Correctional Investigator's Assessment of the Correctional Service of Canada's Progress in Responding to Deaths in Custody


On September 8, 2010, the Correctional Investigator of Canada issued the fourth and final assessment of the Correctional Service of Canada's (CSC) progress in preventing deaths in custody. The quarterly review and reporting exercise assessed CSC's response to recommendations stemming from the Office of the Correctional Investigator's (OCI) 2007 Deaths in Custody Study, 2008 A Failure to Respond and the 2008 report into the death of Ashley Smith, A Preventable Death, in addition to CSC's own National Board of Investigation into Ms. Smith's death. OCI issued an Initial Assessment of CSC's Response in September 2009, followed by two other quarterly assessments in December 2009 and March 2010. This backgrounder summarizes the reports and investigations leading to the release of the final assessment.

Deaths in Custody Study (February 2007)

Concerned about the number of similar recommendations made year after year by CSC's National Board of Investigations, provincial coroners and medical examiners reviewing inmate deaths, the Correctional Investigator undertook a comprehensive review of reports and recommendations dealing with deaths in custody.

In February 2007, OCI publicly released its Deaths in Custody Study, an examination of 82 deaths of inmates while in CSC's custody between 2001 and 2005. The study found that some of the deaths could have been averted through improved risk assessments, more vigorous preventative measures, and more competent and timely responses by CSC staff. Areas of concern included delayed response to medical emergencies, assessment of pre-suicide indicators, availability of medical resources, lack of information-sharing between clinical and front-line staff, and care and custody of offenders with mental health problems.

The study also found that a significant number of recommendations and findings by investigative boards and coroners were not acted upon and that CSC failed to incorporate lessons learned and implement corrective action during the five-year study period, with the same errors and observations being made incident after incident.

The Correctional Investigator called for immediate and sustained corrective action on preventive measures to ensure that identified problems were not repeated and for a comprehensive risk management strategy to be implemented across the federal correctional system.

A Failure to Respond (May 2008)

In October 2006, an Aboriginal inmate attempted suicide in his cell. Correctional service staff who attended the medical emergency called for an ambulance. They did not attempt to determine the nature or extent of the inmate's wound, nor did they administer first aid. The inmate was left alone, locked in his cell, and unmonitored until the arrival of the ambulance 33 minutes later. He was declared dead by the paramedics who arrived at the scene.

In his report of the inmate's death, A Failure to Respond: Report on the Circumstances Surrounding the Death of a Federal Inmate, the Correctional Investigator found correctional staff failed to respond adequately to a medical emergency. He also identified inaccurate communications about the incident, and excessive delays in the investigative process.

Key recommendations of the report included:

  • Development of new policy requiring responses to medical emergencies be videotaped; and,
  • Timely sharing of information related to incidents of death and serious injury with police.

A Preventable Death (June 2008)

In October 2007, Ashley Smith, who had a history of self-harm, died in her cell, after a period of prolonged segregation. Ms. Smith had spent five years in the youth justice system in New Brunswick before being transferred to the care and custody of CSC in October 2006, at age 18.

In his Interim Report, as well as his final report, A Preventable Death, the Correctional Investigator cited a series of serious failures in the correctional system that led to Ashley Smith's death. The final report made 16 recommendations for improvement in the following areas:

  • Compliance with law and policy in correctional operations;
  • Responses to medical emergencies;
  • Use of force interventions;
  • Governance in women's corrections;
  • CSC inmate complaint and grievance procedures;
  • Offender transfer process;
  • Segregation policy and practice; and
  • Delivery of health care, including mental health services.

The Correctional Investigator stated that what troubled him most was that many of the failures observed in his investigation into the death of Ms. Smith had been the subject of previous recommendations and findings, including the Deaths in Custody Study.

Correctional Service of Canada Response (August 2009)

In August 2009, CSC released a public Response to OCI's series of reports and investigations into deaths in federal custody. More than 50 separate key actions and commitments were detailed pertaining to policy revision, instructions to correctional staff, reporting and monitoring measures, training, research, accountability framework action plans and other priority areas.

OCI Initial Assessment of CSC's Response to Deaths in Custody (September 2009)

In his initial assessment of CSC's progress in preventing deaths in custody, the Correctional Investigator acknowledged the Service's willingness to address many of his Office's findings and recommendations, but noted his concern that CSC's commitments focused largely on process and not progress. He stated that recommendations at the very core of accountability and governance within federal corrections continued to be rejected by CSC.

Specific problems identified in the initial assessment included:

  • A continuing refusal to provide direct oversight and responsibility for federal women's institutions at the national level;
  • A continuing failure to provide external monitoring of segregation of mentally ill offenders;
  • A continuing dismissal of the need to ensure independent mental health professionals chairing on national boards of investigation involving offender suicides and incidents of serious or chronic self-injury; and
  • Failure to adequately integrate, implement and communicate corrective actions across different sectors of activity and intervention, namely security, health care, case management, programs and psychological treatment.

The Correctional Investigator called upon CSC to provide a fuller and more integrated response to deaths in custody by addressing systemic accountability and governance deficiencies outlined in previous reports and investigations.

OCI Second Assessment of CSC's Response to Deaths in Custody (December 2009)

In his second quarterly assessment, the Correctional Investigator noted that the number of non-natural deaths in custody had increased by 70%; that the number of offender placements in segregation remained at an all-time high; that the number of self-injurious incidents was on the rise and perceived security needs all too often trumped necessary clinical interventions; and that too many offenders with mental health issues were subjected to unnecessary use of force interventions or involuntary placements in segregation.

Once again, addressing systemic areas of concern, the Correctional Investigator recommended that CSC publicly report on key performance indicators that would measure, in an open and transparent way, the Service's progress in preventing deaths in custody in the following areas:

  • Segregation of inmates with mental health issues that have been moved into alternative custody arrangements;
  • Comprehensive clinical treatment plans developed and implemented by institutional interdisciplinary teams and shared with front-line staff as appropriate;
  • Comprehensive clinical treatment plans fully implemented by institutional interdisciplinary teams;
  • Improvement in vacancy rates for mental health professionals and reduction in the number of under-filled positions;
  • Increased direct contacts between mental health professionals and segregated inmates;
  • Reduction in the use of force interventions involving offenders with serious mental health problems; and
  • Policy compliance regarding notification to and response to medical emergencies.

OCI Third Assessment of CSC's Response to Deaths in Custody (March 2010)

In issuing his Third Assessment, the Correctional Investigator noted a promising series of initiatives and commitments launched by CSC in response to recommendations made in his previous assessment. These included incorporating independent external reviews and public reporting on measures taken to prevent deaths in custody, as well as developing an accountability framework for monitoring progress. The Correctional Investigator also welcomed CSC's commitment to more closely monitor offenders with mental health problems placed in segregation for risk of suicide, self-harm or self-protection.

In concluding his third assessment, the Correctional Investigator reiterated his concerns about CSC's capacity to manage the needs of the increasing number of offenders requiring mental health services and support. He noted that segregation was being used as a default option in the Service's strategy to manage behaviours and responses associated with mental illness, and that mentally disordered offenders, especially those at risk of suicide and serious bodily injury, should not be held in segregated and isolated confinement. He urgently called for CSC to move forward on the implementation of intermediate care units to bridge the gap between acute care offered in regional treatment centres and primary care in the correctional environment, and stated that there was no justification to support the continued use of segregation as a substitute for intermediate care.

OCI Final Assessment of CSC's Response to Deaths in Custody (September 2010)

In his final assessment, the Correctional Investigator acknowledged that CSC had taken some concrete steps toward improving its performance in relation to the prevention and reduction of deaths in federal correctional facilities, but that overall, lessons learned were not consistently applied and that the Service had failed to address systemic deficiencies related to accountability and governance issues, which continued to impede significant progress in preventing deaths in custody.

The final assessment highlighted nine deaths in custody that showed recurring patterns and themes revealing outstanding accountability and compliance issues in federal corrections. The issues were not new for CSC. All of the factors contributing to the nine deaths had been identified in previous reports and investigations.

Six key areas of concern were identified:

  • Responses to medical emergencies that are either inappropriate or inadequate;
  • Critical information-sharing failures between clinical and front-line staff;
  • Recurring pattern of deficiencies in monitoring suicide pre-indicators;
  • Compliance issues related to the quality and frequency of security patrols, rounds and counts;
  • Management of mentally ill offenders too often driven by security responses rather than appropriate health care and treatment; and
  • CSC investigative reports and processes require consistency and improvement.

The Correctional Investigator made the following recommendations:

  • CSC must develop a comprehensive public accountability and performance framework that demonstrates measurable progress in addressing factors related to preventing deaths in custody;
  • CSC's internal investigative framework must be strengthened. External health care professionals should be appointed to chair reviews of suicide and serious self-injury, and these reports should be made public;
  • A senior management position should be created, responsible for promoting and monitoring safe custody practices;
  • The practice of placing mentally ill offenders, or those at risk of suicide or serious self-injury, in prolonged segregation must stop;
  • The quality of security patrols must be enhanced to ensure rounds and counts are conducted in a manner consistent with preservation of life principles;
  • Twenty-four hour health care at all maximum, medium and multi-level institutions must be provided to facilitate better response and management of medical emergencies; and
  • Basic information and instructions for managing offenders at risk of self-injury or suicide should be shared with front-line staff to ensure that effective monitoring, crisis response strategies and prevention protocols are easily and readily accessible.

The Correctional Investigator called for swift implementation of his recommendations and reiterated the critical need for CSC to demonstrate sustained progress and transparency in its efforts to prevent deaths in custody.