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The coroner's inquest into the death of a Sudbury man who died six years ago came to an end Wednesday with seven recommendations, which included having a better procedure for securing telephone connections between crisis negotiators and the subject person during an armed standoff.
The five-person inquest jury, all from Sudbury, presented the formal recommendations Sept. 4, which was the seventh day of the inquest into the death of Steven Thornton, of Garson, who died in 2018 after being barricaded in his home on Sunny Street in Garson.
A team from the Barrie Police Service had also been called in as backup for Sudbury police and to provide relief during the incident.
(You can read Day One of testimony here, Day 2 here, Day 3 here and Day 4 here. Village Media did not have an update on the fifth day of testimony. Testimony from Day 6 can be read here.)
The telephone issue arose during Day 4 of the inquest when it was revealed that Thornton and crisis negotiators experienced telephone difficulties during an all-night armed standoff on Sept. 12-13, 2018.
The telephone negotiations began after Thornton had been in an argument with his wife, had shot her in the back with a shotgun (she recovered) and then barricaded himself alone in the house.
Staff Sgt. Derrick Rose, a crisis negotiator with Greater Sudbury Police Service, had been using a cellphone to speak with Thornton throughout the evening, trying to convince the man to put down his gun and surrender to police.
Twice during the Sept. 12-13 evening, Rose had improvised with non-police cellphones to keep the conversation going with Thornton because the man was armed and was suicidal, but there was still a chance he might surrender.
All during this time, Thornton's home phone was "locked," meaning any outgoing calls he made would automatically go to Rose's cellphone.
At one point during the incident, Sudbury police officers were relieved of the long ordeal by Barrie police, whose officers came on scene to temporarily take over the situation.
During the handover, it was expected that the lock from Thornton's phone would be transferred to the Barrie police command centre. That didn't happen. Thornton tried calling out and that call went to Rose's phone just as he was heading off duty.
Rose took his cellphone into the Barrie police command post and gave it to the Barrie police negotiator Sgt. Toni Talarico, who was on duty.
Although she was able to establish a rapport with Thornton, she found that the call quality was poor. Whether the cellphone battery dying, or the battery in Thornton's cordless phone in the house, was never established.
There were times earlier in the night when Rose had tried to get Thornton to use a landline telephone because the sound quality was poor.
As it would turn out it was shortly before 7 a.m. that Thornton and Talarico agreed to get off the phone to have a coffee break. Talarico made Thornton promise he would call right back after the break. She would use that break to lock Thornton's phone into the Barrie police command post's phone system.
The call never came. Even after Barrie police tried to provide a "throw phone" — a landline with a secure connection — no new connection was ever established. A check with the telephone company revealed that Thornton might have tried calling out after 9 a.m. that morning, but that at least two calls were dropped for some reason.
It was during the noon hour, later that day, that tactical officers breached the house and found Thornton deceased from a self-inflicted gunshot to the head.
The seven recommendations made by the inquest jury were as follows:
1. Consider implementing a procedure to establish an interagency operational debriefing for critical incidents that involve the response of more than one police service.
2. Ensure a formal written record is completed for all operational debriefings, and that the less learned and identified points of improvement are disseminated throughout the involved police service(s).
3. At the earliest opportunity, each involved police service shall conduct the mandatory operational debriefings regarding the critical incident involving Steven Thornton that were required in 2018:
i) For the Greater Sudbury Police Service, pursuant to Greater Sudbury Police Service Procedures MAJ001-Tactical Unit, MAJ009-Major Incident Command, and MAJ013 - Hostage Rescue / Barricaded Persons; and
ii) For the Barrie Police Service, pursuant to Procedure No. 76.
The jury also provided recommendations for policy and equipment directed at both the Sudbury and Barrie police services.
4. Develop a best practice procedure with respect to the locking and unlocking of phones involved in a crisis negotiation, including during any period of transition from one police service to another, including the creation of a formal lockout procedure that requires a (written) form to be completed, with timestamps and signatures.
5. Develop a best practice procedure that requires the transfer to the negotiator's phone kit at the earliest opportunity where negotiations commence using an external phone.
6. Develop a best practice procedure to ensure that during a critical incident any potential threat or "trigger" inside the inner perimeter is not visible to the barricade and/or suicidal person.
The jury's final recommendation spoke to the idea of having access to expert advice during a crisis situation.
7. Consider developing a succession plan so that there continues to be access to an on-call psychiatrist to provide assistance to the Greater Sudbury Police Service as needed.
Bonnie Goldberg, the presiding officer at the inquest, thanked the jury, the witnesses and the lawyers who took part in the event. She said all the recommendations would be forwarded to the office of the Chief Coroner of Ontario for consideration.
The role of an inquest is to make findings of fact with respect to the death of an individual, which is mandatory when a death occurs after an interaction with police.
Inquest juries may not determine blame or reach any legal conclusions. Recommendations are made with the intention of preventing similar deaths in the future.
