Probation officers missed opportunities monitoring murderer of 3 women, review finds
Probation and parole services speaker to address report later in coroner's inquest
Probation officers missed opportunities to more closely monitor the man who repeatedly defied his release conditions and went on to murder three Ottawa Valley women, a newly disclosed review shows.
On Sept. 22, 2015, Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam were all murdered in Renfrew County by the same man who had a known history of violence against women.
An ongoing coroner's inquest examining issues raised by the murders has heard there were more than 100 opportunities for intervention in the five years leading to their deaths in and around the community of Wilno.
"Although we know this was a perpetrator who was in a sense a ticking time bomb in the community, you can't help but feel a bit like maybe things would have been different if he had been more carefully supervised when he was released," said Kirsten Mercer, a lawyer representing End Violence Against Women Renfrew County during the inquest.
Basil Borutski was convicted of three counts of murder in a jury trial and sentenced to life in prison with no chance of parole for 70 years in 2017.
But the Supreme Court of Canada recently declared unconstitutional the 2011 Criminal Code provision that allowed judges to impose consecutive periods of parole ineligibility for multiple murderers, instead of concurrent periods.
The law had been applied in some of the country's most notorious cases, including Borutski's.
Five inquest jurors hearing from experts and first-hand witnesses are being tasked with recommending changes to policies and protocols to better protect and support survivors of intimate partner violence in rural communities in the future.
Contained in their bulky binders is a "death review" report written by two Ontario probation and parole managers just over a month after the murders.
The document outlines Borutski's dealings with probation officers from January 2013, when he was released from jail following an assault conviction tied to Warmerdam, to Sept. 4, 2015 — 18 days before his killing rampage.
In that timeframe, he was jailed a second time after brutally beating Kuzyk and again released under conditions mandating his participation in the Living Without Violence partner assault response (PAR) program.
He never took part in the program, giving probation officers a litany of excuses, and was never charged with breaching his conditions.
Moved closer to victim despite concerns
He was allowed to relocate closer to Warmerdam despite noted concern from local police, Crown attorneys and Ontario's Victim/Witness Assistance Program, according to the report, which has been made public because of the inquest.
Tighter supervision and more background information from people who knew him could have offered "a fairly clear picture of an offence cycle," the report said.
"In this case, sufficient information exists that allows us to see intervening in this cycle may be an effective way to head off future violence or at least minimize the impact," the probation managers wrote of their peers.
"There were opportunities missed that would have assisted with the overall case management, including enhancing victim and public safety, rehabilitation through intervention [and] holding the offender accountable."
CBC News reached out to the Ministry of the Solicitor General, which oversees probation services. The department said it would be inappropriate to comment at length as the inquest continues.
"The information presented during an inquest is for the jury to consider and all parties with standing have the opportunity to present their information and ask questions of witnesses," a spokesperson said.
"Once available, the ministry will closely examine the recommendations put forward by the jury, determine how best to address them and respond to the Office of the Chief Coroner directly."
A representative from Ontario's parole and probation services is expected to testify at the inquest next week.
(Unless otherwise specified, all quotes below are from the death review report.)
- Read the full death review report here or at the bottom of the story.
Deemed high risk months before murders
In April 2013, three months after being released on probation for threatening Warmerdam's family and assaulting a police officer, he was assessed as a low risk to reoffend.
But by February 2015 — after serving jail time for his hours-long beating of Kuzyk — his status was elevated to medium and then high risk due to "several domestic violence risk factors."
Looking back, given the "extreme" number of withdrawn charges against him and his "escalating pattern" of domestic abuse, it would have been reasonable to consider him in need of "intensive" supervision, according to the report.
Leighann Burns, a family lawyer who works with domestic violence survivors, said it's striking in the report to see the drop in noted contact between his probation officer and Warmerdam and Kuzyk in the lead up to the murders, when he was pursuing Culleton.
"This is when he's high-risk," she said.
Kuzyk was last contacted in late December 2014, shortly before he was released from jail for assaulting her. She reported no safety concerns.
Warmerdam was contacted in February 2015, seven months before her death. Three months earlier, when he was being released from jail, she told a probation officer she "was still fearful and wanted more protection."
She was told to contact the provincial Victim/Witness Assistance Program for help on how to seek a peace bond.
"This is just a piece of paper," said lawyer and women's advocate Pamela Cross during the second day of the inquest, holding up a restraining order.
Concerns about Warmerdam's safety had been flagged earlier.
In May 2013, Borutski told the probation service he was moving to Killaloe, Ont., about 21 kilometres northwest of Warmerdam's home.
While allowed under his probation order, the move closer to his victims sparked "backlash" from the Ontario Provincial Police in Killaloe, the Crown attorney's office and the Victim/Witness Assistance Program, according to the report.
Warmerdam attended a "high-risk review meeting" to discuss the move while Borutski's ex-wife was contacted "given the potential risk she continued to be in and the ongoing history of reported abuse she had experienced."
His ex-wife is not named in the report or inquest to protect her identity as a survivor of his abuse.
A sentencing judge ultimately backed the relocation, despite the "grave concerns" sounded.
"Nathalie Warmerdam was pleading with probation and parole for more information, better protections, steps to be taken," said Mercer, the lawyer representing End Violence Against Women Renfrew County during the inquest.
"She was terrified at the idea of him reporting to a PAR program across the street from where she worked. He never showed up for the program. But she lived in fear and she was trying to prevent that."
The inquest heard on Monday that Warmerdam tried to contact probation officers herself.
"She really struggled with getting information from probation and parole," testified Faye Cassista, a Renfrew County victims services worker who helped Warmderdam formulate a safety plan against him in the two years leading up to her murder. "It gave her a lot of anxiety."
While his probation supervisor in Pembroke initially made contact with the victims, "there was no followup at any time to gauge how they were managing" — even after Borutski reported spotting one of his victims in public, according to the report.
Substance abuse not adequately explored
One of the other takeaways from the review is that probation officers "certainly can't just rely on what the offender is telling you," said Burns, the family lawyer who works with survivors.
"You probably have to check with multiple collateral [sources] to see what the full picture of what's going on is."
Under a section titled "What went well," the review said his original probation officer did a good job of contacting his family doctor to try to learn about his substance abuse and mental health issues.
A probation officer in Pembroke did not allow him to check in over the phone, insisting on twice-monthly meetings in person.
But the review also highlighted a failure to connect him with a suite of sorely-needed supports, said psychologist Dr. Peter Jaffe, who reviewed nearly 10,000 documents in the case.
"This case is a tragic example of someone who needed much more than a PAR program," Jaffe testified last week. "He needed support in terms of addictions and mental health."
The topic of substance abuse was not thoroughly explored with him or people who knew him, even after Kuzyk flagged alcohol as a trigger for his brutal beating of her, according to the report. He was never referred to a substance abuse program.
He was assigned and referred to a mental health worker, but the report said their work wasn't consistent enough to address any mental health issues.
As for his failure to attend that PAR partner assault program, the review catalogues a multitude of excuses he gave — everything from confusion, to him saying the program would do no good "due to his anxiety."
"He clearly had no intention of attending the program," Mercer said.
"This is a guy that didn't have any trouble getting a car on the day of the murders … but claims that he wasn't able to access a vehicle in order to get to the program."
He was never charged with breaching his probation orders and officers didn't document why they didn't take any action, according to the report.
The inquest heard on Friday that probation officers, alongside police officers, have the power to lay such charges.
"What sits with me about this report is the sense that there actually might have been reason that he should have been back in jail on the day of the murders," Mercer said.
Calls for change
Dated just over a month after the 2015 murders of Warmerdam, Kuzyk and Culleton, the death review report outlined a number of recommendations, including making PAR more easily available to rural residents by launching a transportation strategy.
Mandatory or refresher training was called for on a number of fronts, including the reality of supervision in rural Ontario, the need for "thoughtful" release conditions, recognizing triggers and flags for high-risk violent offenders, strategic note-taking and "the crucial importance of obtaining detailed offender background information."
"It's a report that should have been sent to every probation officer in the province," Jaffe testified, adding that check-ins with high-risk intimate partner abusers should be weekly.
Burns and Mercer commended Ontario's probation and parole services for critically self-examining their work and recognizing changes were needed.
"It's exactly the kind of thing that we hope our institutions do when something goes wrong," Mercer said.
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With files from Kristy Nease