Introduction

[1] Susan Butlin, a 58-year-old woman, lived alone, next door to Ernie Ross "Junior" Duggan and his spouse, in the community of Bayhead, situated in Colchester County, Nova Scotia. Ms. Butlin and the Duggan family had been neighbours for nearly two decades, forging a good friendship. However, this friendship deteriorated significantly during the summer of 2017.

[2] On September 17, 2017, Mr. Duggan murdered Ms. Butlin in her home.

[3] Six weeks before, Ms. Butlin had called 911 to report that Mr. Duggan had sexually assaulted her in early July 2017. RCMP members from the Bible Hill RCMP Detachment took a statement from Ms. Butlin, but did not pursue charges, believing that her complaint was unfounded.

[4] In the weeks leading up to the murder, Ms. Butlin and others contacted the RCMP to report concerns about the escalating situation with Mr. Duggan.

[5] The Civilian Review and Complaints Commission for the RCMP (the Commission) conducted an in-depth investigation into the RCMP's response to the complaints and concerns related to Ms. Butlin and found serious deficiencies in the handling of every aspect of Ms. Butlin's case.

[6] In February 2017, just six months before Ms. Butlin reported her sexual assault, the Globe and Mail published an investigative series on police handling of sexual assault cases. The resulting public scrutiny prompted the RCMP to make efforts to enhance sexual assault investigations, which included implementing new training and other initiatives. The Commission reviewed the implementation of these measures to assess whether they address the deficiencies observed in Ms. Butlin's case. The Commission found that, despite much work done by dedicated individuals within the organization, these measures were insufficient.

[7] Having reviewed in-depth the issues observed in Ms. Butlin's case, as well as the measures implemented by the RCMP so far, the Commission has concluded that specialized units are needed to ensure that sexual assault complaints are investigated and supervised adequately. The Commission recommends the creation of such a specialized unit in each RCMP division. The Commission also makes recommendations to strengthen the other initiatives implemented by the RCMP, as well as to address the deficiencies observed in the handling of Ms. Butlin's case.

[8] The Commission extends its sincere condolences to Ms. Butlin's family and friends for their tragic loss.

[9] The Commission hopes that the recommended measures in this report will prevent other sexual assault victims from experiencing treatment like that received by Ms. Butlin from the RCMP in the future.

1. The Commission's Investigation

[10] The Commission is an independent agency that investigates and reviews complaints made by the public about RCMP member conduct. It is not part of the RCMP.

[11] On September 27, 2021, the Commission received a written complaint from Cathy Mansley, a retired member of the RCMP with over 24 years of service. She wrote that she had recently been made aware of Ms. Butlin's death and of the events leading up to it, through media reports that discussed this incident in the wake of the Portapique mass killing.^{Footnote 1}

[12] In her complaint, Ms. Mansley asked the Commission to investigate Ms. Butlin's case, as she believed the matter had not been handled appropriately by the RCMP.

[13] Ms. Butlin's three sons (L. M., N. M., and B. M.) authorized Ms. Mansley to launch the public complaint.

[14] The Commission, in turn, extended the time limit for making a complaint, pursuant to section 45.53(6) of the Royal Canadian Mounted Police Act (RCMP Act) due to the seriousness of the issues raised.

[15] On June 2, 2022, pursuant to section 45.59(1) of the RCMP Act, the Commission's Chairperson initiated a complaint into the RCMP's investigation of and response to Ms. Butlin's complaints and concerns about her safety. The Chairperson also determined that, pursuant to section 45.66(1) of the RCMP Act, it was in the public interest for the Commission to conduct the investigation. She directed that the investigation address the following issues:

• The circumstances leading up to Ms. Butlin's death, including relevant calls for service to the RCMP;
• Whether the response of the RCMP to Ms. Butlin's complaint of sexual assault was reasonable. In particular, whether sexual assault myths and/or stereotypes influenced the RCMP members' response and whether the RCMP members understood and applied the law of consent during the investigation;
• Whether the conduct of the RCMP members involved in investigating and responding to the threat reported by Mr. Duggan's spouse and to Ms. Butlin's concerns about her safety in the period leading up to her death was reasonable;
• Whether current RCMP national and divisional policies, procedures and guidelines pertaining to sexual assault investigations are adequate;
• Whether current RCMP national and divisional training pertaining to sexual assault investigations is adequate;
• Whether the supervision model in "H" Division of general duty RCMP members carrying out sexual assault and other investigations is adequate;
• The actions taken by the RCMP to review Ms. Butlin's case and to identify and remedy any deficiencies in the RCMP's handling of the case; and
• The degree to which the RCMP has implemented various initiatives to improve the quality of sexual assault investigations, including whether those initiatives are sufficient to address any deficiencies identified in Ms. Butlin's case.

[16] Throughout its investigation, the Commission reviewed over 20,000 pages of police records, documentary evidence, and other relevant information, as well as approximately 25 hours of audio recordings of police interviews. Commission investigators conducted interviews with 36 witnesses, 23 of whom were specifically interviewed regarding the handling of Ms. Butlin's case. These interviews included Ms. Butlin's friends and family, as well as RCMP subject members. Commission investigators also conducted interviews with RCMP members involved in the implementation of various initiatives related to the conduct of sexual assault investigations, as well as victim advocates and other civilian witnesses with expertise in sexual assault investigations.

[17] Eleven RCMP members were identified as subject members for the investigation. Of those, three members voluntarily attended interviews with Commission investigators, and one member agreed to provide responses to written questions. The seven remaining subject members declined to provide statements or failed to respond to correspondence from the Commission. The Commission exercised its power under section 45.65(1) of the RCMP Act to summon the attendance of those members and compel them to provide evidence.

[18] The RCMP was receptive to the Commission's multiple requests for relevant materials and follow up questions throughout the investigation. Replies were timely and generally met the service standard for provision of materials agreed to in the RCMP – CRCC Memorandum of Understanding.^{Footnote 2}

[19] There were some instances where records relevant to the complaint had been previously destroyed. The RCMP informed the Commission that some of the recordings and radio communications of relevance to the investigation had been destroyed prior to the launch of the Commission's investigation, pursuant to RCMP policy providing for a two-year retention period for this information.^{Footnote 3} The RCMP had also destroyed relevant email communications between subject members, as emails are automatically deleted after 90 days. Nevertheless, the Commission was able to obtain sufficient information to conduct its investigation.

[20] This report outlines the results of the Commission's investigation and its associated findings and recommendations.