a. The tragic circumstances of the victims and the profound impact that has had on family, friends and their communities, as well as the abhorrence that these crimes have had in the minds and hearts of the public, in this region, in the country and to the world.
b. The protection of many women and children within marginalized communities, who, for many reasons and circumstances are, involved in the sex trade.
c. The structures and operation of policing authorities whose integrity and effectiveness have been questioned and the individual officers working within them whose reputations, careers and lives which have become implicated in these events.
d. The implications of these events in undermining the public’s confidence in the policing institutions and its leaders and officers in the discharge of its responsibilities into the future, within the community at large and especially with respect to those most vulnerable within marginalized communities.
It is often the case that systemic failures, as opposed to individual mistakes are the real cause of public disasters and the most appropriate focus of public inquiries. The public identification of individual mistakes or wrongdoing, while important, does not necessarily address the underlying problem. And unless the underlying problem is addressed, the same mistakes or wrongdoing will likely occur again if the system that permitted them is not fixed.
It is a mistake for a Royal Commissioner or public inquiry to focus exclusively on the search for scapegoats when the failure is really an institutional failure in the sense of a lack of appropriate systems, a lack of reasonable resources, a flawed institutional culture, or a breakdown in the machinery of accountability.
…But these problems do not go away simply because individuals have been implicated. These problems only go away when people change their systems, their attitude and the way that they do business.(“The Bernardo Investigation Review” in Allan Manson & David Mullan, eds., Commissions of Inquiry, Praise or Reappraise? at page 399)
While [systemic] issues may seem intangible at first, they often emerge in issues such as leadership, relationships, morale, past practices, and institutional “culture”. They are, essentially, any factors that transcend individual conduct but influence events, including individual conduct. They may impose rigidity in dealing with problems, or create “gaps” by discouraging cooperation and coordination. They may generate insensitivity and create barriers. They often do not appear to be offensive on their face but only upon understanding their influence on consequences. (page 386)
The Bernardo case shows that the motivation, investigative skill, and dedication are not enough. The work of the most dedicated, skilful, and highly motivated investigators, 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 systems. (page 333)
Virtually every inter-jurisdictional 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 Olson 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 turns out to be the same, the mistakes the same, and the systemic failures the same.”(page 1)
And later he says this:
The remarkable thing about serial predator investigations is that the same problems repeat themselves in every investigation with tragic frequency. We seem incapable of learning from previous experience. (page 254)
a. the difficult interface between the policing authorities and the marginalized community of these victims,
b. inter jurisdictional difficulties between different police forces, and
c. shortcomings in organizational systems.
Copyright © Missing Women Commission of Inquiry 2013