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An independent review of a Nova Scotia sexual-assault case that was dismissed as “unfounded” six weeks before the alleged attacker killed the complainant, a 58-year-old woman who lived next door, has found “serious deficiencies in the handling of every aspect” of the investigation.

Susan Butlin was shot and killed by Ernie Duggan in September, 2017 – six weeks after the RCMP dismissed her report that he had sexually assaulted her.

A new report by the Civilian Review and Complaints Commission for the RCMP found the case was “tainted by discredited myths and stereotypes about sexual assault and the expected behaviours of sexual assault victims” – noting that her death occurred just six months after The Globe and Mail drew attention to the problem in its landmark investigation, Unfounded.

The Globe’s analysis found that, on average, police in Canada were dismissing one in five sexual-assault claims as unfounded, meaning the investigator believed the allegation was either false or baseless – a figure dramatically higher than the unfounded rate for other crimes.

Earlier: Police dismiss 1 in 5 sexual assault claims as baseless

The RCMP’s Bible Hill detachment, which served Ms. Butlin’s community of Bayhead, had a sexual assault unfounded rate of 54 per cent, according to the watchdog report – the second highest in Canada.

In its report released Thursday, the RCMP watchdog found that the actions taken by the RCMP in response to the Unfounded series – and to their specific failings in Ms. Butlin’s case – nine years later “has not been sufficient.”

The report makes 79 non-binding recommendations to the RCMP, calling for both sweeping systemic changes to their handling of sexual-assault cases as well as a specific audit into the investigative history of the case’s lead investigator, Constable Patrick Crooks.

The RCMP accepted the majority of the recommendations, including launching an investigation into Constable Crooks’ case history. The service and the officers’ union did not immediately respond to questions from The Globe and Mail about the findings of the commission, which is an independent body that investigates complaints.

The commission’s investigation was spurred by a formal complaint filed on Sept. 27, 2021, by retired RCMP officer Cathy Mansley, after the April, 2020, mass shooting in Portapique, N.S., just an hour’s drive away from Bayhead.

The RCMP was heavily criticized for its response in Portapique, in which a case of intimate partner violence led to the deadliest mass shooting in Canadian history.

On Aug. 7, 2017, Ms. Butlin called the RCMP to report that her next-door neighbour, Mr. Duggan, had sexually assaulted her in early July, after she’d welcomed him in for a drink while babysitting her grandchildren.

After a 15-minute phone call, the initial responding officer concluded that her complaint – the specific details are redacted in the report – was unfounded. A second female officer also dismissed her concerns.

Ms. Butlin was told she could apply for the court to issue a peace bond, which would order Mr. Duggan to stay away from her.

Over the next month and a half, as she awaited her hearing on the peace bond application, concerns about Mr. Duggan escalated.

On Aug. 21, Mr. Duggan’s wife secretly called 911, according to the report, telling the dispatcher she feared her husband had a gun and was “going to kill the neighbour.” Her 911 call ended abruptly with yelling and crying, the report notes, after Mr. Duggan realized she was on the phone with police and kicked in the door of their home. She tossed her phone and fled the house, barefoot.

Officers responded and Mr. Duggan was charged with impaired driving. He was released the next morning without conditions.

“Despite this alarming sequence of events, and the specific information provided, the RCMP members did not take meaningful steps to assess or address the serious threat to Ms. Butlin’s safety,” the report says.

Five days later, on Aug. 26, Ms. Butlin called police again after receiving intimidating text messages from Mr. Duggan, pressuring her into abandoning the peace bond proceeding. The RCMP member who took her call determined the messages were not criminal in nature.

When Ms. Butlin went to court for her peace bond hearing on Aug. 30, the provincial court judge said her allegations seemed “well beyond a peace bond.” He adjourned the hearing, forwarding her application to the Crown Attorney’s office and urging police to investigate.

The RCMP did review the case, the report says, but “instead of using this opportunity to identify and correct the serious deficiencies in the sexual-assault investigation, the RCMP supervisors concurred with the conclusions initially reached, and continued to fail to appreciate the level of threat Ms. Butlin was facing.”

Three days before she was killed, she attended a meeting with police at the detachment where they informed her the investigation was officially closed.

By this point, according to the report, Ms. Butlin was sleeping with a baseball bat by her bed, and told family and friends that she feared for her life.

On the night of Sept. 17, Mr. Duggan showed up at Ms. Butlin’s home, calling out to her through the window. He had a shotgun, and when she came to the door, he fired one shot through the glass, killing her.

Mr. Duggan fled, and was arrested after a shootout with police in a nearby cemetery. He was charged with first-degree murder. He pleaded guilty in June, 2019, to second-degree murder and was sentenced to life in prison with no possibility of parole for 20 years.

The commission reviewed more than 20,000 pages of RCMP records, 25 hours of video and audio recordings, and conducted 36 interviews with witnesses, both police and civilian. The commission concluded that “almost all of the RCMP members involved in the matter lacked a basic understanding of the law of sexual assault.”

They identified systemic problems with the way the RCMP handles sexual-assault cases – despite pledges, in response to the Globe’s Unfounded investigation mere months before Ms. Butlin’s death, to do better.

“Many of the measures fell far short of the level of change required,” the report says. “Notably, no meaningful changes were made to the supervision structure for sexual-assault investigations.”

The RCMP received an interim copy of the report in 2024. Though the recommendations from the Commission are non-binding, the RCMP has agreed to adopt almost all of them, including to create specialized units to investigate sexual assault cases.

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