Jury at triple-homicide inquest makes 86 recommendations to prevent intimate partner violence

The Ontario government is being called upon to improve the way its probation service monitors high-risk perpetrators of intimate partner violence, following a three-week coroner's inquest into the murder of three women in 2015.

Probation service asked to tighten monitoring of high-risk abusers

From left: Anastasia Kuzyk, Nathalie Warmerdam and Carol Culleton were murdered in and around Renfrew County west of Ottawa on Sept. 22, 2015. (Photo illustration/CBC)

The Ontario government is being called upon to improve the way its probation service monitors high-risk perpetrators of intimate partner violence (IPV), following a three-week coroner's inquest that asked jurors to suggest ways to help prevent gender-based violence.

It's one of 86 recommendations, many of them sweeping in scope, made by the jury at the inquest into the 2015 murders of three women — Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam — in and around rural Renfrew County. 

The man responsible repeatedly defied his probation order without reprimand and had a known history of gender-based violence. Basil Borutski was convicted of three counts of murder and is in prison. 

The inquest began on June 6 in Pembroke, Ont., northeast of where the murders occurred. Jurors heard not only about the day of the murders but also about the systemic challenges that led up to them. 

In particular, the inquest heard that Ontario's probation service missed opportunities to more closely monitor the man while he was out on probation following prior convictions for intimate partner violence against two of his victims. 

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Probation officers also failed to take action when the man gave excuse after excuse for not attending a program meant to treat men who commit intimate partner violence.

The inquest also heard about the importance of listening to survivors and incorporating their input into the monitoring of abusers.

Warmerdam told a probation officer early on that the murderer got violent when he was drinking, but he was never referred to a substance abuse program. He was also allowed to move closer to Warmerdam at one point, despite her concerns for her safety. 

Contact between probation officers and Kuzyk, who had been brutally beaten by the man, also stopped in the months leading up to the murders, when the man was deemed a high risk to reoffend. This is also when he began stalking Carol Culleton, his third fatal victim. 

"We're not here to place blame on any individuals who may have been involved. But I think we've really found some areas that will be very good for improvement," said Valerie Warmerdam, the daughter of Nathalie Warmerdam. 

The jury has called on the probation service to review its mandate in order to prioritize victim safety — including regular contact with survivors — to enforce the law when conditions are breached, and to improve efforts to rehabilitate offenders.

Treating offenders early

Experts testifying at the inquest also emphasized the need to educate and treat abusers before they are ever charged or enter the criminal justice system. 

The murderer's first conviction related to intimate partner violence was in 1977, when he was 20 years old.

The jury is recommending education programs for students in primary school and above about the signs of gender-based violence, including subtler non-physical forms of abuse known as coercive control. 

Valerie Warmerdam said the murderer, who lived with the family for two years, needed people to flag his behaviour. 

"He needed to have his community tell him that there was a problem and that he needed to get help to change it. And I think those conversations needed to happen 20 years before," she said. 

Valerie Warmerdam, the daughter of Nathalie Warmerdam, has been participating in the coroner's inquest. It heard testimony over three weeks before the jury made its recommendations. (Guy Quenneville/CBC)

There should also be improved collaboration between corrections and probation staff when planning an abuser's rehabilitation upon release, the jury said. 

Shelters, sexual assault centres and other organizations that help survivors need to receive more from the province, the jury said. The inquest heard that per-capita funding shortchanges rural areas where the need for services is high despite their relatively small populations. 

Reviewing mandatory charging

A number of policies are also being recommended for review or consideration. 

The killer was not under electronic monitoring at the time of the murders, but the jury has asked the province to explore the idea of making people charged or convicted of IPV wear electronic bracelets. That would alert police if a perpetrator moved to a restricted area near a survivor. 

Warmerdam had a panic button supplied by Victim Services in Renfrew County, but was not able to get to it in time, the inquest has heard. 

The practice of mandatory charging, where police are required to charge someone with assault if they feel they have reasonable grounds to do so, should also be reviewed for any unintended consequences, the jury said.

The inquest heard that some survivors fear they may suffer more abuse if their partner suspects they're responsible for the charges.

The jury also wants the province to consider allowing police services to disclose information about a person's history of IPV to new or future partners. Saskatchewan, Alberta and Manitoba have already adopted similar laws.

Some of the other ideas put forward by the jury include:

  • Funding for safe rooms in the homes of survivors of high-risk perpetrators.
  • Including psychological abuse, also known as coercive control, as well as femicide in the Criminal Code of Canada.
  • Formally declaring intimate partner violence an epidemic.
  • Allowing victims of abuse to testify in court via video.
  • Establishing a royal commission to review and recommend changes to the criminal justice system "to make it more victim-centric [and] more responsive to root causes of crime." 

The need for follow-through

None of the jury's recommendations to the Ontario government are binding. 

That's why the jury also called for an oversight body that will monitor steps taken by the government to act on the recommendations. 

Under another proposed change, recipients of recommendations stemming from a coroner's inquest would be required by law to report back on why they did not take action in certain areas.

After a news conference Tuesday, inquest participants will gather at a monument in nearby Petawawa, Ont., that commemorates Renfrew County women who have been murdered by men. 

Construction on a similar monument in Barry's Bay, Ont., is scheduled to begin in August, according to End Violence Against Women Renfrew County.


Guy Quenneville

Reporter at CBC Ottawa

Guy Quenneville is a reporter at CBC Ottawa. He can be reached at