On February 1, jurors at the coroner’s inquest into the shooting death of Sammy Yatim by a Toronto police officer more than a decade ago ruled his death was a homicide, and announced 63 recommendations to improve training and supports for those killed or seriously injured by law enforcement. Coroner’s inquests are mandatory for any death that occurs in Ontario involving the police. Unlike a criminal trial, they consider systemic issues related to police violence, not the criminal culpability of individual officers.

Just before midnight on July 26, 2013, then Constable James Forcillo, along with at least nine other Toronto police officers, responded to an emergency call about an individual threatening passengers with a knife on a city streetcar. Forcillo and his partner were the first to arrive on scene. Shortly thereafter, Forcillo began yelling commands at Yatim—“drop the knife! Drop the knife! Drop the fucking knife!” Less than a minute later, Forcillo opened fire on Yatim after the 18-year-old started to move toward the streetcar doors. Forcillo initially fired three bullets which knocked Yatim to the floor and ultimately killed him. After a five second pause, Forcillo fired six more bullets at Yatim’s supine body, striking him in the legs and lower torso.

Just under a month after the incident, Forcillo was charged with second-degree murder by Ontario’s police watchdog, the Special Investigations Unit (SIU). Following a preliminary hearing in which Ontario Chief Forensic Pathologist Michael Pollanen stated that it appeared Yatim was still alive during the second volley of six bullets, Crown prosecutors added a second charge of attempted murder strictly tied to that volley. While Forcillo was acquitted for the first volley that killed Yatim, he was found guilty for the second volley and sentenced to six years in federal prison. He was released on parole at the earliest possible date, two years into his sentence (which has now been served in full).

The stated purpose of a coroner’s inquest is to evaluate systemic and organizational factors that contributed to a lethal outcome. They are also an occasion to consider organizational changes to help prevent such outcomes in the future. Jurors can make recommendations to police services that they believe will deliver such change.

Yet, something troubling occurred during the Yatim inquest that could deter systemic change at the Toronto Police Service (TPS). During the proceedings, Forcillo was able to enter a new ‘official’ narrative of the incident. Through his testimony to the inquest, he suggested that he had not followed his training on the night he killed Yatim. This corresponds with statements made at his parole board hearing, in what could be perceived as a cynical effort to secure his release. This statement, while convenient and perhaps satisfying to some, contradicts what was found at criminal trial. It is also potentially a major roadblock to instituting much-needed reforms.

At trial, Forcillo argued he was following his training during his encounter with Yatim. Under cross examination, he stated that the Ontario Police College’s (OPC) “dynamic simulation scenario” training instructed him to adopt “a survivor mindset” that pits police officers against the public they are legally obliged to serve. Forcillo told prosecution counsel, “My job is to get that situation under control, to get things resolved, hopefully with no force involved for anybody, but that’s ultimately Mr. Yatim’s decision. But one way or the other… I’m going home at the end of the night.”

Two witnesses were called to give evidence about police training: TPS Deputy Chief Michael Federico was summoned by the prosecution, and OPC “defensive tactics” trainer Paul Bonner by the defense. While neither would testify directly to the images of Forcillo shouting commands at Yatim, neither contradicted the former officer’s account of his training. Forcillo was indeed, it seems, instructed to “win”—apparently at all costs.

For better or worse, this is what the jury found at trial. Forcillo had, at least in killing Yatim, followed his training. The jury found Forcillo not guilty for fatally shooting Yatim three times in the chest and arm. In other words, according to his own testimony, as well as that of Federico and Bonner, Forcillo had done as he was instructed.

The problem with accepting this new narrative (that Forcillo did not adhere to his training) is that it absolves the OPC, and the TPS broadly, for their responsibility in fostering a culture of which Forcillo’s actions were a by-product. Instead of owning up to this reality, Forcillo’s new testimony redefines his actions as an aberration—an unfortunate anomaly caused by a ‘bad apple.’

Police culture, or the prevailing attitudes, beliefs, and values of the TPS, were identified by former Supreme Court Justice Frank Iacobucci as a major obstacle to systemic reform in the profession of policing itself. It is this culture that is notorious for fostering hostile attitudes toward the public. If the TPS is successful in casting Forcillo as a deviation from the norm, and not a product of its internal training, culture, and formal value structure, these attitudes are unlikely to change.

According to the Tracking (In)Justice database, 28 people have been killed by TPS officers in use-of-force incidents since the murder of Yatim. Many of these, including Andrew Loku, Devon LaFleur, and Alex Wetlaufer, were killed while experiencing what witnesses or coroner’s inquests have identified as psychological crises. None of these incidents have resulted in criminal charges, let alone convictions, but it is equally important to note the consistent confluence of people in crisis and police violence. When the TPS and OPC instruct officers to believe that people in crisis pose elevated risk, it is difficult to envision how the Yatim inquest, like so many before it, could deliver much needed change.

There is evidence that Forcillo was poorly suited for policing. He was cautioned by supervisors about his brusque interactions with the public, and there is evidence he was quick to draw his gun. But a jury found Forcillo followed his training when he killed Yatim, and the TPS and OPC bear responsibility for that. By throwing himself on his sword, Forcillo defended the institution of policing and put forward a revisionist account of the killing. Regrettably, this outcome may only hinder the type of change required to revive the public’s trust in law enforcement.

Patrick G. Watson is an Assistant Professor in the Centre for Criminology and Socio-Legal Studies at the University of Toronto. He studies criminal trials and investigations into police use-of-force incidents.