Independent Observer’s Report 2025: Death of Robert Pickton

Official title: Independent Observer’s Report 2025, January 17, 2025: Board of investigation into the assault of an inmate on May 19, 2024, at Port-Cartier Institution, resulting in their death at the hospital on May 31, 2024

The Board of Investigation (BOI) was comprised of the Chair, Marie Eve CHARTRAND, National Investigator, Incident Investigations Branch, National Headquarters; Marc-Olivier BOUCHARD, Senior Project Advisor, Preventive Security and Intelligence Branch, National Headquarters; and Mark FALARDEAU, community member, completed the BOI. The undersigned, Réginald Laurent, acted as the Independent Observer (IO).

The BOI submitted its report on October 18, 2024, and the IO filed its final report on January 17, 2025, 2 weeks after the joint Regional/National Debriefing. 

As per its mandate, the IO did not actively participate in the investigation, but attended all interviews and consultations with the convening experts, while having access to all information relevant to the fulfillment of their mandate. The IO also had the opportunity to discuss freely with the BOI throughout the process.

The BOI conducted a meticulous, highly professional and impartial investigation of a sensitive nature involving numerous interviews and several hours of extensive research in the Correctional Service of Canada (CSC) databases to obtain all the relevant information. During the interviews, members of the BOI tactfully tackled difficult issues and fulfilled their mandate in accordance with the Convening Order of the Commissioner of CSC. The investigation took place in accordance with the Values and Ethics Code of the Government of Canada. 

CSC should reinforce with staff the need to submit timely, detailed and comprehensive operational reports, especially following incidents involving a high-profile case, such as that of PICKTON. This could make it easier for the BOI to reconstruct events and ensure greater transparency.

On May 19, 2024, at approximately 1715 hours, when medication was being dispensed, inmate Martin CHAREST [redacted] violently assaulted inmate Robert PICKTON [redacted] in the common room in [redacted] at Port-Cartier Institution (PCI). CHAREST prompted PICKTON to [redacted] thrusting a broken broomstick into his face. [redacted] were used to cease the assault. [redacted]. PICKTON [redacted]. [redacted] PICKTON [redacted] to the Centre de Santé et de Services sociaux de Sept-Îles, then, given his critical state, was transported via air ambulance to the Hôpital Enfant-Jésus in Quebec City, where he was admitted to intensive care. PICKTON died on May 31, 2024.

Following this incident, the Commissioner of CSC, by virtue of sections 19 and 20 of the Corrections and Conditional Release Act (CCRA), has convened a national BOI, the terms of which are described under the attached Convening Order.

CSC named an IO and entrusted with them the task of ensuring the thoroughness, impartiality, integrity and professionalism of the investigation process, without directing it. In carrying out its duties, the IO had the freedom to make observations and recommendations to the BOI on any matter related to the mandate. In the event that the observations or recommendations concerned the work of the BOI, the IO also had the right to bring them to the attention of the Senior Deputy Commissioner of CSC and propose solutions to address these concerns.

To fulfill this mandate, the IO obtained full access to the relevant documents and necessary audio and video recordings. The IO also attended all interviews the BOI led, but without intervening during them (e.g., asking questions, offering suggestions).

The IO attended all virtual interviews (35) led by the BOI. As per the procedures governing the IO’s work, the laptop’s camera and microphone were disabled. However, the people interviewed were all aware that an independent observer was present. The people interviewed represented a wide range of witnesses and experts, who helped the BOI to delve into all aspects of the investigation in order to arrive at objective and robust conclusions: PCI staff, including management team members; staff from other institutions where CHAREST and PICKTON previously resided; CSC National Headquarters staff, including Health Services staff; experts on the use of [redacted]. The BOI also met with the Sûreté du Québec lead investigator responsible for the case, following an avenue of investigation obtained during an interview with a member of the PCI staff.

The IO and BOI held timely and open discussions on the progress of the investigation, including before and after interviews. These exchanges allowed the IO to observe the BOI’s preparation and analysis process and to understand how it arrived at its conclusions.

The IO reviewed (alone or with the BOI) the following documents: observation reports from Correctional Officers; reports from medical staff who responded to the incident; psychological reports for CHAREST and PICKTON; security patrol reports; 45-day structured casework reports; logbooks; SIU daily reports; photos of the scene after the incident; the use of force report; and the use of chemical agents report.

The IO viewed several times (alone and with the BOI) the video of the incident and a video from [redacted] providing the control post operator’s perspective. The IO also listened to all audio recordings from the control post around the time of the incident. These review sessions provided an opportunity for open and objective discussion to analyze events and arrive at conclusions based on the facts observed thanks to the extensive audio and video documentation.

The IO reviewed the relevant CSC policies and directives, namely those concerning the use of force. Refer to the References section for a list of documents consulted. 

Expertise: The composition of the BOI met high standards of competence and experience. A good mix of recent operational experience in an institution and very good knowledge of the correctional system in general. Every BOI member contributed to the process fully and without restriction. The IO consistently noted these strengths in terms of the interview techniques used, the relevance of the questions and the follow-through on lines of inquiry.

Respecting the Convening Order: The BOI respected the parameters and always clearly explained the framework of the investigation to interviewees; all witnesses received a copy of the Convening Order with the interview request.

Application of the process (Commissioner’s Directive 041 – Incident Investigations): The BOI acted in accordance with all the elements set out, in particular:

Paragraph 30: Interview offered in the official language of their choice

Paragraph 33: Protection of section 13 of the Inquiries Act mentioned and explained to each interviewee (except the SQ officer)

Paragraph 37: Consultation with relevant policy holders

Paragraph 41: Local debriefing with PCI authorities

The BOI carried out its duties with the utmost professionalism, with due regard for the CSC’s values and mission. The BOI worked diligently to meet deadlines, conscious of the importance of the work entrusted to it. The whole process was carried out in accordance with the policies and directives. 

The IO also noted that the BOI established a climate of respect and trust in its interactions with other employees, an important aspect when investigating a high-profile case.

The BOI has worked meticulously and diligently. The preparation prior to each meeting reflected a methodical approach that left nothing to chance: reading of relevant documents, reports, CSC policies and directives; local PCI processes. The BOI followed up on interview responses to corroborate facts. This allowed the BOI to develop the content of its report. The following are examples of the work done in this respect: research in the Offender Management System; verification of the training status of staff involved in the incident; additional interviews/consultations with non-PCI staff (e.g., IIB Strategic and Corporate Services staff from NHQ). There was also careful gathering of information from all available sources (staff and CSC databases) when reporting non-compliance with policies and procedures.

The IO did not detect any bias in the BOI’s approach, or any desire to place fault on interviewees. The interviews were conducted professionally, in an environment that encouraged collaboration and active listening. At no time did the IO observe the BOI acting inappropriately towards the interviewees. The BOI’s work was strictly guided by a desire to obtain, objectively and professionally, all the necessary information from those involved in the case (and through CSC database research), in order to arrive at conclusions backed up by solid arguments. BOI members held honest, unbiased discussions among themselves about the information they obtained, and each member contributed to the process without constraint.

The BOI completed its task without encountering any unwanted pressure, and the IO found no inappropriate attempts to influence its conclusions or compromise its independence. All the CSC employees interviewed expressed themselves freely, to the best of their knowledge.

The BOI demonstrated integrity in its approach, and its interactions (verbal and written) with all stakeholders were conducted with transparency and respect. The members tactfully addressed sensitive issues during the interviews. The BOI also showed understanding and flexibility by, for example, allowing a witness to answer questions in writing, given the individual’s personal circumstances. The BOI’s amicable approach to the entire process helped to foster cooperation. This contributed to frank and open discussions, despite some of the differences of opinion that arise in such investigations. The members carried out their work in accordance with the CSC policies and the mandate assigned to them. 

The BOI carried out its duties in accordance with the values of the public sector and the expected behaviours of public servants. Following the BOI’s work, the IO paid particular attention to these 3 behaviours, deemed most relevant for the purposes of this case: respect for people, integrity and excellence. The IO has commented on the achievement of these behavioural targets elsewhere in this report. 

Post-incident reports (including observation reports) from staff involved in the incident lacked rigour. The BOI obtained important information during interviews that had not been recorded in the file or had to ask for this information to be added to incomplete reports. The IO would like to stress that this shortcoming did not hinder the investigation, and the IO in no way questions the staff’s good faith. However, more rigorous record-keeping facilitates the BOI’s job and ensures greater transparency when reconstructing the facts, especially following an incident that has led to the death of an individual.

CSC should reinforce with staff the need to submit timely, detailed and comprehensive operational reports, especially following incidents involving a high-profile case, such as that of PICKTON. This could make it easier for the BOI to reconstruct events and ensure greater transparency.

None.

CSC is required by law to investigate incidents where an inmate in its care dies or suffers serious bodily injury. The Commissioner of CSC issued a Convening Order, asking the BOI to provide an account of all the circumstances surrounding the above-mentioned incident, including the context in which the incident took place, and a chronology of events. The BOI was also instructed to specifically analyze 4 areas of investigation, as well as any non-compliance with the law, policies, procedures and the CSC Values Statement that had a direct impact on this incident.

The BOI was asked to carry out a highly sensitive investigation following an incident involving a person of some notoriety. The BOI has successfully and professionally fulfilled its task in an impartial manner. The IO certifies that the BOI’s report objectively reflects its conclusions, based on information obtained from numerous interviews and extensive research. The IO would like to congratulate the BOI on its enthusiasm in completing a challenging job on time.

1. Commissioner’s Directive 041, Incident Investigations, paragraphs 5 to10 (September 9, 2020)
2. Corrections and Conditional Release Act, sections 3.1 and 4
3. Values and Ethics Code for the Public Sector
4. Bulletin – The Hub, Policy for use of force
5. Commissioner’s Directive 567-5, Use of Firearms (2018-12-10)
6. Bulletin – The Hub, Procedures when an incident occurs
7. Case management bulletins, The Hub, Managing Offenders who are at Risk of Suicide and/or Engage in Self-Injurious Behaviour (2019-12-16, update: 2025-01-06)
8. Bulletin – The Hub, Interviews with a board of investigation
9. Bulletin – The Hub, Conducting a Tier I or Tier II investigation
10. The Hub, Port-Cartier Institution, Site procedures and guidelines (emergency plans manual)
11. Bulletin – The Hub, Standards of professional conduct
12.  Bulletin – The Hub, Commissioner’s introduction to the standards of professional conduct 

Board of Investigation into the assault of an inmate on May 19, 2024, at Port-Cartier Institution, resulting in their death at the hospital on May 31, 2024

On May 19, 2024, at approximately 1715 hours, when medication was being dispensed, inmate Martin CHAREST [redacted] violently assaulted inmate Robert PICKTON [redacted] in the common room in [redacted] at Port-Cartier Institution. CHAREST prompted PICKTON to [redacted] thrust the end of a broken broomstick into his face. [redacted] were used to cease the assault. CHAREST was handcuffed [redacted]. PICKTON [redacted] PICKTON [redacted] to the Centre de Santé et de Services sociaux de Sept-Îles, then, given his critical state, was transported via air ambulance to the Hôpital Enfant-Jésus in Quebec City, where he was admitted to intensive care. On May 31, 2024, PICKTON was pronounced dead.

In response to this incident, the Commissioner of Correctional Service Canada, by virtue of sections 19 and 20 of the CCRA, has convened a national investigation, the terms of which are described under the attached Convening Order.

CSC is appointing an Independent Observer (IO) to take part in the investigation, whose role and responsibilities are described in the Terms of Reference below.

1. The IO will assess whether the work of the Board of Investigation (BOI) is thorough, impartial and professional.
   1. Thorough will be understood as the adherence to the parameters set out in the Convening Order, as well as the consistent application of a rigorous established investigation process, as defined under Commissioner’s Directive 041 as well as the Incident Investigations Branch’s (IIB’s) own internal guidelines, norms and standards.
   2. Impartiality will be understood as an absence of prejudice or bias, actual or perceived, in the outcome of the investigation that will be guided solely by the evidence.
   3. Professional will be understood as assessing that all interviews, verbal and written interactions/communications with involved parties and stakeholders, are carried out in a respectful and timely manner.
2.  Throughout the course of all activities, the IO is expected to make observations and/or recommendations on any issues related to their mandate. The observations and recommendations may be made to the BOI, or in the event the observations and recommendations relate to the BOI or at the preference of the IO, to CSC Senior Deputy Commissioner (SDC). This includes identifying potential concerns and proposing solutions for resolution of such concerns.
3. The IO will provide a final report of their observations and findings no later than 2 weeks after the joint regional debriefing. The format of such report shall be determined by the IO and the report shall be made public by CSC.
4. The IO will liaise with the chair of the BOI to obtain access to all the information and documents they deem to be required.
5. The IO will also liaise with the Director General, IIB, and her office for assistance regarding any procedural or administrative matter related to the conduct of the investigation.
6. CSC shall provide the IO office supplies and material (i.e., CSC laptop) as required.
7. The IO shall maintain document security, including respecting the need to know principle, as provided by the Policy on Government Security.
8. The IO will respect the provisions of the Privacy Act as they relate to personal information.
9. The IO will inform the SDC of any media or government requests for engagement.
10. The IO will be reimbursed for any necessary travel and disbursements in accordance with Government of Canada policy.

In consideration of the foregoing and in accordance with the Terms of Reference set out above, I agree to act as the Independent Observer in this matter.

Assented to this 14th day of August 2024 at Ottawa, Ontario.

Original signed by:

_____________________________________________________

Réginald Laurent