The Regina Police Service released a redacted copy of the “Independent File Review: Sudden Death Investigation of Nadine Machiskinic” on Thursday.
Regina Police Service originally received the report in November of 2018. Police said it would not make the results of the report public, which was met with backlash from Machiskinic’s family.
Machiskinic fell to her death in a laundry chute in Regina's Delta Hotel in January 2015. Her death was ruled an accident, but a jury at a coroner's inquest changed that ruling to undetermined.
The review, conducted by RCMP’s “F” Division, states, “The reviewers do not support the sudden death investigation of Nadine Machinskinic as meeting the standards of a professional, sudden death investigation.”
The independent review, commissioned by police Chief Evan Bray, says that the finding was concluded as a result of the “absence of a Command Triangle, and an effective Case Management system to manage the investigation.”
The Regina Police Service wanted the review conducted in the spirit of transparency.
The review includes 14 recommendations to improve investigations within the police service. RPS says most of those recommendations have been implemented.
According to the review, there are nine major case management principles, several of which the investigation into Machinkisnic’s death lacked.
Command Triangle
A command triangle, the core of major case management according to the RCMP review, is comprised of a team commander, primary investigator, and file coordinator. The team commander is responsible for overseeing the investigation, the primary investigator manages the investigations speed and flow and the file coordinator manages investigative work and product disclosure.
The review states that there was no evidence indicating that a command triangle was ever established or considered in this case.
Case Management
In terms of case management, the review also states there is, save for one exception, no evidence to support the use of “any formal tasking or tracking mechanism in which to assign investigative tasks or monitor their completion.”
Accountability Mechanisms
The review specifically mentions accountability mechanisms saying the lack of which were detrimental to the case, in addition to a lack of both a command triangle and case management system.
“It is the belief of the reviewers that accountability measures were inadequate during the investigation and that application of the command triangle and an improved case management system could have avoided pitfalls and promoted more timely collection of evidence to the benefit of the investigation and stakeholders.”
According to the review summary, despite these findings, the investigation did demonstrate critical thinking and best practice in some aspects.
Communication
According to the review there was little to no evidence presented to RCMP that indicate that investigational briefings existed. These briefings consist of formal discussions that exist to maintain accountability from various contributors. These briefing would, in theory, be led by the command triangle.
Leadership and teambuilding
The review states there was no evidence to demonstrate that any one investigator ever took on a leadership role. “It did not appear that anyone was tasked as the primary investigator or file coordinator to ensure investigational tasks were identified, assigned or reviewed as was needed to ensure completion and quality control.”
Managerial considerations
Based on material provided for the review, the review states that there was nothing found to clarify what role management played in the investigation, or how much influence they had. In addition, there was no evidence to indicate managerial engagement, review or oversight in the investigation save for travel approval late in the investigation.
The review identifies a single exception: a notebook entry that mentions the presence of management at meetings with the coroner’s office.
Crime solving strategies and assessment of investigative techniques
- Medical
Though there is evidence to indicate that investigators read Machiskinic’s records at the hospital but it did not seem that a copy was ever requested by the coroner.
The review states it is not expected that the review of these records by the coroner would have changed the direction of the investigation, but for sake of thoroughness, all medical records should be obtained in the future, during investigations.
- Delta Hotel
The review identifies that due to the delay in police notification, exceptional challenges were presented to investigators from the onset. Police were not dispatched to the hotel upon the discovery of Machiskinic on January 10, 2015. The opportunity to immediately assess the scene and form their own ideas of what transpired was not afforded to Regina Police. The delay in notification also prevented police from securing the laundry room and tenth floor for forensic examination, and allowed for Machiskinic’s personal items to become lost.
There are a number of other points made with reference to the role of the hotel in the investigation. Gaps in critical surveillance video from the Delta Hotel occurred, including “inoperability of several surveillance cameras led to poor coverage of the facility that would otherwise be expected to shed light on the incident.”
The investigation also states that incident reports filled out by Delta Hotel employees were unreliable.
Based on investigative material, it’s believed that a hotel guest list was requested by investigators on January 12, 2015. That list was not handed over to police until a second formal request was filed on February 3, 2016. Once that list was given to police, it had been partially purged.
Delta Hotel director of operations Ian Johnson told police that the only room occupied on the tenth floor on the morning in question was room 1008. It was requested that the room remain untouched and locked; however forensic investigators said that when he arrived the room was locked but the manner was not established.
The review recommends that “greater efforts should have been undertaken to preserve the integrity of these potential and actual scenes.”
- Cell phone examination
The review also details a lack of clarity around when Machiskinic’s cellphone was examined which caused a delay in police requesting surveillance video from Casino Regina, resulting in the video from the night in question having already been purged.
Machiskinic’scell phone was seized by forensic identification on Janunary 12, 2015, two days after her death. The item was turned over to investigators on January 14. The review says material provided to them did not clearly state wether the cell phone was examine immediatley after it was obtained by investigators. Based on documentation the reviwers believe the cell phone was not examined until January 28.
"It is the opinion of the reviewers that, had the cell phone been examined immediatley upon its seizure, investgators may have learned of Ms. Machiskinic's attendance at Casino Regina earlier in the investigation. This may have produced an opprotunity to view and seize surveillance video from the casino which may have shed light on MS Machinskinic's activites and/or associates prior to her death."
Witness statements
“None of the witness interviews taken during the course of the investigation were transcribed,” the review reads. It goes on to say that the interviews reflected best practices, but reviewers believe two handwritten statements provided by EMS who treated Machiskinic should have been followed up on.
There was a significant delay in the interview of Delta Hotel employees.
Ethical considerations
The review found no breach of ethics.
Read the full review:
RCMP review into death of Nadine Machiskinic by Saskatchewan Web on Scribd
