OPERATIONAL

REVIEW of
investigation into
the death of
Ms Holly Bartlett

Halifax Integrated
Criminal Investigation
Division

Case # 10-42394

Prepared by: Captain John L. Nolan
D/Sgt Robert Morais

Direction adjointe des enqutes et services
spcialiss
Section des enqutes

SPVQ


Date : July 23, 2014
Table of content


1. MANDATE ......................................................................................................................................... 2
2. BACKGROUND ............................................................................................................................... 3
3. METHODOLOGY ........................................................................................................................... 4
HRP ....................................................................................................................................................... 4
Family and Friends ......................................................................................................................... 4
4. ANALYSIS ........................................................................................................................................... 6
Crime Scene ...................................................................................................................................... 6
Investigation ...................................................................................................................................... 7
Autopsy and Medical Examiners Report .............................................................................. 9
Alcohol Consumption ................................................................................................................... 9
Polygraph ........................................................................................................................................ 10
5. CONCLUSION & RECOMMENDATIONS .................................................................. 11



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1. MANDATE

Given that the criminal investigation division in Halifax operates with members of both the Halifax Regional Police and the Royal
Canadian Mounted Police, the Quebec City Police service was asked to conduct an operational review into the death of Ms Holly Bartlett.
The Quebec City Police Service has a large major crimes section and is familiar with the operations of major case management involving
crimes against persons.
The mandate given to our agency is to provide a thorough review of the investigational steps and processes related to the
integrated HRP/RCMP investigation into the death of Ms. Bartlett. This mandate excludes re-opening the investigation. The reviewers had
full and unrestricted access to all of the investigative material and information related to the file in order to fulfill the mandate. The
communication of the said review is completed in the form of a final report outlining findings and recommendations, to the attention of the
HRP Chief of Police and the Officer in Charge of Halifax District RCMP.


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2. BACKGROUND

On March 27, 2010, Halifax Regional Police (HRP) attended the area under the MacKay Bridge, located on the northern portion
of the Halifax peninsula, where a female suffering from serious physical injuries had been located. She was identified as Holly Bartlett
(D.O.B. 1978-12-16). Ms. Bartlett later succumbed to her injuries and an investigation was undertaken by the Integrated HRP/RCMP
Criminal Investigation Division (CID) to determine the circumstances surrounding the incident. After a complete investigation, it was
determined that Ms. Bartlett, who was blind, had consumed a significant amount of alcohol and, while returning to her residence, had
fallen from a large concrete support pillar of the bridge. The injuries sustained in the fall resulted in her death.
In 2013, the immediate family of Ms. Bartlett contacted the Chief of Halifax Regional Police and the Officer in charge of Hal ifax
District RCMP to express their concern with the adequacy of the investigation. The main investigator in the file and her line officer met
with the family to answer their questions. Despite this meeting, the family still had concerns about the adequacy of the poli ce
investigation.
Questions and concerns raised by the Bartlett family and friends brought the investigation to the management teams of HRP
and Halifax District RCMP. A second look was then given to the case. Due to the highly unusual circumstances surrounding this matter,
management of both HRP and Halifax District RCMP have determined that an independent review into the investigation should be
conducted. The purpose of the operational review is to engage an outside agency to conduct a comprehensive review of the poli ce
investigation regarding the death of Ms. Bartlett, in order to address, where possible, the outstanding questions of the family.


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3. METHODOLOGY
On March 20, 2014 the Quebec City police service received the complete file from the Halifax regional police designated
liaison officer, Superintendent Jim Perrin.
The following weeks, the file was meticulously analysed in order to eventually complete a chronological table containing
actions that were taken by the integrated HRP/RCMP investigators. Simultaneously, taking in consideration the information available to
the HRP/RCMP investigators, the reviewers added to the said document actions that needed to be taken by the investigators at the time
the events unfolded. The purpose of this process is to ascertain that this investigation was complete as per major crimes unit standards.
On April 21, 2014 the reviewers travelled to Halifax in order to meet with officers involved in the case as well as family members
and friends. The following individuals were met and interviewed:
HRP
Jim Perrin (liaison)
Kim Robinson (file coordinator)
Paul Jessen (K-9 handler)
James Wasson (Ident officer)
Family and Friends


During the visit the reviewers walked the scene with officers in order to visualize the events. Although the scene has slightly
changed due to modifications made to render the area more secure, the reviewers were able to complete the visit with pictures of the
scene taken in 2010 by ident officer Wasson.

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During meetings with family and friends, the reviewers also obtained a copy of a letter sent by
l on July 16, 2013 addressed to the Halifax Regional Police Chief Jean-Michel Blais and to Supt. Roland Wells of the Halifax district
RCMP. In the said document, numerous concerns were raised in regards to the handling of the investigation.
Upon returning to Quebec City, the reviewers contacted the Montreal Forensic laboratory and the Quebec City K-9 unit in order
to clarify certain questionings resulting from the Halifax meetings.


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4. ANALYSIS

As mentioned previously, the purpose of this review is not to re-open the file but to provide an objective point of view based on
personal training and experience of the reviewers using procedures in place within the Quebec City police service major crimes unit. By
doing so, issues raised by the family in regards to the case will be addressed and hopefully answered.
Crime Scene
After reviewing the reports, walking the area and speaking with the K-9 officer who attended the scene, we believe that it was
covered adequately. The familys interrogation in regards to the reason why Hollys cane and the 5$ note were not found by the police
can be explained by the presence of a whirlwind between the building and the Mackay bridge. Indeed this is the location where the
items were later found. The said explanation was confirmed by the Quebec City K-9 unit. Searching an area with a K-9 dog does not
guarantee results and the animal can miss certain objects under certain circumstances. The reviewers were explained that an odour is
like an invisible cloud and with time gets bigger in volume. Furthermore, adding a wind factor increases the possibility of failure to locate
objects by the dog.
Knowing the nature of the item to be located and the fact that a white cane is fluorescent due to the reflective covering, the
Quebec City police would have searched the scene after sunset with a light source.
The reviewers believe that 2 hours for police to retrieve items found by citizens, and linked to a suspicious death case, is far
too lengthy.
The family mentioned that the location identified to them by Sgt Mark McKinley as where Holly was found was inconsistent with
report received by workers present when she was located. It is the reviewers opinion that the fact that Sgt McKinley could not identify the
exact location where Holly was found does not change the course of the investigation. Sgt McKinley was not the ident officer in charge of
processing the scene.
The cane and $5 bank note were properly processed for fingerprints by ident officer James Wasson with negative results.

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Investigation
During early discussions with Cst Kim Robinson admitted that she mistakenly believed that Holly lived in the
apartment building located on the corner of Novalea and Kencrest. The reviewers believe that this fact did not affect the investigation in
any way simply because Cst Robinsons role in the case was that of the file coordinator. Besides, upon reviewing Cst Robinsons
personal notes it is clearly indicated that Hollys residence was located at Northridge.
Concerns in regard to the quality of the canvassing performed by police were also raised by the family. More than often
canvassing the neighborhood is an excellent source of intelligence and information for any type of investigation. In the case of a
suspicious death, this should be conducted as soon as possible in order not to lose any potential witnesses. An investigator cannot limit
the canvassing of the area by attempting to only locate surveillance cameras. Locating surveillance cameras is only a small portion of
canvassing the area.
In this investigation, some residents were only canvassed on august 12, 2010, more than 4 months after the occurrence. At that
time, only 6 residents were met by the police. Considering the location where Holly was found, all residents of Kencrest, as well as
the residents along the possible routes journeyed by Holly that night, should have been rapidly met by the police officers.
was briefly interviewed by Cst Marriott on March 27, 2010 and provided information in
regards to next of kin and preliminary information on Holly. It is the reviewers opinion that should have been revisited by
investigators for a more thorough interview.
In the domain of major crimes investigations it is known that social medias and computers are valuable sources of information,
especially if investigators want to retrace the previous 24hrs of an individual. Hollys Facebook account and computer were analysed in
January and February 2014. It is the reviewers opinion that this task should have been completed during the first hours of the case.
Although we believe that was too emotionally involved to render an objective opinion in regards to Hollys
mobility and limitations, police should have consulted another member of CNIB in order to inquire about orientation skills of a blind
person and possible effects of the consumption of alcohol in regards to those skills. The scene could have been visited by the CNIB
member in order to assist in the investigation.

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The cab driver, is the last person that saw Holly uninjured and alive; should have been considered the most
important witness. was met at on March 27 2010, between 16h09 and 16h34. was interviewed for 25 mins in a place
that we feel was not appropriate for such interview. A more in depth interview should have been conducted at the police station.
On July 23, 2010, was interviewed a second time, this time by Sgt McKinley and Cst Robinson. This took place in
A video footage from a city bus which shows vehicle at the corner of Novalea and Kencrest was shown to This
intersection is not far from the location where Holly was found. It is the reviewers opinion that this interview should have been well
prepared and conducted at the police station. Investigators confronted






In this case, Hollys medical file was never asked for in order to find out what medical procedure was performed on her as well
as what medication was given to her at the hospital.
Based on the bus video, Hollys family believes that she was not delivered safely to her building. Upon reviewing the said
video, it can be determined that there is 1 minute and 11 seconds between the time cab leaves and the time the bus
departs. The fact that we do not see Holly on the video does not allow us to conclude that she was not dropped off in front of her place. 1
minute and 11 seconds is a short period of time to cover the distance between her front door and the location of the bus, more so for a
person under the influence of alcohol.
The fact that did not see Holly when decided to go back and check on her leaves us somewhat perplexed on
real efforts in locating her. However, this does not prove that she was not in trouble in the area.




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Some of Hollys personal belongings (cell phone, wallet and lip stick) were found by a resident near parking spot of
Hollys building at Northridge. Furthermore, on May 12, 2010, owner of the vehicle where the said objects
were located, confirmed to police that noticed on March 27,2010 , traces of handprints on the passenger side window of vehicle
as if someone had leaned on it. We cannot confirm that those were Hollys handprints but it is possible, even probable, that they were.
This information was never shared with the family.
Autopsy and Medical Examiners Report
The family is also concerned that an incomplete police investigation may have contributed to potentially misleading information
provided to the medical examiner. It is the reviewers knowledge that medical examiners are very well qualified and brilliant individuals
and the court recognizes them as expert witnesses. A medical examiners report is not based on police explanation of events only, but
on observations and facts noted during the autopsy. There are no reasons to have doubts in regards to the conclusions and findings of
when determined that the cause of death was blunt force injury to the head () attributable to a fall and that the
manner of death was accidental.
Alcohol Consumption
Private investigator alleges that Holly had only 6 alcoholic beverages in 6 hours. This does not correspond to the
blood sample analysis performed by the forensic laboratory nor to the scientific scenario of alcohol evacuation in the human body.
Hollys Blood alcohol level was on a sample taken at 10h30 on March 27, 2010. This would make her blood alcohol level between
at the time of the fall. In order to confirm certain aspect of blood evacuation in the human body, biologist and forensic
toxicologist from the Montreal forensic laboratory, was contacted. confirmed that any type of transfusion would
lower the blood alcohol level in the samples and in no circumstances would increase it. also confirmed that if a person has multiple
fractures it would not affect the blood analysis results. concludes by informing us that the only type of injury affecting alcohol
elimination is a serious injury to the liver or a punctured liver. This type of injury was not observed by the Medical examiner.
Evidence shows that had spent the entire day with Holly. is the one who called the cab after having a
discussion with Holly concerning the fact that she had too many drinks and should stop drinking. describes Hollys state as being
very intoxicated. Investigators rely on facts and on scientific evidence. They have to trust blood alcohol results obtained by qualified
judicial biologists and toxicologists that are recognized as expert witnesses during court proceedings.
Trying to establish a scenario of consumption of alcohol is a technique used by defence lawyers in order to raise a reasonable
doubt in court in order to have their client acquitted. We all know that this evaluation of blood alcohol level based on witness testimony
only is not scientific and, more often, far from the truth.

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Polygraph
The family is concerned about the fact that was never notified as to when the rescheduled polygraph test
would take place. The reviewers have to admit that involvement in this particular investigation was very useful in
providing valuable information; nevertheless was not a member of the family. If the Quebec City police service had been in charge of
this case, would not have been informed of any results of the investigation, nor be allowed, in any circumstances, to be present during
the polygraph test.
Information was given to by Cst Robinson following the results of the polygraph test to the effect that the
polygraph examiner Blencowe described . Such statement was
never uttered by Mr. Blencowe. In fact the polygraph examiner stated that














?


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5. CONCLUSION & RECOMMENDATIONS

Ms Holly Bartletts death is without a doubt heartbreaking. However, based on the evidence presented to the reviewers, it is
accidental. No evidence presented to us can allow the reviewers to conclude that her death resulted from a criminal act. Indeed,
behavior the night of the events as well as the various versions provided to the police might be unacceptable for most of us.
Lets keep in mind that dropped off Holly at her residence.

The Quebec City police service major crimes unit would have accepted the results from the polygraph examination and would
have dismissed the possibility that Holly had been dropped off by at the corner of Kencrest and Novalea.
Of course some questions remain unanswered:
1. How did Holly react and what was her thought processes?
2. Why wasnt she wearing her gloves?
3. Why travel away from her residence?
4. What route did she take?

In all cases of suspicious death, like this one, the beginning of the investigation is crucial and no lead can be ignored. Meeting
the last person that saw Holly unarmed and alive is the key to the beginning of the investigation. should not have been met at
to obtain initial version and based on our experience; a valuable interview can in no way be conducted in 25 minutes.
On August 27, 2010,
Seeking potential witnesses has to be done during the first hours of the investigation; undeniably few buildings were visited by
police and a search for potential surveillance cameras was completed but the door to door was not completely executed. We
recommend that a canvassing form be created by police agencies in order to tally this important aspect of investigating.
To the best of our knowledge and after reviewing the entire file, it is still impossible for the reviewers to detail all actions taken
by Holly that night. Nevertheless, we can only notice the absence of any evidence which would make us believe that Hollys death
resulted from a criminal offence.
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Pretending to know exactly what happened that night appears to us as a lack of open-minded attitude towards the
investigation. All doors should have been kept open until the end of the investigation.

We cannot keep under silence the incident where Hollys family requested to attend the location where Holly was found. A
different day than the day of Hollys funerals would have been more proper. As far as we are concerned, this gives the perception of a
lack of empathy on Sgt McKinleys part. Then again the reviewers did not meet with Sgt Mckinley since this process was an operational
review and not an inquiry into the quality of the interactions between the police and the family.

The reviewers were made aware that information from a psychic (medium) was given to police and that investigators acted on
it. The Quebec police service major crime unit does not act on information provided by mediums based on the fact that this information is
not considered as real evidence and, most importantly, it cant be used in court.

Communication is a key issue in any investigation, especially while communicating with the family. We recommend for future
major cases involving communication with family members that a family liaison officer be designated and that all information obtained
from and given to the family be processed through this individual. This procedure would allow evaluating and controlling the accuracy of
the information provided to the family and prevent any parallel investigation conducted by citizens with only good intentions in mind.

Considering the level of intoxication of Holly Bartlett;
Considering that dropped off Holly Bartlett at her residence;
Considering the absence of any injuries on Hollys body which would suggest that she had been the victim of an assault;
Considering the initiative of volunteers who met with 97 residents and still no witnesses of the incident were found;
Considering that accidents happen regularly to individuals that are not visually impaired and under the influence of alcohol,
this means it can also happen to a visually impaired person under the influence of alcohol;
Considering that no evidence leads us to believe that a criminal offence was committed in regards to Hollys death;
The Quebec City police service would have concluded the file as accidental death only after evaluating and investigating all
the possible avenues.
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Only then, the family would have been met by the liaison officer and the lead investigator to inform them of the results of the
investigation. At that time the family would have been informed that there is no evidence suggesting that Holly had been the victim of a
crime, which eventually led to her death. We would also unfortunately communicate to them the impossibility to determine accurately the
moments prior to her fall.

Respectfully submitted,




John L Nolan Robert Morais
Captain Detective/ SGT