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British Columbia’s police watchdog lacked clear procedures and training for investigators after an officer-involved shooting led to a man’s death, says a former RCMP superintendent who reviewed the agency’s operations.

Doug Kiloh said in a report that the Independent Investigations Office did not have a disciplined structure in a case where a 48-year-old distraught man was shot in the parking lot of a casino in New Westminster on Nov. 8, 2012.

Kiloh, who is also a former emergency response team member, said the agency learned the man could possibly be available for an interview after he was transferred from an intensive care unit but the office delayed speaking with him and failed to provide any rationale for that decision.

Mehrdad Bayrami died 10 days after being shot, and his daughter later told a coroner’s inquest he was taking medication for severe depression.

Kiloh said the man’s former partner, who he held hostage, was also not interviewed by the watchdog’s investigators, but was interviewed by police for about three hours.

As well, investigators did not interview a crisis negotiator liaison at the scene with police, said Kiloh, who he called a potentially significant witness.

“His notes, recollection and accuracy may have had the ability to independently confirm or refute comments, information, statements or orders provided by officers in the negotiation or command groups.”

Kiloh also called into question investigators’ handling of exhibits, saying the organization did not have a management system or an investigative manual.

“The lack of organizational direction appeared to lead to confusion among investigators with respect to managing exhibits and forensic material.”

The Independent Investigations Office report to Crown counsel contained mistakes and summaries were not reflective of the available evidence, Kiloh said, adding the Crown made several requests for more information, including input from a use-of-force expert whose report appeared to indicate an officer’s actions were in accordance with his training.

The officer with the Delta Police Department was charged with second-degree murder in October 2014.

However, the Crown entered a stay of proceedings in July 2015 following an independent review.

In March 2016, the Delta Police Association complained to the Independent Investigations Office about alleged defects in its investigation, resulting in it conducting a review before hiring Kiloh to report on its procedures.

“At the onset of the investigation, it appears that the IIO focused on officers who witnessed critical moments,” he said in the report, which was redacted to remove identifying information. “However, a full interview plan, including witness officers and civilians, was not documented, prioritized or sequenced, and I cannot confirm that potential evidentiary points were clearly articulated to investigators.

“I believe some opportunities were missed, which may have provided useful information or improved the overall investigative structure,” Kiloh said, adding investigators did not seize all available video from the casino and did not immediately analyze or document content they did obtain.

The report says the office has made significant improvements since its investigation, but Kiloh made 10 recommendations including more supervisory training involving critical thinking and decision making.

Ronald J. MacDonald, the office’s chief civilian director, said in a statement that changes include adopting a manual to guide investigators, along with rigorous training and a new approach in presenting cases to Crown counsel.

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