Zimmer, Laval Donovan

Contributing factors

• repeated tasering and arrest the day prior to death
• mental health history not recorded on police database (QPrime)
• lack of call-taker training in de-escalation and mental health response
• absence of safer alternatives to police dispatch (PoliceLink not offered, negotiators not deployed)
• lack of real-time information sharing between communications and attending officers
• previous Emergency Examination Order not flagged in police records
• rapid escalation upon police arrival

Coroner's recommendations

1. The recommendations phase of the inquest should examine ways for QPS to deal with nuisance callers experiencing mental illness without placing safety of police and public at risk
2. Consider earlier referral to PoliceLink, use of trained negotiators, or shift supervisor discretion in dealing with nuisance callers
3. Evaluate use of technical capability to transfer 000 calls directly to PoliceLink call-takers
4. Review training for Communications Coordinators regarding PoliceLink referral options
5. Examine call-taker training to improve de-escalation skills with callers experiencing mental health crises
6. Assess whether mental health information should be recorded and flagged on QPrime to assist police decision-making
7. Consider whether training regarding handcuff application after use of lethal force should be modified
8. Review post-incident protocols for officer separation and interview timing after critical incidents
9. Examine whether officers should be permitted to remove biological contamination before forensic testing