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Two men embrace during a vigil for victims in the wake of the sentencing of Canadian serial killer Bruce McArthur, in Toronto on Feb. 10, 2019.MARK BLINCH/Reuters

The Toronto Police Service needs a culture shift to deal with “profound systemic failures” that led to serial killer Bruce McArthur stalking the city’s LGBTQ community for nearly eight years before being caught, according to an external review into the police investigation.

The review, by retired Ontario Court of Appeal Justice Gloria Epstein, was launched in 2018 to examine how police handled the cases of eight men Mr. McArthur murdered between 2010 and 2017 in the city’s Gay Village. It was expanded to look at two cases from 2017: the botched search for Tess Richey, and Alloura Wells, a transgender woman whose death remains unexplained.

At more than 1,200 pages, Missing and Missed offers “an account of what went wrong, and how things could have been done differently,” according to Justice Epstein.

She identified a number of specific failures – instances where investigators could have identified Mr. McArthur as a suspect, or linked the related disappearances, but failed to do so.

But the failures were also systemic. LGBTQ people, sex workers, migrants, drug users, and other marginalized populations, Justice Epstein concluded, have been “overpoliced, underserviced, and discriminated against.”

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A mourner leaves a bouquet of flowers on a memorial in an alleyway where the body of Tess Richey was found, in the Church and Wellesley area of Toronto, on Dec. 7, 2017.Christopher Katsarov/For The Globe and Mail

Among her more than 150 recommendations, she calls for better community policing; an expanded role for civilian officers; more involvement for community groups in missing-persons investigations; better communication with the public; and improved record management.

Devolving responsibilities to civilian officers and community groups is necessary to address the “serious flaws” in how the city handles missing-persons cases, Justice Epstein found.

After Mr. McArthur’s arrest prompted an outcry, the Toronto Police Service set up a dedicated missing-persons unit. Justice Epstein found that unit, however, had only four investigators and “no realistic budget.”

“These deficiencies represent a painful reminder that the professed priority of these cases is not reflected in practice,” she wrote.

Numerous reports in Canada have highlighted the dangers of systemic discrimination against marginalized communities, and how information siloes can hobble investigations, but the calls to action have gone unaddressed. That includes the 1981 report into the Toronto bathhouse raids, the 1996 report into serial killer Paul Bernardo, and the 2012 inquiry into B.C. serial killer Robert Pickton.

The Toronto Police Service said Tuesday that they would implement every single recommendation.

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Toronto Police officers patrolling the Church and Wellesley St. area of Toronto on Dec. 7, 2017.Christopher Katsarov/For The Globe and Mail

Interim Police Chief James Ramer said the service would immediately double the complement of investigators assigned to the missing persons unit, dedicate liaison officers in every division to handle those cases, and hire more civilian officers responsible for missing-persons investigations.

Chief Ramer pleaded with marginalized communities in the city to “work with us,” promising to dedicate new resources to investigating violence against those populations.

“Nothing short of building that trust is acceptable,” Chief Ramer said. He said the force would work toward “reconciliation.”

When she analyzed the work done on individual missing-persons cases, Justice Epstein wrote that she was “struck” by the “randomness of what was done in each investigation.”

She found a lack of consistency and, often, a dismissive attitude. “The Toronto police didn’t even have a checklist of conventional steps to be taken in investigating such disappearances.” Some disappearances were given “no priority.”

Mark Sandler, a lawyer who worked on the review, described the saga as “a series of lost opportunities to identify and apprehend McArthur.”

Skandaraj Navaratnam, Abdulbasir Faizi and Majeed Kayhan disappeared between 2010 and 2012. The review found instances where police neglected to do basic searches of Mr. Navaratnam’s computer, a refusal to engage with neighbouring Peel Police’s inquiries on Mr. Faizi’s disappearance, and a failure to note Mr. Kayhan’s ties to the LGBTQ community, among other things.

In a 2013 interview with Mr. McArthur about the disappearances, police overlooked evidence that he lied about his relationship with Mr. Navaratnam, the report found.

When Soroush Mahmudi disappeared in 2015, his case was marked as “low” priority. Justice Epstein found investigators did not uncover Mr. Mahmudi’s past ties to the Village.

Kirushna Kumar Kanagaratnam, whose refugee claim was denied and who feared deportation, and Dean Lisowick, who was homeless at the time of his disappearance, vanished without being reported missing.

Justice Epstein found that police work often depended on advocacy and luck. It was because of dogged advocacy from an individual officer tasked with the disappearance of Selim Esen, and the friends and family of Andrew Kinsman, that police set up a dedicated task force in 2017.

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Poster for missing person Andrew Kinsman in Barbara Hall park in the Church St. neighbourhood of Toronto on Dec. 7, 2017.Christopher Katsarov/For The Globe and Mail

“Proper missing person investigations, however, should not depend on whose voices are the loudest in sounding the alarm,” Justice Epstein wrote.

The review found repeated instances where the Toronto Police Service did not trust the public or the community with crucial information. That includes “inaccurate and unfortunately misleading” comments from then-police chief Mark Saunders insisting there was no evidence of a serial killer, just weeks before Mr. McArthur’s arrest.

In other cases, such as the disappearance of Ms. Wells, the police did not notify the community even though they knew the body of a trans woman had been discovered.

“If the police are to act in true partnership with affected communities, they must provide those communities with basic knowledge to enable them to assist,” Justice Epstein found.

But there is a feeling in some of the communities affected by the case that the review, and the police response, is inadequate.

Maggie’s Sex Work Action Project, which counted Ms. Wells as a member, told The Globe and Mail that the report “minimizes the targeted harassment and discrimination sex workers face at the hands of local police.”

While Justice Epstein spoke glowingly of the group in her remarks on Tuesday, saying her visit to their offices was “life altering,” spokesperson Ellie Ade Kur told The Globe in a statement that more funding and training wouldn’t be enough to rectify the issues at hand. “Police officers that target, harass, abuse and violate sex workers in Toronto’s downtown east end have no shortage of opportunities for cultural sensitivity training, diversity and inclusion workshops.”

Justice Epstein and Mr. Sandler, for their part, said recommendations on sex work, drug use, and homelessness – which were at play in many of the investigations – fell outside their mandate. In their report, which includes specific steps on how it is to be implemented, they called for a significant culture shift inside the police force. “A more open and collaborative, and less insular and hierarchical, institution,” Justice Epstein wrote.

Justice Epstein reviewed a number of other missing-persons cases in the city. While Jon Riley is not named in the report, Justice Epstein wrote to the Ontario Provincial Police to urge a renewed look at his disappearance near Toronto’s Gay Village in 2013. His case remains unresolved.

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