For a variety of reasons, investigators found, different officers in separate investigations overlooked evidence and leads connecting McArthur, who is now 69, to three of his victims. They also dismissed as irrelevant his 2003 conviction for hitting a man over the head with a lead pipe.
"There was institutional resistance to the notion that these cases night be linked and that a serial killer might be preying on" Toronto's LGBTQ community, Gloria Epstein, a retired justice of the Ontario Court of Appeal who headed the inquiry, wrote in its report released Tuesday. "This systemic failure is perhaps the most troubling."
At a news conference, Epstein said that the "systems and practices that were in place discriminate" against the LGBTQ community and against "marginalised and vulnerable communities generally."
Epstein said that it was not possible for her to determine whether McArthur, a landscaper who was sentenced to life in prison, would have been caught earlier had there not been so many missteps and shortcomings in the investigations.
But Mark Sandler, the review's lawyer, told reporters that "there were a series of lost opportunities to apprehend and identify McArthur."
The report, commissioned by the board that oversees the Toronto police, also strongly criticized Mark Saunders, who stepped down as the city's chief of police last year, for publicly dismissing concerns that a serial killer was targeting Toronto's gay community, finding that he corroded public confidence within that group.
At the top of the 151 recommendations in the four-volume report is a proposal that police turn over some missing persons investigations to public health and social services agencies and nonprofit community groups.
The report also proposes that within the police force, missing person cases be coordinated by civilians and be centralised rather than spread out through individual precincts. And it calls for Toronto's police to support friends and family members of missing people.
Shakir Rahim, the former vice chairman of the Alliance for South Asian AIDS Prevention, said that the report "vindicates the community's concerns that there were systemic failures in the investigation."
But Rahim, whose group was among those that criticized the police for not treating the missing-persons cases as possible serial killings earlier, said that the report was just "a starting point," and that it remained to be seen if the police were receptive to change.
"I think that is an open question," Rahim said.
Epstein said that she was confident that police force would change, and that she believed the appointment of a permanent replacement for Saunders would help.
The interim chief, James Ramer, struck a tone of contrition Tuesday.
"The deficiencies were neither overt nor intentional," he said at a news conference. "There were too many times that we did not live up to what is expected — and in some cases required — of us to keep you safe. And the consequences were grave."
Ramer committed the department to fulfilling the review's recommendations, and said that the force has already established a central missing persons unit and would review all open cases back to 1919.
The report cited a number of police investigations, including one by a force in a Toronto suburb, that touched on McArthur's killings. But a widespread rejection within Toronto's police force of a provincial major case-management database meant that a lot of evidence went unshared — including interviews with McArthur.
That made it impossible to for subsequent inquiries to connect the dots.
The first major investigation into the deaths of three of McArthur's victims was prompted by a tip from law enforcement in Switzerland. It indicated that an Ontario man might have been part of an international cannibalism ring and that he may have killed one of McArthur's victims. Evidence gathered in that investigation connected all three victims to McArthur.
But, the review found, that investigation was plagued with "tunnel vision," focusing entirely on the cannibalism claims. After they were eventually dismissed as the grisly fantasies of the man identified by the Swiss, who was charged with child pornography offenses, the investigators left it at that, the review found.
Other investigators, including some of those who interviewed McArthur, did not check databases for his criminal history or, in one case, dismissed his record as irrelevant because of the time that had passed.
In 2016, McArthur was arrested after a man said McArthur had choked him during sex. He was released, the review said, after the police concluded that "McArthur honestly, though mistakenly, believed" the man had consented. No effort was made to re-interview the accuser before officers drew that conclusion.
Ultimately, the investigation that finally led to McArthur was only set off by the disappearance of Andrew Kinsman, the last of his murder victims. A public campaign by family and friends of Kinsman, who was white, pushed the police into action.
While Epstein credited them for their efforts, she said that they should not have been necessary.
"Proper missing person investigations should not depend on whose voices are the loudest or most empowered in sounding the alarm," she said.
Written by: Ian Austen
Photographs by: Aaron Vincent Elkaim
© 2021 THE NEW YORK TIMES
