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Lessons learned: Sweeping changes recommended in final report into N.S. mass shooting

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Two-and-a-half years after it was established, Nova Scotia’s Mass Casualty Commission (MCC) has recommended sweeping changes to everything from gun control to mental health services, although there’s no guarantee any will ever be implemented.

In a message published in the MCC report’s executive summary, the trio of commissioners suggested the prevention of future tragedies was a primary objective.

“Our recommendations are designed with two objectives in mind: prevention of violence and ensuring effective critical incident response by police, other public safety partners, health and victim service providers, and communities,” the report reads.

“Crucially, we also consider the broader root causes of violence, how such violence can be prevented, and how we can all help to improve community safety and well-being.”

Established in October 2020, the commission was tasked with examining the worst mass shooting in Canadian history.

On April 18 and 19 of that year, denturist Gabriel Wortman shot and killed 22 people, including a pregnant woman.  Wortman was dressed as an RCMP officer and was driving a strikingly authentic-looking police cruiser.

The 13-hour rampage began in the quiet community of Portapique, N.S., but spread to other communities before Wortman was shot to death by police at a gas station in Enfield, N.S.

Out of respect for the victims, his name appears nowhere in the 317-page summary of the final report.

“There were many warning signs of the perpetrator’s violence and missed opportunities to intervene in the years before the mass casualty,” reads the report.

“There were also gaps and errors in the critical incident response to the mass casualty as it unfolded on April 18 and 19, 2020. Additionally, there were failures in the communications with the public during and in the aftermath of the mass casualty. These issues can be addressed, and responses, including public alerting, can be improved.”

“The report includes a set of recommendations that people across our governments, institutions, and communities can begin to take action on right away,” it says.

Some of the recommendations are listed below:

Firearms

In addition to revoking firearms licences for anyone convicted of gender-based, intimate partner or family violence, the commission recommends tighter restrictions on automatic and semi-automatic weapons.

The commission recommends that:

  • The federal government should amend the Criminal Code to prohibit all semi-automatic handguns and all semi-automatic rifles and shotguns that discharge centre-fire ammunition and that are designed to accept detachable magazines with capacities of more than five rounds.
  • The federal government should amend the Criminal Code to prohibit the use of a magazine with more than five rounds so as to close the loopholes in the existing law that permit such firearms.
  • The federal government should amend the Firearms Act (i) to require a licence to possess ammunition; (ii) to require a licence to buy a magazine for a firearm; and (iii) to require a licensee to purchase ammunition only for the gun for which they are licensed.
  • The federal government should establish limits on the stockpiling of ammunition by individual firearms owners.

It also recommends the prohibition of transferring ownership of firearms through estates when someone dies, and more cooperation with U.S. authorities to keep illegal weapons from entering Canada through that country.

Police Paraphernalia and Vehicles

The commission is urging RCMP and other police agencies to review policies around management and disposal of police uniforms and kits.

“The RCMP and other police services should ensure that when police officers retire or otherwise cease their roles as peace officers, they return all items of police uniform and kit, including ceremonial uniform and badges,” says the report.

“Police services may make arrangements to return badges to members in good standing, after encasing them in a block of hard plastic of sufficient size to render the badge unusable,” it says, adding retired officers in good standing could have access to an appropriate veteran’s blazer if they want one.

The report also recommends the minister for public safety maintain a moratorium on the sale of decommissioned RCMP vehicles to the public until a third-party review of the decommissioning process has been completed, and any recommendations implemented. 

Vehicles in good condition should be considered for other government fleets, even if they’re no longer suitable for policing.

Police Officer Consumption of Alcohol and Recreational Drugs

“The Commission recommends RCMP should amend its Code of Conduct to state clearly that members must have no alcohol or recreational drugs in their system while on duty, and that they must not report for duty or self-deploy if they have consumed alcohol or recreational drugs.”

The issue was noted during the inquiry.

“Sgt. Andrew (Andy) O’Brien was the operations officer for Bible Hill detachment. He was off duty on April 18. After Acting Cpl. Beselt called to alert him to the serious incident in Portapique, Sgt. O’Brien phoned his supervisor, S/Sgt. Carroll, and informed him he had consumed alcohol and should not attend the scene. His consumption of alcohol was in no way improper – he was off duty and not on call. However, from approximately 10:30 pm on, Sgt. O’Brien participated in the critical incident response in a supervisory capacity, without attending the scene,” says the report.

Capturing Information from 911 Calls

The commission recommends that all staff at the RCMP Operational Communications Centre and staff at other public safety answering points should have access to 911 call recordings at their desk and be trained in how to play the calls back.

RCMP Communication During Critical Events

“The commission recommends RCMP policies, procedures, and training to reflect the approach recommended in the 2014 MacNeil Report about the RCMP’s response to the Moncton Mass Casualty; that is, that the RCMP should activate public communications staff as part of the critical incident package.”

  • The responsibility to prioritize and engage public communications staff must be clearly allocated.
  • A public communications officer should be embedded within the command post.

“The widespread beliefs that community members will panic and that they cannot be trusted to respond appropriately to information about threats to their safety are myths,” the report reads.

The report also acknowledges a lack of timely public information may have been a contributing factor.

“Essential workers, including Victorian Order of Nurses (VON) employees, were particularly at risk because of the nature of their work. The RCMP did not share accurate and timely information, including information about the perpetrator’s replica RCMP cruiser and disguise, with these workers or their employers. By not sharing this information, they deprived these essential workers and their employers of the opportunity to evaluate risks to the safety of the workers. This opportunity would have allowed them to take measures to better protect themselves.”

Victims Kristen Beaton, who was pregnant, and Heather O’Brien were both shot to death on Plains Road in the Debert Business Park on the morning of April 19.

Both were VON nurses.

The report also chastises the force for not keeping local media informed during the shooting.

“The RCMP’s approach of sharing information primarily via social media was insufficient to strategically engage local media outlets. The media was insufficiently utilized as a partner in public communications on April 18 and 19, 2020.”

Mental Health Care for Nova Scotians

The report recommends Nova Scotia establish a comprehensive and adequately funded model of mental health care services, including first response to those in crisis. It says Ottawa should subsidize the cost “at a minimum proportion equal to the proportion to which it subsidizes RCMP policing services.”

Review of Alert Ready System

The commission recommends federal, provincial, and territorial governments review public emergency alerting to determine whether and how the Alert Ready system can be reformed in such a way that it meets the legal responsibility to warn the population of an emergency that threatens life, livelihoods, health, and property.

Post-Mass Casualty Incident Support Plans

The report says Health Canada should work with provincial and territorial counterparts to develop a national policy for those affected by a mass casualty event.

Promoting Bystander Intervention

The commission is urging the federal government to renew and extend bystander intervention awareness and education campaigns and support their implementation in a wide range of settings, including in education, workplaces, and public services.

Awareness and education about gender-based violence should start early – in kindergarten.

Implementing and Mutual Accountability

The commission recommends the governments of Canada and Nova Scotia establish and fund an “Implementation and Mutual Accountability Body” with a mandate to provide mutual accountability, exchange of knowledge, and support among all organizations and actors involved in the implementation process.”

It says that should happen by May 31, 2023.

Mobilizing a Society-Wide Response

The Commission recommends that:

  • All levels of government in Canada declare gender-based, intimate partner, and family violence to be an epidemic that warrants a meaningful and sustained society-wide response.
  • Non-governmental bodies, including learning institutions, professional and trade associations, and businesses, declare gender-based, intimate partner, and family violence to be an epidemic that warrants a meaningful and sustained society-wide response.
  • Men take up individual and concerted action to contribute to ending this epidemic.

“We conclude that preventing mass casualties requires a holistic, public health approach that addresses root causes, including poverty and inequality, and focuses primarily on prevention and early intervention in patterns of behaviour that cause harm and have the potential to escalate to mass violence. Prevention requires active and concerted “whole of society” response and engagement, all of us working together to address violence in the home and inadequate community support systems,” the report reads.

Along with site visits and interviews with more than 230 people, the report says commissioners reviewed tens of thousands of documents, videos, and audio files gathered through subpoenas from the RCMP and others.

It also collected submissions from 61 participants and heard from 60 witnesses during public hearings.

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