Winnipeg Police Chief Devon Clunis held a hastily called press conference today announcing a number of Police Service Communications Center staff have been placed on administrative leave after concerns surfaced regarding the handling of a 911 call connected to the recent murder at the Opera Night Club at 441 Main Street.

On May 4, 2014, at 1:39:36 am, staff at the Club contacted the 911 Communications Center reporting a number of people had been fighting outside of the establishment.  Some of these people were still present when staff requested Police attend as they felt the situation may escalate.

Police offered the following timeline;

  • 1:39:36 – staff at Opera Night Club call 911 reporting fight call
  • 1:42:30 – a call for service was generated and entered
  • 1:59:45 – the call for service was cancelled from within the 911 Communications Center
  • 2:03:13 – the 911 Communications Center received another call from the Night Club indicating a firearm had been discharged.  Numerous emergency services personnel were dispatched and responded
  • 2:06:04 – the first Police Unit arrives on scene

Clunis advised he’s ordered an internal investigation to examine the circumstances surrounding the cancellation of the first call for service.

The WPS Communications Center is almost entirely staffed by civilian members of the Police Service.  These civilian members perform many functions including the handling of emergency and non-emergency calls for service.  The highest ranking member of the Communications Center is a sworn Police Officer called the “Duty Officer.”  The Duty Officer normally holds the rank of Inspector however, the position may be filled with a Staff Sergeant in an acting capacity when circumstances dictate.

Clunis did not provide any information regarding the rank, position or number of staff members placed on administrative leave.

Media reports indicate the Duty Officer was one of the casualties.

The news sparked a media frenzy with crime reporters gravitating to some of the most controversial and speculative aspects of the situation.

  • Who cancelled the call?
  • Why was the call cancelled?
  • Could the murder have been prevented if the Police would have been dispatched to the call?

These questions are now the subject of an internal investigation that may take days or weeks to complete.

In the mean time, I’ll try to shed some light on some of the controversial and speculative media enquiries.

Why was the call cancelled?

There could be any number of reasons that contributed to the cancellation of the Opera Night Club call.  The reason why the 911 call was cancelled remains the subject of the internal investigation. Reasons that can contribute to the cancellation of these types of calls could be;

  • The staff call Police and indicate they are no longer required as the people causing the problem have left
  • A considerable amount of time passes since the call was entered and someone makes the decision to close the call
  • Police are dispatched, check the area and advise dispatch the problem appears to have resolved itself

It’s important to remember this incident happened after midnight on a Saturday night.  In Winnipeg, and most other major urban centres, Saturday nights can be extremely busy nights for the Police. The dispatch queue is often overwhelmed with dozens of calls for service putting immense pressure on Police, dispatchers and support staff.

It’s interesting to note the call was cancelled at precisely 1:59:45 am. The Opera Ultralounge closed that night at 2:00 am. Considering seventeen minutes and fifteen seconds (17.15) elapsed since the call was originally entered it’s not difficult to assume someone may have used their discretion to close the call under the belief Police were no longer required.

Duty Officers, Dispatchers and Call Takers are on the front lines in Winnipeg’s emergency command center.  When the Police queue is jumping someone has to take the responsibility to assess the priority of calls and in some cases, close calls where the Police may no longer be required.  If they don’t triage these calls, prime response cars can be needlessly tied up when someone has a legitimate emergency.  It’s a balancing act that comes with a certain degree of risk.

Considering the Opera Night Club was essentially closed and with no follow-up call from staff for almost eighteen (18) minutes, it’s tough to view the cancellation of the call as grossly negligent.  Of course, in light of what happened, a decision that may have been made in the best interests of the Police Service and public now comes under the microscope.

It’s unfortunate the focus of a criminal gang related murder now turns to an investigation into Police Communication Center Staff.  Especially when a killer remains on the loose.

Make no mistake, the WPS Homicide Unit is tirelessly working the case and chances are they’ll file this one in the solved column as they do with almost 90% of murder cases they catch.  The internal investigation now becomes a side-show and an annoying distraction for Homicide investigators.

There are those in the Police Service who question the need to make the internal investigation public?

Confederates of murder victim Rustom Paclipan may now view the Police as adversaries who contributed to the Homicide by neglecting to respond to the 911 call.  That hostility may prove to complicate things for the investigators.  That leads me to the other burning question;

Could the murder have been prevented if the Police would have been dispatched to the call?

While it’s possible, the answer requires wild speculation and consideration of literally dozens of scenarios that may or may not have played out.  You can play the “what if” game all you want on this one but no one will ever be able to say, with certainty, the murder could have been prevented if Police had been dispatched to the call.

The entire investigation now becomes an unfortunate quagmire.

Having been intimately involved in the last 911 controversy (circa 2000) I’m reminded a career in Law Enforcement is not for the faint of heart.


On February 16, 2000, William Dunlop brutally murdered his girlfriend Corrine McKeown and her sister Doreen Leclair after the women made several telephone calls to 911.  The case put the operations of the WPS 911 Communications Center squarely under the microscope and proved to be an extremely painful and difficult time for WPS Communications Center staff.

The incident contributed to significant changes to the 911 call center and the WPS domestic violence policy.


The Gazette – Steve Lambert montrealgazette.com “Winnipeg Police Chief Calls Investigation into Why 911 Call Cancelled” (Police Insider Quotes)


  1. James G Jewell

    Opposing opinions are always welcome.

    I learn much more from disagreement than agreement.

    Glad you found the site and appreciate your feedback.

    Thank you!

  2. James G Jewell

    Very much appreciate your perspective.

    Thank you for adding to the conversation.

  3. Morning!

    I did. My emotional reaction was to my opinion of a possible systemic problem (and my personal history with systemic problems here in Ontario), not you, or anyone elses comments. People have a right to draw possible conclusions based on history and facts. Police officers and lawyers (case history) do it all the time.

    In this case, it looks pretty cut and dry to me. That’s just how I see it. I don’t want it to be true.

    Just in case you were wondering, I ended up here after reading a yahoo news article (of this story) which linked to your website. I don’t normally comment on articles outside of Ontario, but I liked your website so much I couldn’t help myself.

  4. As to triage, that’s where we might look outside the organization to see how the assessments are done elsewhere in 911 response. Perhaps even outside of 911 into say, military command centres where a lot of experience has been gained in recent years into prioritizing emergency response. In the end though, standards of practice often provide only an illusion of control in systems that are complex, widely variable, and often unpredictable. Resilience is the key. It’s the leading edge in safety thinking for complex environments. When we can’t control the wide variability of events, we need an new model of adaptive thinking. It can be achieved with a disciplined team.

    You’re absolutely right, the idea of individual culpability is a canard. No one came to work that night to do a bad job. Malfeasance or nonfeasance are not factors here. Rules won’t keep us safe. Because you can’t have a rule for every situation, and writing a bunch more would be illusory.

  5. James G Jewell

    You might want to review Darrell Horns comments and my reply.

    It’s not as black and white as you might think.

    Thank you for commenting.

  6. James G Jewell

    Excellent points to consider and they add much to the conversation.

    The only question I have is, if there is no violation of standards or practise then can we still make a finding that “normalized deviance” is a contributory factor in this case.

    To clarify, if people working in the Communications Center have been given the rank, authority and discretionary powers to “triage” and close 911 calls then there is no deviance from standards or practise. It may be that, in the absence of a definitive policy or procedure, reviewing, assessing and closing calls for service under certain circumstances is the standard and practise that’s been in place.

    If that’s the case the issue becomes a systemic one for which the Police Service is liable and not the employees.

    It will be interesting to see how it all plays out.

  7. James G Jewell

    You make some valid points.

    Mike McIntyre wrote a piece in the Free Press the other day that provided some clarity on some of the issues you raise. The Police Insider was quoted extensively in the article. You can find it on The Police Insider Facebook page or the WFP website. The story was called, “Matter of Resources, Priorities.”

  8. James G Jewell

    A point I made on Alder’s show on CJOB.

    “The real villain in this case are not the 911 Communications Center Staff, the real villain is the street thug who took a gun to a night club and decided to play God with a young man’s life.”

    Let’s hope that message isn’t lost on the Police Chief when he determines the fate of his people.

  9. Are you kidding me? The call was cancelled internally. Clearly the onus of blame is on the 911 staff! Who told you that you could just opt to cancel calls at your own discretion anyways? All calls require investigation. The only persons who can cancel those calls are the people who made the original call, and guaranteed it won’t be in this case because the person who made the call told staff it was ESCALATING. If a second call had been made to 911, there would be no investigation to discuss. That’s how I know STAFF is to blame. Be interesting to see how this situation pans out. Lets hope ALL guilty parties are dealt with. We don’t need this kind of flagrant disregard for public safety in our system. Sickening.

  10. Hi James:

    As a patient safety investigator, I have looked at many instances of communication breakdown in various dispatch environments. I thought I’d pass on a few thoughts.

    Most people will have a real hard time understanding how this could happen. Human Factors Analysis would point to three well established phenomena. Normalized deviance is the first. In the absence of a negative outcome, the phenomena (cancelling of a response to a 911 call) is normalized, even though there may be associated jeopardy. The effect is exacerbated the more often calls are terminated with no negative consequence. And when considered in retrospect (outcome bias), the cancelling of the call takes on new and important meaning and leads almost inevitably to the statement “what were they thinking?” The jeopardy appears to remain in the protocols for changing the disposition of calls. The solutions are systemic. Punishing any particular operator might satisfy a lust for justice, but won’t keep any potential future victim safe.

    Normalized Deviance:
    “Over time, even egregious violations of standards of practice may become ‘normalized’ in complex systems”.

    Outcome Bias:
    “Outcome bias is an error made in evaluating the quality of a decision when the outcome of that decision is already known. Specifically, the outcome effect occurs when the same “behavior produce[s] more ethical condemnation when it happen[s] to produce bad rather than good outcome, even if the outcome is determined by chance.”

    Hindsight Bias:
    “People who know the outcome of a complex prior history of tangled, indeterminate events, remember that history as being much more determinant, leading ’inevitably’ to the outcome they already knew”

    Very few organizations are capable of rigorous self-examination. An internal police investigation will be suspect for many reasons. Disregarding the social/political implications, from a system safety standpoint, the most notable concern would be that the types of investigations police normally conduct are geared to identifying and prosecuting through evidence a guilty party. Unfortunately, these are not particularly effective safety investigations, which ideally are geared to identifying system issues and nominating solutions, as in this instance, based of best practices within 911 response communities. As well, experienced investigators will often will draw on expertise from high reliability domains outside of the one in question. As a starting point, the investigators should possess acquired discipline in safety investigations, and a thorough understanding of high reliability communication techniques and human factors analysis.

    best regards,
    Darrell Horn

  11. I wonder why the police chief would throw the 9/11 communication staff under the bus like this . Then to hear Chief Clunis say there is going to be an investigation to see what happened . Without knowing what took place . I just can’t figure this out . And the whole thing that ‘s over looked is the person who used a gun to kill and murder someone . I find it’s so strange we hear how downtown has all these cadets and police and on this night not one in sight ? As a citizen I find this whole situation to be not right . I can’t wait to see what comes of this. But in the end we can’t bring the person murdered back to life. So I expect some lip service and the earth will continue to rotate like it usually does.

  12. Tom Anderson

    And you may also recall from that 2000 case, one vicious guy caused all that trouble and some crime-fighters did go out and successufully bring him to justice. Yet in one of those twisted turns of unjust fate, the boss of Internal Affairs, was nominated and won an award as top cop in Manitoba, for his investigation of the wrongs commited by Comm Centre staff. Lets hope that doesn’t happen here because, just like the year 2000 case the real bad person, doesn’t work in the Comm Centre of the Winnipeg Police Service!

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