Report finds ‘serious flaws’ in how Toronto police investigated missing-persons cases

Toronto Police failed the victims of the city's most notorious serial killer, according to a review into missing persons investigations. Faiza Amin with the reported 'serious flaws' and systemic discrimination that left communities in terror.

Systemic discrimination contributed to “serious flaws” in a number of missing-persons investigations conducted by Toronto police in recent years, including the case of a serial killer who preyed on men in the city’s gay village for close to a decade, an independent review found Tuesday.

Those flaws exacerbated the mistrust some marginalized communities feel towards police, the report said in calling for a significant overhaul of how missing-persons cases are handled in the city.

Officers unfamiliar with marginalized and vulnerable groups failed to effectively engage those communities to help solve cases and understand the significance of evidence, and some cases didn’t receive the attention they deserved, the report found.

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As well, some officers had “misconceptions or stereotypical ideas” about the LGBTQ2S+ communities that impeded their work at times, the document said.

Poor communication, including public statements made by the force’s then-chief, and excessive secrecy surrounding the investigations were also deemed “disturbing” in the report.

The review, led by former Appeal Court judge Gloria Epstein, recommends implementing a more “holistic approach” to missing-persons investigations that would see greater reliance on civilians and social services rather than just law enforcement.

Epstein acknowledged some improvements have already been made, including the creation of a centralized missing-persons unit, but said more work is needed.

“These investigations continue to be severely under-resourced, an issue that is deeply troubling given the disproportionate number of marginalized and vulnerable people who go missing, and who are exposed to risks while they are gone,” she said.

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“Moreover, barriers that prevent some vulnerable people from being reported missing to the police are equally concerning.”

The roughly 900-page report examines policies and procedures related to missing-persons cases, as well as how officers investigated the disappearances of residents who were later found to have been killed.

It focuses on the eight men murdered by serial killer Bruce McArthur — Andrew Kinsman, Selim Esen, Majeed Kayhan, Soroush Mahmudi, Dean Lisowick, Skandaraj Navaratnam, Abdulbasir Faizi, and Kirushnakumar Kanagaratnam — as well as Tess Richey, a young woman whose body was found in an outdoor stairwell by her mother, and Alloura Wells, a trans woman found dead in a ravine.

“Virtually all the people who went missing from the Village between 2010 and 2017 were marginalized for one reason or another, and often for multiple reasons,” including race, religion, sexuality, gender identity, Epstein wrote.

In cases where more than one police force or division was involved, there was often little to no co-operation, and as a result, some tasks were duplicated and others fell through the cracks, she found.

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Epstein also found investigations were inconsistent, and in many instances, “basic investigative steps were overlooked or delayed,” while searches were at times “disorganized, incomplete or poorly documented.”

Toronto Police Services Board and the Toronto Police Service issued a lengthy joint statement on the report. Read below.

Tps Tpsb Joint Statement Independent Civilian Review Missing Person Investigations by CityNewsToronto on Scribd


In the McArthur investigation, officers’ repeated failure to identify the missing-persons reports as major cases, combined with some investigators’ dislike of the provincially mandated case-management system for such cases, meant very little data was entered in it at first, the report found.

During Project Houston, which investigated the disappearances of Navaratnam, Faizi and Kayhan, “tracking of vital assignments depended largely on human memory and handwritten notes,” the report found.

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As a result, investigators failed to quickly identify leads and possible connections between the cases and others, it found.

“One can never know for sure whether or not McArthur would have been apprehended earlier had these deficiencies not existed, nonetheless (Epstein) has also found that there were a series of lost opportunities to apprehend and identify McArthur,” said Mark Sandler, the lead counsel for the review.

The report also highlights the “inaccurate, and unfortunately misleading” comments then-chief Mark Saunders made regarding the investigation in December 2017, when he said evidence did not indicate the presence of a serial killer.

His words had the effect of “further rupturing the already precarious relationship” with community, the report said.

An interview Saunders gave to a newspaper the following year, in which he defended the investigation and stated that no one from the community had come forward to help investigators, also stirred backlash, the document found.

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The report makes 151 recommendations, including that police regularly provide information about missing-persons cases to those affected and not “erect unnecessary barriers” to giving such information “based on an overly broad interpretation of what must be withheld to preserve the integrity of an investigation.”

It also calls for police to commit to using the mandated case-management system as required, and revise its procedures so that, whenever possible, missing-persons cases are largely investigated by the force or division where the person was last seen.

It also recommends doubling the size of the missing-persons unit to eight investigators and creating jobs within the unit for workers who would exclusively provide support for those directly affected by the disappearance of individuals.

The new investigative model proposed in the report would involve triaging cases in a way that could sometimes see social service agencies, public health agencies, community organizations or others take the lead rather than police.

Epstein noted many have voiced concern the recommendations won’t be implemented, but stressed she had laid out a detailed plan that involves regular public reporting. She also expressed hope the force would prioritize a commitment to making those changes.

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Richey’s mother welcomed the report.

“A shift in police attitude and understanding would go a long way in better serving and protecting all members of our community,” Christine Hermeston said.

Mayor John Tory also commented, saying he was “strongly in favour of this unprecedented independent review.”

“As Mayor, the safety of all Toronto residents – every single resident in every community – is my number one priority,” Tory said in a statement. Maintaining the trust of all our communities is extremely important to the ongoing success of the Toronto Police Service. When that trust is lost, we all have a responsibility to restore that trust in our police service and its officers.”

“The report today outlines a path to restore that trust and ensure that the Toronto Police will be a world leader in missing person investigations. That success will rely on the service also improving its relationship with the LGBTQ2S+ communities and other communities. Both as Mayor and as a member of the Toronto Police Services Board, I am personally committed to helping renew that relationship in any way I can.”

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The review, which cannot make findings of misconduct or criminal liability, was ordered in the summer of 2018 after McArthur’s arrest but did not initially include his crimes in order to preserve his right to a fair trial. Its scope was later expanded to include that case after McArthur pleaded guilty to eight counts of first-degree murder.


The review is broken into four volumes. See the documents below.


Missed and Missing – Vol I by CityNewsToronto

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Missed and Missing – Vol II by CityNewsToronto

Missed and Missing – Vol III by CityNewsToronto

Missed and Missing – Vol IV by CityNewsToronto