Process Management Directive #2

  1. In furtherance of Process Management Directive 1, issued on January 11, 2012, this is Process Directive 2.
  2. Speaking to the future through recommendations is a fundamental aspect of my mandate which I am empowered to exercise through a process which will enable me to do so effectively and efficiently.

  4. Understanding past events is important to properly discharge the Commission’s responsibility to make findings and recommendations.
  5. In informing and framing recommendations, I must have regard to a wide range of considerations including:

    a. The tragic circumstances of the victims and the profound impact that has had on family, friends and their communities, as well as the abhorrence that these crimes have had in the minds and hearts of the public, in this region, in the country and to the world.

    b. The protection of many women and children within marginalized communities, who, for many reasons and circumstances are, involved in the sex trade.

    c. The structures and operation of policing authorities whose integrity and effectiveness have been questioned and the individual officers working within them whose reputations, careers and lives which have become implicated in these events.

    d. The implications of these events in undermining the public’s confidence in the policing institutions and its leaders and officers in the discharge of its responsibilities into the future, within the community at large and especially with respect to those most vulnerable within marginalized communities.

  6. Sadly, grotesque serial crimes have happened before in BC, in Canada, and in many other countries including the US and the UK. Many reviews of these notorious serial crimes have produced important reports. I am particularly mindful of the guidance offered by the late and distinguished Mr. Justice Archie Campbell following a review of the Bernardo case:

    It is often the case that systemic failures, as opposed to individual mistakes are the real cause of public disasters and the most appropriate focus of public inquiries. The public identification of individual mistakes or wrongdoing, while important, does not necessarily address the underlying problem. And unless the underlying problem is addressed, the same mistakes or wrongdoing will likely occur again if the system that permitted them is not fixed.

    It is a mistake for a Royal Commissioner or public inquiry to focus exclusively on the search for scapegoats when the failure is really an institutional failure in the sense of a lack of appropriate systems, a lack of reasonable resources, a flawed institutional culture, or a breakdown in the machinery of accountability.

    …But these problems do not go away simply because individuals have been implicated. These problems only go away when people change their systems, their attitude and the way that they do business.(“The Bernardo Investigation Review” in Allan Manson & David Mullan, eds., Commissions of Inquiry, Praise or Reappraise? at page 399) 

  7. In The Conduct of Public Inquiries: Law Policy and Practice Professor Ratushny has this to say:

    While [systemic] issues may seem intangible at first, they often emerge in issues such as leadership, relationships, morale, past practices, and institutional “culture”. They are, essentially, any factors that transcend individual conduct but influence events, including individual conduct. They may impose rigidity in dealing with problems, or create “gaps” by discouraging cooperation and coordination. They may generate insensitivity and create barriers. They often do not appear to be offensive on their face but only upon understanding their influence on consequences. (page 386)

  8. Thus far the evidence before me raises the same concerns that Mr. Justice Campbell and Professor Ratushny highlighted with respect to systemic failures. Where systemic failures have been identified in these reports the simple fact is that even if every individual officer did their job, the overall job did not get done. Justice Campbell puts the point in this way:

    The Bernardo case shows that the motivation, investigative skill, and dedication are not enough. The work of the most dedicated, skilful, and highly motivated investigators, supervisors and forensic scientists can be defeated by the lack of effective case management systems and the lack of systems to ensure communication and co- operation among law enforcement systems. (page 333)


  10. I am deeply struck by what Mr. Justice Campbell said at the very outset of his report:
  11. Virtually every inter-jurisdictional serial killer case including Sutcliffe( the Yorkshire Ripper) and Black ( the cross-border child killer ) in England, Ted Bundy and the green River Killer in the United States and Clifford Olson in Canada, demonstrate the same problems and raise the same questions. And always the answer turns out to be the same- systemic failure. Always the problems turns out to be the same, the mistakes the same, and the systemic failures the same.”(page 1)

    And later he says this:

    The remarkable thing about serial predator investigations is that the same problems repeat themselves in every investigation with tragic frequency. We seem incapable of learning from previous experience. (page 254)

  12. What happened here must never happen again. I consider my paramount duty to do everything that I can do to contribute to that end within my power as a Commissioner. If the reviews and reports that have followed each of these serial crimes, with such similar characteristics, and the recommendations that have followed have failed to effect change, I have concluded that I must ask myself what it is that this Commission can do differently to make a difference.

  14. Our work must focus on doing whatever we can to make sure we make a difference in very practical terms in advancing the ability to prevent these horrific crimes. I can now say that I will address in my Final Report any elements of systemic failure that may have occurred here, and expect that it will speak to at least the following categories of recommendations:

    a. the difficult interface between the policing authorities and the marginalized community of these victims,

    b. inter jurisdictional difficulties between different police forces, and

    c. shortcomings in organizational systems.

  15. I wish to consider all options as to how the process can be shaped so that I can inform and frame my recommendations in the best possible way to fulfill the duties pursuant to my mandate within the powers vested in me under the Pubic Inquiry Act. I have instructed Commission Counsel to undertake such discussions as they consider may be helpful, including with participants, and to consult with other professionals he considers have the background and experience to assist him in providing advice and guidance to me.

  17. I have directed Commission Counsel that I now wish to hear from three lead investigators in the missing women investigations including: Det/Cst. Shenher, Mr. Connor and Mr. Adam.

  19. I reiterate the importance I attach to moving forward in a timely and focused way as set out in Process directive 1, and will be issuing further process directives in the days ahead.