnote 466 There was even uncertainty as to whether he had to personally attend every two hours to sign in, or whether it was possible for him merely to check in by telephone.Footnote 467 In fact, many members believed Cpl Langridge could simply call every two hours.Footnote 468 By his own admission, Cpl Langridge was not complying with the restrictions on alcohol and drug consumption.Footnote 469 Since the sign-in sheets for the days preceding his suicide were never found and few other records exist, his behaviour and comings and goings cannot be verified. Although Cpl Langridge’s activity was restricted to some extent, Ms. A told the Commission he had managed to visit her at her parents’ home and other locations during that time.Footnote 470 She specifically indicated that Cpl Langridge had, on some of those occasions, seen her by “evading his caretakers.”Footnote 471 She also told the Commission that during his absences Cpl Langridge had been drinking.Footnote 472

71. Throughout this period of time, Cpl Langridge and Ms. A continued to see and call each other. Sometimes Cpl Langridge would show up at places where Ms. A was, other times they would plan to meet.Footnote 473 However, the relationship continued to be unpredictable, and Ms. A testified Cpl Langridge’s mood was very volatile.Footnote 474 A few days before Cpl Langridge’s death, Ms. A contacted Capt Lubiniecki to discuss whether, as a result of signing the common-law declaration, she would be responsible for the payment of outstanding debts if Cpl Langridge defaulted on payment.Footnote 475 Capt Lubiniecki testified Ms. A told him she still loved Cpl Langridge but needed a break from him.Footnote 476 Capt Lubiniecki stated Ms. A had asked if the military was able to place a restraining order on Cpl Langridge, and he had informed her that was not possible, but he did provide her with the name of a lawyer.Footnote 477 Capt Lubiniecki also testified, following his phone conversation with Ms. A, he spoke to Cpl Langridge, explained Ms. A needed a break from him, and Cpl Langridge agreed to give her the space she needed.Footnote 478 In testimony, Ms. A agreed she had discussed separating for a few days from Cpl Langridge, but stated it was not her intention they would separate permanently.Footnote 479 She also testified she did not recall discussing the issue of a restraining order with anyone around that time.Footnote 480 There is mention in Cpl Langridge’s medical records he had reportedly been harassing her.Footnote 481 Ms. A stated she and Cpl Langridge had continued to discuss plans for the future right up until the day before he died, including plans for Ms. A to visit Cpl Langridge when the CF arranged for him to attend a second residential treatment facility.Footnote 482 Cpl Langridge’s medical records indicate he attended the Base Clinic and renewed six prescriptions on March 14th. The prescribing physician is noted as Dr. Robin Lamoreux.Footnote 483

72. On Saturday, March 15, 2008, Cpl Langridge signed in at the Duty Centre at 0700 hrs and again at 0905 hrs.Footnote 484 It was indicated on the sign-in sheet he was in the room he had been given in the single quarters (colloquially known as the “shacks”).Footnote 485 There was conflicting evidence about his activities, but there was evidence Cpl Langridge’s mood was brightFootnote 486 and he may have, on his own initiative, shovelled the front walk to the Harvey Building since it was snowing.Footnote 487 At 1100 hrs, he signed in again and had a conversation with the Duty Officer Sgt Hiscock.Footnote 488 Cpl Langridge told Sgt Hiscock there had been a change in his medications. In addition, he said the medications had not taken away his nightmares last night and, as a result, he was very tired.Footnote 489 There also was some conversation about a movie Sgt Hiscock had seen.Footnote 490 Cpl Langridge then went back to his room in the shacks.Footnote 491

73. The day of March 15, 2008, many CF members were attending the funeral of Trooper Hayakaze, who had been killed in Afghanistan,Footnote 492 but Cpl Langridge remained at LDSH and went to the shacks, ostensibly to do laundry.Footnote 493 The sign-in sheet records Cpl Langridge signed in again at the Duty Desk at 1235 hrs.Footnote 494 When he did not show up for his next sign in, efforts were made to contact him by phoneFootnote 495 and by knocking on the door of his room in the shacks.Footnote 496 When he did not respond, the master key was obtained, and entry was gained to the room.Footnote 497 At 15:20, Cpl Langridge was found dead, hanging from the chin-up bar in his room.Footnote 498 On his desk was a suicide note, which read as follows:

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 499

Stuart Langridge’s Death: The Fallout

74. Mr. and Mrs. Fynes were informed of Cpl Langridge’s death in a phone call from LCol Demers,Footnote 500 on the evening of March 15, 2008. The notification was done in accordance with the Personal Emergency Notification (PEN) form completed by Cpl Langridge and on file at the Regiment.Footnote 501 Cpl Langridge had named his parents as his emergency contacts and also as his next of kin.Footnote 502 A short time after the phone call, the Fynes were notified in person by a CF notification team.Footnote 503

75. Ms. A was also formally advised of the death. Unlike the Fynes, she had not been named by Cpl Langridge as either a contact or as a next of kin on the PEN form at the Regiment.Footnote 504 The Regiment, however, determined she should be contacted.Footnote 505 Since she was located in Edmonton, LCol Demers advised her in person after he had contacted the Fynes.Footnote 506

76. During the notification, neither the Fynes nor Ms. A were told Cpl Langridge had left a suicide note. The note had been found in Cpl Langridge’s room by the CFNIS members who responded at the scene. The Fynes were not advised for another 14 months that a suicide note even existed.Footnote 507

77. Shortly after the notification, both the Fynes and Ms. A were assigned Assisting Officers (AO) by the CF. The role of the AO was to provide a link to the military and help the family navigate the military’s system of benefits and rules surrounding the death. This included explaining the benefits provided by the CF for the funeral. Footnote 508 Mr. and Mrs. Fynes lived in Victoria and their AO was Maj Stewart Parkinson, who was also located in British Columbia.Footnote 509 Ms. A’s AO was 2Lt Adam Brown who was located in Edmonton and was part of LDSH.Footnote 510

Appointment of Next of Kin

78. In making arrangements, the military assumed the “Primary Next of Kin” (PNOK) was entitled to plan Cpl Langridge’s funeral.Footnote 511 (Although legally distinct, the documents and the testimony at the hearings sometimes refer simply to “Next of Kin” (NOK) interchangeably with PNOK.) Initially, the Fynes were identified as Cpl Langridge’s PNOK and SNOK (“Secondary Next of Kin”) in correspondence sent within the CFFootnote 512 as well as during the initial briefing Maj Parkinson received as the Fynes’ AO.Footnote 513 They were also identified as his PNOK and SNOK on the PEN form at the Regiment. The Fynes began to provide Maj Parkinson with instructions concerning what they wanted for the funeral.Footnote 514 However, on March 17, 2008, two days after Cpl Langridge’s death, they were informed by Maj Parkinson the Regiment had decided Ms. A was Cpl Langridge’s PNOK.Footnote 515 Mr. and Mrs. Fynes were deeply upset and saddened when confronted with this decisionFootnote 516 as they were told final decision making authority over funeral planning now lay with Ms. A,Footnote 517 whom they considered simply to be Cpl Langridge’s ex-girlfriend.Footnote 518

79. How the Regiment made the decision to assign PNOK status to Ms. A is not known precisely, though it seems to have been based on the common-law declaration which Cpl Langridge and Ms. A had signed in December 2007. An email from LCol Demers on the morning of March 17, 2008, stated, Given the docs on file, it seems [Ms. A] is PNOK, so we need to follow her wishes.”Footnote 519 In a casualty coordination meeting held shortly afterwards and attended by senior members of the Regiment and a military lawyer (Assistant Judge Advocate General, or AJAG), further discussions took place about who was PNOK.Footnote 520 Later that day, Capt Lubiniecki wrote in an email [the] AO in Victoria will inform [the] parents that [Ms. A] is the PNOK.”Footnote 521 While the Fynes and Ms. A were encouraged to work together,Footnote 522 it was understood from that point forward if there was disagreement about decisions regarding the funeral, the Regiment would accede to Ms. A’s wishes.Footnote 523

80. In October 2008, many months after the funeral, the Fynes discovered Cpl Langridge had specifically named them as PNOK and SNOK on the PEN form, which was in the possession of the Regiment.Footnote 524 This form had been part of Cpl Langridge’s file when the PNOK decision was made.Footnote 525 Based on this revelation, the Fynes were confused and upset over what they believed to be the Regiment deliberately ignoring the explicit written wishes of their son for the Fynes, and specifically Mr. Fynes, to act as his PNOK and therefore plan his funeral.Footnote 526

The “Found” Documents

81. On March 20, 2008, three days following the PNOK decision, four partially completed and previously unknown administrative documents belonging to Cpl Langridge were foundFootnote 527 behind a filing cabinet during some routine house cleaning. Footnote 528 Each of the “found” documents related to the post-death administration of Cpl Langridge’s affairs. The “found” documents were new versions of a PEN form,Footnote 529 a Designation of Memorial Cross Recipients form,Footnote 530 a willFootnote 531 and a Supplementary Death Benefits (SDB) form.Footnote 532 None of the forms was fully completed.

82. Prior to the discovery of these “found” documents, the Regiment was in possession of a series of fully completed and valid forms belonging to Cpl Langridge including the PEN form, an SDB form and a will.Footnote 533 The “found” documents were significant because Cpl Langridge had changed the executor of his will from his friend David White to Mr. Fynes, changed the beneficiary of his SDB from Ms. A to Mrs. Fynes and again had named his parents as his NOK on his PEN form.Footnote 534

83. The “found” documents were turned over to Capt Lubiniecki on March 21, 2008,Footnote 535 and forwarded to the Office of the Director of Estates in Ottawa on March 26, 2008.Footnote 536 Capt Lubiniecki was advised by Suzanne Touchette, a Service Estate and Elections Officer for the JAG, the “found” documents were of “no value as they are unsigned.”Footnote 537 Some months later, this initial position was reversed and the “found” will designating Mr. Fynes as executor was deemed by DND to be valid pursuant to the Alberta Wills Act.Footnote 538

84. The Fynes were told about the existence of a second will in an email from Maj Jared on March 26, 2008, but they were only advised that Mrs. Fynes was the beneficiary.Footnote 539 Mr. Fynes was not advised there was any change in the estate executor until June 17, 2008,Footnote 540 almost three months after the second will was found. In a letter dated June 19, 2008, Mr. Fynes was formally advised the “found” will was valid, and he, in fact, was the executor of the estate.Footnote 541

Funeral Planning

85. With respect to the actual planning of Cpl Langridge’s funeral, Ms. A attended a local funeral home with her AO, 2Lt Brown, and her and Cpl Langridge’s mutual friend, Cpl Rohmer.Footnote 542 The funeral director testified it is the executor who plans the funeral.Footnote 543 The executor, according to the first will, was Mr. White. In a telephone conversation, he told the funeral director he did not wish to be involved in funeral planning.Footnote 544 When the funeral director asked Ms. A about Cpl Langridge’s parents, he was told his father was not involved and his mother lived out of province and would not be coming to make funeral arrangements.Footnote 545 2Lt Brown told the funeral director Ms. A was Cpl Langridge’s common-law wife,Footnote 546 and the funeral director satisfied himself Ms. A and Cpl Langridge had cohabited for two years.Footnote 547 It was the funeral director’s evidence he was told by 2Lt Brown for funeral arrangements, “It’s [Ms. A] that you will be dealing with.”Footnote 548

86. The funeral director also received information, possibly from 2Lt Brown,Footnote 549 possibly from Ms. A,Footnote 550 which he used to complete the Registration of Death.Footnote 551 However, the information he received was incorrect. This led to several different versions of the Proof of Death being produced over the course of the next few weeks, each containing slightly different but still legally or factually incorrect information.Footnote 552 Finally, more than a year later, the Fynes had the information on the Registration of Death concerning Cpl Langridge’s marital status, his place of residence and the name of the informant corrected by means of an ex parte court order.Footnote 553

87. In planning the funeral, Ms. A consulted with the Fynes, seeking their input on some of the decisions.Footnote 554 However, the final decisions were ultimately made by Ms. A. In particular, the Fynes acceded to Ms. A’s choice of flag to be draped on the casket so Ms. A would agree to Cpl Langridge’s remains being buried rather than cremated.Footnote 555 The Fynes also had other requests, including a closed casket, but they ultimately acquiesced to Ms. A having a viewing of the body prior to the funeral.Footnote 556 It was particularly upsetting for the Fynes because, while they had asked for and were presented with Cpl Langridge’s beret and medals,Footnote 557 it was Ms. A who received the flag from his casket.Footnote 558

88. The funeral for Cpl Langridge was held on March 26, 2008, at the chapel on the Base.Footnote 559 Since neither the Fynes nor Ms. A were aware Cpl Langridge had left a suicide note requesting a small, family funeral, there was a large, military funeral.Footnote 560 The interment for Cpl Langridge was held on March 29, 2008, in Victoria and was attended by, among others, the Fynes and Ms. A.Footnote 561 Their relationship had been slowly deteriorating, and, by the end of the interment, all communications between Mr. and Mrs. Fynes and Ms. A had irrevocably broken down.Footnote 562

The Fynes’ Complaints and CF Responses

89. In the aftermath of Cpl Langridge’s death, there were three CFNIS investigations. The first began immediately following Cpl Langridge’s death and was tasked to investigate the circumstances of his death.Footnote 563 The second CFNIS investigation began in late 2009 and was tasked to investigate whether LDSH leadership had been negligent in the performance of their military duty in assigning PNOK status to Ms. A after Cpl Langridge’s death.Footnote 564 The third investigation began in May 2010 and focused on whether the LDSH chain of command and the medical community were negligent in failing to provide appropriate medical treatment and care to Cpl Langridge, thereby contributing to his death.Footnote 565

90. There were other administrative proceedings relating to Cpl Langridge’s death. It was a requirement, following Cpl Langridge’s death, that an internal CF administrative investigation be conducted.Footnote 566 In this case, both a Board of Inquiry (BOI) and a Summary Investigation (SI) were held. These are internal CF fact-finding processes involving gathering documents and interviewing witnesses and, in the case of the BOI, compelling testimony from witnesses.Footnote 567 Generally, a BOI is a more formal process to investigate more significant issues.Footnote 568

91. The BOI was convened after much delayFootnote 569 on January 13, 2009,Footnote 570 almost ten months after Cpl Langridge’s death. The mandate of the BOI was “to investigate the cause and contributing factors that may have lead (sic) to the death of Cpl Langridge and identify applicable preventative measures.”Footnote 571 The Fynes attended the BOI hearing and were of the strong opinion it was tainted by bias in favour of the military and failed to address many of the questions relevant to Cpl Langridge’s death.Footnote 572 The BOI made findings of fact, as well as recommendations, generally exonerating the CF of any responsibility in connection with Cpl Langridge’s death.Footnote 573 While the BOI report was first submitted for the necessary approvals on June 1, 2009,Footnote 574 the report has yet to receive final approval by the Chief of the Defence Staff.

92. It was as the result of an inquiry by the President of the BOI that the existence of Cpl Langridge’s suicide note first came to light.Footnote 575 There was a delay of several weeks between the initial inquiry and the actual disclosure of the existence of the note to the Fynes on May 22, 2009.Footnote 576 The Fynes were informed of the existence of the suicide note by the BOI President and not by the CFNIS, which had stored it as “evidence” and subsequently apparently forgot about its existence.Footnote 577

93. The terms of reference for the SI were issued June 22, 2009.Footnote 578 They state the SI was being conducted “in anticipation of litigation.”Footnote 579 By this time, the Fynes had hired legal counsel in an effort to resolve their outstanding claims against the military and had, with their lawyer, met with legal representatives from the CF.Footnote 580

94. The mandate of the SI was focused on investigating the administrative procedures followed by LDSH after Cpl Langridge’s death.Footnote 581 The report generally concluded there was nothing wrong with the existing CF forms or procedures.Footnote 582 In his capacity as the reviewing authority for the SI report, BGen K. A. (André) Corbould wrote:

I concur with the findings of the Investigation Officer and that the various possible administrative errors that occurred following the death of Corporal Langridge were not caused through intentional neglect nor that any documentation was mismanaged by a staff member at the Lord Strathcona’s Horse (Royal Canadians) (LdSH(RC)), contrary to current regulations.Footnote 583

95. The Fynes had been advised of the possibility of an SI in an email from Maj Lubiniecki on April 29, 2009, indicating that he understood there would be a summary investigation conducted by the Regiment.Footnote 584 They heard nothing further about an SI until their May 5, 2010 CFNIS interview with Maj Dandurand and MCpl Mitchell, when Maj Dandurand suggested that the SI had looked into administrative issues following Cpl Langridge’s death. Mr. Fynes stated, “Sorry, and I'll thank you both for sharing it with us, because two years-plus, you can understand our frustration, because nobody ever briefed us or told about that Summary Investigation.”Footnote 585

96. The SI had been designated solicitor-client privileged and was not to be disclosed or released to any person outside of the CF.Footnote 586 Indeed, BGen Corbould wrote, “this topic has been dwelled into enough, and [I] do not believe there to be any benefit of disclosing any of the SI to the Corporal Langridge family, [as] it simply would not provide or console them in any manner.”Footnote 587 The Fynes did not receive a copy of the SI report until the MPCC public hearing.

97. As time went on, the Fynes grew increasingly frustrated with what they felt was a lack of answers concerning Cpl Langridge’s death and the subsequent administrative aftermath. They raised a number of issues including questions about the adequacy of the medical care Cpl Langridge had received and his treatment by the military, the storage and return of Cpl Langridge’s personal property, the retention of Cpl Langridge’s suicide note, and the mishandling of Cpl Langridge’s personal paperwork.Footnote 588 They sought, and ultimately received, disclosure of the contents of the 2008 Sudden Death Investigation file, but voiced concerns about its contents and about the redactions made to the copy disclosed to them.Footnote 589

98. The Fynes contacted the DND/CF Ombudsman for assistance.Footnote 590 They maintained ongoing contact with the Regiment and the BrigadeFootnote 591 and did receive assistance regarding their outstanding concerns from DND Casualty Support,Footnote 592 as well as meeting with the CFNIS as part of their ongoing investigations.Footnote 593 With the exception of their contact with the Ombudsmen, most, if not all of these interactions were problematic from the Fynes’ point of view.

99. On August 31, 2009, the Fynes were successful in having Cpl Langridge’s registration of death corrected.Footnote 594 They directed their lawyer to attempt to get reimbursement from the CF for the legal fees they paid to achieve this outcome.Footnote 595 In September 2010, the Fynes’ lawyer received a letter from legal counsel for the CF advising the Fynes to no longer “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 [Mrs. Fynes] has demanded from the Crown.”Footnote 596 This led to Mrs. Fynes coming to Ottawa and holding a press conference in which she denounced the lack of progress in resolving the outstanding issues related to her son’s death.Footnote 597 The Chief of the Defence Staff responded with a public apology about the delay in releasing the suicide note as well as about the poor communications with the Fynes regarding Cpl Langridge’s estate.Footnote 598 He later clarified he was specifically not apologizing for the medical care Cpl Langridge had received from the CF.Footnote 599

100. In the fall of 2010, a senior officer, Col Gerard Blais, was appointed by the Minister of National Defence to act as the single point of contact to respond to the Fynes (and other families) who had “expressed concerns for BOI/NIS and other investigations and concerns related to the death of their loved ones.”Footnote 600 Col Blais did attempt to provide information to the Fynes about all of their remaining concerns,Footnote 601 but, in their opinion, the answers received did not sufficiently address their questions.Footnote 602 The Fynes went on to file a complaint in January 2011 with the MPCC concerning alleged deficiencies in the three CFNIS investigations into the events before and after Cpl Langridge’s death.Footnote 603 That complaint led to the Public Interest Hearing, which forms the basis for this report.

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 CFNISFootnote 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 2007Footnote 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 2nd 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 PhysicsFootnote 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 1985Footnote 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 1st 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 1st 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 ActFootnote 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 ActFootnote 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 CodeFootnote 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 hangingFootnote 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 buildingFootnote 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 deceasedFootnote 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:

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 observationsFootnote 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 minutesFootnote 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 timeFootnote 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 deathFootnote 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 hospitalFootnote 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 1108which 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 HannahFootnote 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 1149who 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 suicideFootnote 1165 but theorized it could have been the result of attention-seeking behaviourFootnote 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 1187diagnoses 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 ActFootnote 1204 or to exercise similar powers under the other provincial Acts. In addition, both OntarioFootnote 1205 and AlbertaFootnote 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:

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


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 laterFootnote 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:

  1. Cpl Langridge Will Wear uniform during normal duty hours and perform duties as directed by the RSM.
  2. A Normal Work Day will be from Mon-Fri. 0800-1630 daily. Weekends will be free unless otherwise directed By the RSM
  3. 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 meetingsFootnote 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 7th, 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 BowdenFootnote 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 2008Footnote 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 apparentFootnote 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 1534When 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 DemersFootnote 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 testimonyFootnote 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:

  1. whether Langridge agreed to the conditions put on him;
  2. what the purpose of the conditions was;
  3. whether the requirement Langridge had to sleep with the door open was a sign the conditions were a form of suicide watch;
  4. whether there was a plan to send Langridge to treatment in Ontario;
  5. whether there was a plan to release Langridge from the military if he failed to comply with his conditions;
  6. whether and how the conditions were being enforced; and
  7. 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 weekFootnote 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 RemarksFootnote 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.