BERNARDO INVESTIGATION REVIEW SUMMARY REPORT OF MR. JUSTICE ARCHIE CAMPBELL JUNE 1996 TERMS OF REFERENCE On the recommendation of the undersigned, the Lieutenant Governor, by and with the advice and concurrence of the Executive Council, on December 13, 1995, orders that: WHEREAS it has been determined that it is desirable to appoint by order in council an individual to review various aspects of the investigations that led to certain charges being laid against Paul Bernardo; AND WHEREAS it is desirable to set out the terms of reference for such a review in an order in council; NOW THEREFORE the Honourable Mr. Justice Archie G. Campbell be appointed to conduct such a review; AND THAT Mr. Justice Campbell's mandate be as follows: 1. to review the role of the Green Ribbon Task Force and its investigation into the deaths of the victims, and the Metropolitan Toronto Police Service investigation into the Scarborough sexual assaults; 2. to review the involvement of the Centre of Forensic Sciences and the analysis of samples submitted for DNA testing regarding the Scarborough sexual assaults; 3. to review the issues concerning the autopsies performed on Tammy Homolka and the police and coroner's investigation into her death; 4. to review the role of the Provincial Government in the provision of funding for the Green Ribbon Task Force; 5. to provide a written report to the Solicitor General and Minister of Correctional Services by March 31, 1996, comprised of an identification of issues and recommended policies or procedures that would improve the responses of the police, the Centre of Forensic Sciences and the Coroner's Office to effectively and efficiently deal with crimes of the nature investigated. AND THAT Mr. Justice Campbell's review will consist of a review of internal reports produced by the agencies involved and additional review of the agencies involved, if required. AND THAT all Government Ministries, Boards, Agencies and Commissions, shall assist Mr. Justice Campbell to the fullest extent in order that he may carry out his review, and that he shall have authority to engage, subject to Ministry and Government policies and procedures with respect to the engagement of consulting services, such counsel, investigators, expert technical advisers, research and other staff as he deems it proper at rates of remuneration and reimbursement to be approved by the Ministry of the Solicitor General and Correctional Services in order that a complete and comprehensive report may be prepared and submitted to the Solicitor General and Minister of Correctional Services. Recommended "R. W. Runciman" Solicitor General and Minister of Correctional Services Concurred "R. W. Runciman" Chair of Cabinet Approved and Ordered: Date- DEC 13 1995 "H.N.R. Jackman" Lieutenant Governor INTRODUCTION Between May of 1987 and December of 1992, Paul Bernardo raped or sexually assaulted at least eighteen women in Scarborough, Peel, and St. Catharines and killed three women in St. Catharines and Burlington. Paul Bernardo is a unique type of criminal, a determined, organized, mobile, sadistic serial rapist and killer who demonstrates the ability of such predators to strike in any Ontario community. The tragic history of this case, and similar cases from other countries, shows that these predators pose a unique challenge to the systemic investigative capacity of local law enforcement agencies throughout North America and Europe. The Bernardo case proves that Ontario is no exception. This is a review of the work done by local and provincial law enforcement and forensic agencies during the Bernardo investigations. The Bernardo case, like every similar investigation, had its share of human error. But this is not a story of human error or lack of dedication or investigative skill. It is a story of systemic failure. It is easy, knowing now that Bernardo was the rapist and the killer, to ask why he was not identified earlier for what he was. But the same question and the same problems have arisen in so many other similar tragedies in other countries. Virtually every interjurisdictional 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 Olsen 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 turn out to be the same, the mistakes the same, and the systemic failures the same. What is needed is a system of case management for major and interjurisdictional serial predator investigations, a system that corrects the defects demonstrated by this and so many similar cases. A case management system is needed that is based on co- operation, rather than rivalry, among law enforcement agencies. A case management system is needed that depends on specialized training, early recognition of linked offences, co-ordination of interdiscip linary and forensic resources, and some simple mechanisms to ensure unified management, accountability and co-ordination when serial predators cross police borders. There were times during the separate investigations of the Scarborough rapes and the St. Catharines rapes and murders that the different police forces might as well have been operating in different countries. As one Metro investigator said about the way the Scarborough rapist looked in 1992, before Bernardo was identified: “This boy is better than we might give him credit for, or he's fallen through the cracks.” Because of the systemic weaknesses and the inability of the different law enforcement agencies to pool their information and co-operate effectively, Bernardo fell through the cracks. The Bernardo case shows that motivation, investigative skill, and dedication are not enough. The work of the most dedicated, skilful, and highly motivated investigators and 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 agencies. Some of the systemic weaknesses have been identified and corrected in Ontario through changes in investigative procedures and advances in the application of forensic science. Other systemic weaknesses urgently require correction in order to guard against a tragic repetition of the problems that arose in the Bernardo investigations. Ontario has, in its existing law enforcement agencies, the essential capacity to respond effectively to another case like this, but only if certain components of those agencies are strengthened and only if systems are put in place to co-ordinate and manage the work of the different agencies. There must be a public recognition that these problems are not just problems for the police and law enforcement communities. They are problems for the community as a whole. A commitment to correct them is necessary in order to guard against another case like this. SUMMARY CHAPTER 1: INTRODUCTION The Bernardo case, like every similar investigation, had its share of human error. But this is not a story of human error or lack of dedication or investigative skill. It is a story of systemic failure. It is easy with hindsight, knowing now that Bernardo was the rapist and the killer, to ask why he was not identified earlier for what he was. But the same question and the same problems have arisen in so many similar tragedies in other countries, because serial predators pose a unique challenge to all law enforcement agencies. What is needed is a system of case management for major and inter-jurisdictional serial predator investigations, a system that corrects the defects demonstrated by this and so many similar cases. A case management system is needed that is based on co- operation, rather than rivalry, among law enforcement agencies. A case management system is needed that depends on specialized training, early recognition of linked offences, co-ordination of inter-disciplinary and forensic resources, and some simple mechanisms to ensure unified management, accountability and co-ordination when serial predators cross police borders. There were times during the separate investigations of the Scarborough rapes and the St. Catharines rapes and murders that the different police forces might as well have been operating in different countries. Because of the systemic weaknesses and the inability of the different law enforcement agencies to pool their information and co-operate effectively, Bernardo fell through the cracks. The Bernardo case shows that motivation, investigative skill, and dedication are not enough. The work of the most dedicated, skilful, and highly motivated investigators and 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 agencies. Some of the systemic weaknesses have been identified and corrected in Ontario through changes in investigative procedures and advances in the application of forensic science. Other systemic weaknesses urgently require correction in order to guard against a tragic repetition of the problems that arose in the Bernardo investigations. Ontario has, in its existing law enforcement agencies, the essential capacity to respond effectively to another case like this, but only if certain components of those agencies are strengthened and only if systems are put in place to co-ordinate and manage the work of the different agencies. CHAPTER 2: THE METROPOLITAN TORONTO POLICE INVESTIGATION Excellent investigative work was done by the Metropolitan Toronto Police Service during the Scarborough rape investigations. The difficulties faced by the investigators were enormous. Finding the rapist was like finding a needle in a haystack. There were thousands of tips including tips about suspects who looked very promising, to the extent that they devoured very significant investigative attention and resources. There was no lack of hard work, dedication, and investigative skill by individual officers. The investigative strategies were sound but the investigation was hampered by systemic weaknesses. There was no single person in charge at the beginning and until Superintendent Wolfe took over there was very little continuity of investigators. Conspicuous by its absence was any system whereby senior officers monitored and followed up the investigation and set time lines and ensured follow up. Although the DNA submission went into a black hole no alarm bells went off, even when it was returned untested by the CFS because there was no monitoring or supervisory system in place to ensure follow up with the CFS and high level co-ordination when necessary. There was no information system to ensure that all the tips called in about one suspect were put together and followed up when appropriate. The McNiff report was ignored for over two and a half years. It is discouraging that a report from an experienced officer should disappear into a hole like that. Even after other tips about Bernardo started to come in they were not put together. They were scattered throughout the files and index books and binders and desk drawers in a paper driven process described by one investigator as a nightmare. The final Smirnis tip about Bernardo, the third unrelated tip about the same suspect, was only followed up because of the persistence of the caller because there was no system to show immediately that it was the third separate tip about the same suspect. There was no consistent organized system for suspect classification and elimination. The problems that arose from lack of a case management system show that motivation, investigative skill, and dedication are not enough. The work of the most dedicated, skilful, and highly motivated investigators and supervisors can be defeated by the lack of an effective case management system. Communication between police forces was inadequate. There was at that time no ViCLAS automated crime linkage system in place. There was not even any system to ensure that the zone alert from the Henley Island rape was considered by the Metro investigators, a zone alert that would have suggested strongly to any experienced investigator that the Scarborough rapist was operating in St. Catharines. There was no system to put that information together with the fact that Bernardo, one of the Scarborough rape suspects, had moved to within a mile of the strikingly similar Henley Island rape. There was no system in place to recognize that the Scarborough rapist was still operating almost next door. There was no system to ensure full communication between Metro and GRT when GRT inquired about Bernardo as a Scarborough rape suspect. So far as Bernardo was concerned, the Metro force and the GRT might as well have been operating in different countries. The chase of a suspect from a stakeout on May 25, 1988, now believed to be Bernardo, and the rape by Bernardo four days later in Mississauga suggests that serial predators will move their base of operation to avoid a tightening police cordon. When the Scarborough rapes stopped, the investigation wound down and Metro put it on the back burner because of competing workload from other recent sexual assaults. There was no provincial system in place to recognize that serial predators are mobile, and to ensure that the investigation was continued vigorously after the local police force no longer considers it a priority. There was no system in place to recognize a wider public interest in tracking down the predator, wider than the interest of Metro taxpayers but just as high in priority for the residents of other communities at risk from the mobile serial predator. When Bernardo stopped stalking and raping in Toronto and started stalking and raping and killing in St. Catharines and Burlington he might as well have moved to another country for a fresh start. CHAPTER 3: THE CENTRE OF FORENSIC SCIENCES Bernardo's samples were submitted to the CFS on November 21, 1990 for conventional serology testing and, if the serology was right, for DNA testing. The serology results on December 13, 1990 showed that his serology was right for DNA testing. Thus on December 13, 1990, the CFS had a written request from Metro to test Bernardo's sample for DNA. Despite this request for DNA testing, effective December 13, 1990, Bernardo's test results were not obtained until February 1, 1993. It appears that Bernardo's DNA submission went into a black hole at the end of 1990. The overall delay between December 13, 1990 and February 1, 1993 was over 25 1/2 months. If the five suspect samples including Bernardo's had been given the highest priority on December 13, 1990, the DNA match to Bernardo could have been found in early January 1991. The CFS test of Bernardo's DNA sample on February 1, 1993 led to his arrest and prevented him from raping or killing again. The tragic converse of this fact is that Bernardo, during the 25 1/2 months his DNA was waiting to be tested, raped four young women and raped, tortured, and murdered two others. In hindsight, it is clear that these rapes and murders could have been prevented if Bernardo's DNA sample had been tested by the CFS within 30 or even 90 days of the December 13, 1990 serology test. The underlying reason for the delay was the limited capacity of the DNA lab during its start up period to conduct the labour intensive and time consuming RFLP DNA tests in a timely fashion in the face of a heavy work-load. This was compounded by the lack of any supervisory system within the Metro police department to ensure that the case was monitored and followed up vigorously at a higher level, and by communication problems between the CFS and the Metropolitan Toronto Police and within the CFS itself. At the heart of the tragedy was a systemic failure. There was no system to recognize that the Scarborough rapist was going to kill someone and to give the case a high level of co-ordination among all agencies involved in the investigation. For Metro and the CFS it was business as usual. The people working on the case had no mandate or direction to set everything else aside and stop the Scarborough rapist before he killed someone. After he stopped raping in Toronto, he naturally became a lower priority in Toronto. There was no system to recognize that a serial predator like Bernardo is not just a problem for Toronto but also for every other community he may move to when things get too hot for him at home. There was no system to recognize a wider