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ARCHIVED - "A Failure to Respond"

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Correctional Investigator of Canada Releases
Report On the Death of a Federal Inmate

OTTAWA, May 21, 2008 - A report into the October 2006 death of an inmate has found Correctional Service of Canada (CSC) staff failed to respond adequately to a medical emergency, allegations of discrimination toward a First Nation offender who died, inaccurate communications about the incident, and excessive delays in the investigative process.

"Unfortunately, these disturbing findings continue a well documented pattern as detailed in numerous reports from this office, by the Correctional Service's own national investigations and by provincial coroners and medical examiners," said the Correctional Investigator, Mr. Howard Sapers.

The Correctional Investigator's findings concerning the circumstances surrounding the death were consistent with internal investigations conducted by the CSC. Both organizations' reviews concluded staff who attended the medical emergency failed to perform their duties by not determining the nature and extent of the inmate's wound and not administering first aid in the 30 minutes prior to the arrival of an ambulance. Moreover, the inmate was left alone, locked in his cell, and unmonitored for large portions of this 30 minute period. For their failure to administer first aid and failing to action any attempts to save human life, four CSC employees directly involved in the incident received disciplinary sanctions. These sanctions ranged from ten to twenty days without pay.

Further, allegations were made by both offenders and staff that the inmate's race played a role in the failure of staff to reasonably respond to the medical emergency. These allegations were not reasonably addressed by the Correctional Service at the time they were made.

"Yet again we find that the Correctional Service falls short in its legal mandate to preserve life and quickly act on recommendations related to inmate deaths. We will continue to see tragic deaths like this until the Correctional Service implements corrective action in all its institutions to improve mental health services, address the program needs of inmates and improve staff responsiveness to emergency situations," said Mr. Sapers.

Key recommendations in this latest report by the Correctional Investigator on the death of a federal inmate include that the Correctional Service:

  • Develop new policy requiring responses to medical emergencies be videotaped.
  • Immediately deliver a Diversity Awareness/Sensitivity Program to all CSC employees across Canada.
  • Share all information related to incidents of death and serious injury with police in a timely manner.
  • Develop a policy on how CSC management is to address allegations of discrimination against offenders when those allegations originate with CSC staff members or when they are raised during the course of an investigation.

The Correctional Service has received the Report and has committed to a full response to its recommendations. After reviewing the Report, the Service has also convened a Fact Finding Investigation in the allegations of discrimination.

The deceased's name is not included in the Report at the request of his family and in consideration of privacy legislation.

The Correctional Investigator is mandated by an Act of Parliament to be an independent Ombudsman for federal offenders. This work includes ensuring that systemic areas of concern are identified and addressed. The report into the circumstances surrounding this death, as well as the 2007 Deaths in Custody Study which examined 82 reported suicides, homicides, and accidental deaths of prisoners while in custody of the Correctional Service during a five year period from 2001 - 2005, are on the Correctional Investigator's website at


For further information:

Ivan Zinger, LL.B., Ph.D.
Director of Policy and Senior Counsel
Office of the Correctional Investigator
(613) 990-2690