Annual Report of the Office of the Correctional Investigator 2013-2014

June 27, 2014

The Honourable Steven Blaney 
Minister of Public Safety 
House of Commons 
Ottawa, Ontario

Dear Minister,

In accordance with section 192 of the Corrections and Conditional Release Act , it is my privilege and duty to submit to you the 41 ^st Annual Report of the Correctional Investigator.

Yours respectfully,

Howard Sapers 
Correctional Investigator

Table of Contents

Correctional Investigator's Message 

Mission and Mandate 

Executive Director's Message 

Special Focus on Safe and Timely Reintegration 

An Investigation of Community Correctional Centres 

1. Access to Health Care 

2. Deaths in Custody 

3. Conditions of Confinement 

4. Aboriginal Corrections 

5. Federally Sentenced Women 

Correctional Investigator's Outlook for 2014-15 

Ed McIsaac Human Rights in Corrections Award 

Annex A: Summary of Recommendations 

Annex B: Annual Statistics 

Annex C: Other Statistics 

Correctional Investigator's Message

This is my 10 ^th Annual Report to Parliament. Looking back over the years since my appointment as Correctional Investigator in April 2004, while much has changed, my focus on effective corrections remains the same: contribute to safe and humane custody, timely reintegration, and improvement of correctional outcomes. This focus is achieved through independent oversight and accessible, impartial and timely investigation of individual and systemic concerns.

The most visible change during my tenure as Correctional Investigator has been the growth in the overall size, complexity and diversity of the offender population. It is not a new observation that some of Canada's minority, vulnerable or disadvantaged groups are disproportionately involved in the criminal justice system. These trends are accelerating within federal prisons. Since March 2005, the federal inmate population has increased by 17.5%. Over the same period, the Aboriginal population grew by 47.4% and Black offenders by over 75%. These groups now comprise 22.8% and 9.8% of the total incarcerated population respectively. The federally sentenced women population has increased 66%, with the Aboriginal women count growing by 112%. Over the same period, the number of Caucasian offenders has actually declined by 3%. As I am constantly reminded, the demographics of imprisonment reflect the larger society.

More offenders are presenting with complex mental health, substance abuse and addictions issues. For example, upon admission 80% of federally sentenced male offenders have a substance abuse problem and nearly two-thirds reported that they were under the influence of substances during the commission of their offence. Individuals with histories involving a combination of mental health and substance abuse issues are often more difficult to treat, more prone to relapse and have the highest risk for self-harm. Issues involving the care and treatment of mentally disordered offenders have become an increasing preoccupation. As I report this year, there were more than 1,000 self-inflicted injuries involving 295 offenders recorded in federal facilities, a rate that has more than tripled in the last five years. Incidents involving self-injurious behaviour represented 19% of all use of force interventions reviewed by this Office in 2013-14. 28% of all use of force interventions involved an offender with a mental health concern as identified by the Correctional Service of Canada (CSC) . The use of pepper spray in nearly 60.4% of all use of force incidents reviewed suggests an increasing reliance on security-driven responses to behaviours that are often associated with mental illness. These numbers should be cause for alarm.

In my first Annual Report in 2003-04, I made findings and recommendations on double bunking (placing two inmates in a cell designed for one), inmate pay, use of isolation/segregation in mental health treatment, elderly/aging offenders, and barriers facing the safe and timely reintegration of Aboriginal offenders. To a great extent, these issues remain with us a decade removed from my initial observations. For example, the double-bunking rate now stands at just under 20% nationally, with some regions approaching 30%. Even accounting for the new 2,700 cells that will open at 37 institutions in the next year or so, the CSC still expects significant double bunking to continue into the foreseeable future.

One in five inmates is now 50 years of age or older. With one-quarter of the incarcerated population serving a life or indeterminate sentence, issues involving the care and treatment of elderly people including chronic disease management and palliative care will increasingly define federal incarceration. I first called for an action plan to address the needs of elderly offenders ten years ago. There is still no national correctional strategy to manage this growing demographic several years later.

Use of force interventions, inmate fights and assaults, offender grievances and segregation placements are all trending upward in recent years. Key indicators against which safe and humane custody may be measured show there is more crowding, more disease and more violence in federal institutions. Reflecting these trends, the Office conducted a total of 1,740 uses of force reviews in 2013-14, the most ever recorded in a single reporting period since I have been Correctional Investigator. The federal correctional system has become increasingly compromised in meeting its rehabilitation and reintegration mandate. There is arguably not enough educational, vocational and meaningful work opportunities being offered inside federal institutions, and declining parole grant rates are linked to the capacity of the Correctional Service to address unmet needs linked to offending.

An increasing proportion of the offender population is spending more of their sentence behind bars before first release, reaching its highest point since 2003-04. Last year, 71% of all releases were by statutory release, meaning that the two-thirds point of the sentence had been reached and that the offender was required, by law, to be released under supervision. The rate of statutory release for federally sentenced Aboriginal offenders has now surpassed 80%. When the Corrections and Conditional Release Act was passed by Parliament in 1992, statutory release was intended to be a release option of last, not first resort.

As my more recent reports and investigations into deaths in custody indicate, prisons that are filled beyond their rated cell capacities are at higher risk of jeopardizing safety and security of the person. Unnatural or preventable deaths in custody (suicides, homicides, overdoses) are perhaps the most visible failing, but too many other lives are cut short by premature death or marked by injury.

It is troubling that a number of prison suicides continue to take place in segregation or observation cells, places where monitoring and surveillance is expected to be very close. The majority of those who take their own life in prison have a history of mental health problems, previous suicide attempts and/or self-harming behaviour. This finding is related to the Service's refusal to prohibit long-term segregation of mentally disordered inmates or those at risk of suicide or serious self-injury. While prison suicide is not a focus in this years' Annual Report, an update on this area of concern is currently underway.

If there is one thing that I have learned in my role it is that we should be under no illusions of what is possible. Prison is the bluntest of our criminal justice instruments. A federal penitentiary does not easily bend to meet the needs of mood, behaviour or disability in managing the increasingly high numbers of concurrently mentally ill and addicted persons behind bars. Separation from supportive networks in places that are often crowded, cramped, noisy and violent makes it more, not less, difficult to improve the lives of people struggling with mental health or substance abuse disorders. Addressing the rising number of incidents involving mentally disordered offenders by means of physical restraints, pepper spray or placements in isolation or observation cells are increasingly counter-productive and harmful practices.

A sentence of imprisonment needs to be seen as an investment, an opportunity for a convicted person to make positive change in his or her life by addressing individual needs and risks that contribute to crime. Nearly all but a few offenders will eventually be returned to society. Beyond safe and humane custody, the Service's mandate rightly emphasizes preparing offenders for their gradual and structured reintegration.

Appropriately, this year's Annual Report begins with a special focus on safe and timely reintegration of offenders to the community. At the same time that the correctional budget swelled to finance the construction of new prison units, the operating budgets to prepare offenders for resettlement and safely maintain them in the community have seen no new investments and are set to decline in real terms in 2014-15 and beyond. Even though these activities arguably deliver significant impact in terms of value for money, efficacy and contribution to public safety, community corrections appears to be treated as the “poor cousin” to institutions.

Howard Sapers 
Correctional Investigator of Canada 
June, 2014

The Office of the Correctional Investigator Mission and Mandate

As the ombudsman for federally sentenced offenders, the Office of the Correctional Investigator serves Canadians and contributes to safe, lawful and humane corrections through independent oversight of the Correctional Service of Canada by providing accessible, impartial and timely investigation of individual and systemic concerns. 

2013-14

• 36 full time employees
• $4.068M operating budget
• 423 cumulative days spent in penitentiaries
• 5,434 offender complaints
• 1,886 interviews with offenders
• 1,740 use of force reviews
• 185 mandated reviews (deaths, assaults, serious bodily injury)
• 18,867 toll-free telephone contacts

Principles that guide our work

• Independence
• Impartiality
• Accessibility
• Fairness
• Confidentiality
• Respect
• Integrity
• Professionalism

Executive Director's Message

This has been another productive and busy year for the Office. In the reporting period, the Office completed and publicly released three in-depth investigations: Risky Business: An Investigation of the Treatment and Management of Chronic Self-Injury Among Federally Sentenced Women (September 2013); An Investigation of the Correctional Service of Canada's Mortality Review Process (February 2014), and; A Case Study of Diversity in Corrections: The Black Inmate Experience in Federal Penitentiaries (published in last year's Annual Report). A follow-up investigation at a maximum security institution in the Pacific Region was also completed and posted on our website. For a small Office, these reports represent a significant investment in terms of human and financial resources.

Other highlights included the completion of a Code of Conduct and the launch of a Mission Statement for the Office. Pursuant to section 169 of the Corrections and Conditional Release Act , new promotional literature was distributed to all federal correctional institutions, Parole Offices, Community Correctional Centres, and Community Residential Facilities across the country. The Office's redesigned website was launched that incorporated a more accessible and user-friendly platform. In support of a renewed focus on safe and timely reintegration, investigative staff has been assigned to community facilities operated exclusively by CSC. 

Staff assigned to review of use of force interventions were especially busy conducting more than 1,740 reviews. The number of mandated reviews covering deaths in custody, major incidents and serious bodily injury was also up in 2013-14.

On the human resources side of the house, like the rest of the core public service, the Office participated in the Clerk's Blueprint 2020 initiative. As part of the OCI's engagement in this exercise, the Executive Director initiated four projects:

1. Corporate Services Ideas Campaign
2. Working Group on Innovation and Technology
3. Research and Strategy Development to Enhance OCI Mission Delivery
4. Strategic Planning Exercise

The Office also adopted the Common Human Resources Business Process ( CHRBP ) and developed a Project Charter to guide how human resource activities are managed and assessed. New case management tools have been purchased which should improve the quality of the Office's reporting systems. Finally, the OCI was selected by the Office of the Comptroller General for inclusion in the Horizontal Audit of the Protection of Personal Information in Small Departments. The objective of the audit was to assess compliance with the Policy on Privacy Protection and related directives. The audit report was positive overall, and the management action plan in response to the three audit recommendations was completed by March 31, 2014.

Ivan Zinger, J.D., PhD 

Executive Director and General Counsel

Special Focus on Safe and Timely Reintegration

In the past five years, parole grant rates have declined by 20%. Excluding life and indeterminate sentences, the proportion of sentence served incarcerated prior to first release is increasing, reaching its highest point since 2003-04. ¹ Overall, 71% of all releases from a federal penitentiary in 2013-14 were by statutory release, meaning that these offenders had reached the two-thirds point of their sentence and were required, by law, to be released unless there was compelling justification to detain them to warrant expiry. For Aboriginal offenders, 80.9% of all releases now take place by statutory release. The distribution of the population incarcerated (63.24%) versus supervised in the community (36.76%) is now decidedly lopsided in favour of penitentiary-based corrections. In sum, more federally sentenced offenders are serving longer portions of their sentence behind bars.

Although CSC is not the paroling authority, declining grant rates speak to its capacity to adequately and efficiently prepare offenders for community release. As the Auditor General of Canada recently reported: “While CSC cannot control the number of offenders admitted to its penitentiaries, it has some influence over the length of time that offenders remain in custody, and at what security levels, by offering programs and other interventions to prepare them for early discretionary release.” ² Time spent in prison should be about addressing unmet needs that contribute to crime so that offenders are better equipped to re-enter society and lead constructive, pro-social lives.

The needs of the inmate population are extensive and multiple with health, education, employment and substance abuse among the more prevalent areas of concern. High needs often go hand in hand with higher levels of risk. These offenders stay longer and are incarcerated at higher security levels, and ironically, have the most limited access to programs.

The Service is obligated to provide a range of programs designed to address criminal behaviour, reduce reoffending and contribute to successful reintegration. CSC 's planned spending on correctional reintegration programs for 2014-15 is $110M. ³ This allocation represents just 4.7% of CSC 's total planned spending of $2.334B in 2014-15. Inclusive of some of the more significant identified needs among federal offenders, planned spending in key program and intervention areas for 2014-14 breaks down as follows:

Research demonstrates that offenders who participate in correctional interventions that are commensurate to their risks and needs are less likely to reoffend than those who do not. ⁵ On a promising note, program enrolment and completion rates are trending in positive directions, the effect of the roll-out of the Integrated Correctional Program Model, which prioritizes moving offenders into programs earlier targeting multiple risk factors within a single program and for shorter durations overall. While this is good news, the new program delivery model has yet to be accredited so its effectiveness in reducing recidivism is still unknown.

Providing meaningful prison employment, vocational skills training and opportunities to upgrade educational levels are increasingly important activities and factors in support of safe reintegration. In 2012-13, upon admission 61% of offenders have an identified education upgrading need, which is defined as less than Grade 12. Of the 5,043 offenders assessed at intake in 2012-13, 37% had Grade 8 or less education. ⁶ Functional literacy and critical thinking skills are important as Grade 8 or its equivalent is the foundation for meaningful participation in correctional programs. Though the percentage of offenders who upgrade their education prior to reaching full parole eligibility is trending upward, far too many offenders still reach their full parole eligibility date with an identified education deficit.

A December 2013 audit of employment and employability programs indicates that institutions are the largest employer of offenders, providing over 80% of all employment in jobs like maintenance, custodial duties and kitchen work. ⁷ Corcan industries, which is a Special Operating Agency within CSC , runs prison-based industries in 36 facilities, mainly in textiles, manufacturing, construction and services. The audit showed that, as of mid-April 2012, 11.8% of the total inmate population was engaged in a Corcan industry or pursuing vocational training. In assessing employment and employability initiatives, the key is to link meaningful jobs, skills and training to community release plans that are aligned with current labour market realities. Significantly, the recent employment audit was unable to find an integrated vision, strategic objectives or governance structure, for institutional-based employment. A policy specific to employment and employability has yet to be developed. CSC staff indicated that they could not always provide enough employment to keep offenders busy. Meantime, the use of work releases is declining; only 389 inmates benefited from a discretionary work release in 2012-13. ⁸ 

Safe and timely release relies on quality and active case management assessments and interventions. The Institutional Parole Officer ( IPO ) is responsible for developing the Correctional Plan which identifies appropriate programming and treatment to address risks and needs that lead to criminal activity. In the past year, the Office received a number of complaints from inmates claiming to have little or no contact with their assigned IPO s. Ensuring some minimal level of communication or frequency of personal contact between IPO s and offenders has important consequences. When quality case management practices begin to fall off, it can have a number of deleterious effects: offenders staying at higher than necessary security levels; failure to meet progress against the Correctional Plan; waiting too long for programs; parole applications or hearings that are waived or postponed because of a perceived lack of support from Parole Officers and; case records that are poorly or not efficiently prepared. The high number of waived or postponed parole hearings continues to be tied, at least in part, to quality and frequency of contact concerns.

Finally, lack of resources can be a significant barrier to remaining crime free after a period of incarceration. Inmates have limited means or capacity to earn money or save while in prison for their eventual release. Those fortunate enough to be at the top rate of pay earn a daily wage of $6.90. After mandatory food, accommodation and other expenses are deducted, “take home“ pay can be reduced to as little as 40 cents an hour. Releasing an offender from prison to the community with little in the way of savings, limited means or capacity to secure and retain employment, apply for a record suspension, pay rent, obtain a health card, or buy a bus pass undercuts chances for long-term success.

An Investigation of Community Correctional Centres

As part of the Office of the Correctional Investigator's ( OCI) focus on safe and timely reintegration, an investigation was conducted over a three month period (January 2014-March 2014) examining the role and function of Community Correctional Centres ( CCC s). The investigation included site visits to at least one CCC in each of the five regions (Atlantic: Carlton and Carlton Annex; Quebec: Sherbrooke; Ontario: Portsmouth, Keele and Hamilton; Prairie: Oskana; and Pacific: Chilliwack) to ensure both a national and regional perspective. In total, individual interviews were conducted with a number of offenders, some of whom had been residing in a CCC for up to 5 years and some who had only recently arrived (4-5 weeks). Individual and group interviews were also conducted with several CSC personnel.

Role of Community Correctional Centres

CCC s are community-based residential facilities operated by CSC that accommodate offenders under federal jurisdiction conditionally released to the community on unescorted temporary absences, day parole, full parole, work releases, statutory release as well as those subject to long-term supervision orders. While CCC s are located within the community, they are designated minimum security facilities in policy, ⁹ though they are not required to conform to all minimum security facility standards. These community-based facilities provide a very structured and secure living environment that incorporates the following activities:

• 24-hour supervision
• Monitoring by on-site Parole Officers
• Established curfews and leave privileges ¹⁰ 
• Sign-in and sign-out procedures

They also offer additional programs and treatment resources such as community correctional programming, employment assistance and volunteer opportunities as well as access to community support groups and services (e.g. Alcoholics Anonymous, religious-based groups). CCC s provide an important structured transition period from full custody to a more independent community living environment. Residents are expected to contribute to and participate in the community, buy their own food, clean, cook, work, and volunteer.

Profile of Offenders

The first federal CCC s were established in the 1960's and were meant to accommodate inmates at the end of their sentence on day parole or inmates who had been suspended. ¹¹ Over time the CCC offender population has changed dramatically from those on day parole to those serving full parole with a condition to reside to the current population which largely consists of offenders on statutory release or a long-term supervision order ( LTSO ) with a residency condition imposed by the Parole Board of Canada ( PBC ). ¹² At present, over half (55%) of offenders residing in a CCC are on statutory release and 26% are on a long-term supervision order. Only 17% of the CCC population are on day parole and another 2% are on full parole. ¹³ 

The PBC has increasingly relied upon the residency condition to help manage the risk of offenders on statutory release. ¹⁴ Over the five year period from 2008/2009 to 2012/13, the number of residency conditions imposed or prolonged by the PBC for offenders on statutory release increased by one-third. In 2012/13, the PBC imposed or prolonged a residency condition on 42% of offenders released on statutory release, an increase from 30% in 2008/09. ¹⁵ 

Compared to day parolees, the current CCC population is a more complex, diverse and challenging population in terms of risk and need profile. Many offenders who currently reside in CCC s have been denied both day and full parole. CSC data indicate that three-quarters of offenders in a CCC are considered high risk to reoffend, 70% have high needs (e.g. employment, education, substance abuse, family/marital, community functioning) and one-fifth is considered to have low motivation levels. ¹⁶ CSC staff also indicated during interviews that there are more offenders with mental health needs, ¹⁷ a greater number of elderly and palliative offenders, more offenders requiring prescription medications, and a growing number of offenders requiring assistance in multiple areas (e.g. addictions, mental health and employment).

Despite these challenges, in the CCC s that were visited at least half (up to three-quarters in one CCC ) of offenders were working, some were engaged in vocational training, most had completed both institutional and community programming, a few were continuing their education, and many were actively participating in support groups or volunteering in the community. ¹⁸ Over the last ten years, nearly three-fifths of offenders completed their supervision term successfully while residing in a CCC . ¹⁹ Day parolees residing at a CCC are the most likely to successfully complete their community supervision period (84%) while approximately half of those on statutory release and nearly 60% of offenders on a LTSO s completed their term successfully. ²⁰ 
 

Findings

Readiness to transfer to a CCC 

While a few offenders interviewed for the investigation felt prepared for their transfer to a CCC , most stated that they did not feel ready prior to arriving at the CCC . For example, many stated that they did not have what would seem like simple resources, such as a birth certificate or health card (which can take 4-6 weeks to obtain), despite CSC policy which provides that these documents must be obtained as part of the release process from an institution. ²¹ As well, most offenders reported that they had not spoken to their institutional or community Parole Officer about their plan for release to a CCC , ²² some were not aware if they had a community release plan on file ²³ and others had not completed their institutional programming. ²⁴ Community staff was clear that the lack of adequate pre-release services and supports left many offenders in potentially vulnerable situations. For example, offenders frequently arrive without a health card and only two weeks supply of medication after which they must go to a clinic/family doctor to refill their prescription.

Several offenders also discussed the difficulty of providing for themselves when arriving at a CCC , particularly those who were not immediately employed or could not work as a result of health issues. For example, one offender reported that he no longer eats breakfast as he cannot afford three meals each day and has been unable to find employment. While CCC residents on day parole, statutory release and LTSO with residency who do not have access to an alternate revenue source can be provided with a living allowance to meet basic needs, the amount is meagre, particularly when the number of items offenders must purchase using their own resources are factored in (food, personal hygiene products, over the counter medications, transportation costs such as a bus pass). Proposed changes to the maintenance allowance could mean that those residing in a CCC where meals are provided would receive $5/day and those residing in a CCC where meals are not provided would get $10/day. The challenges that these individuals face are compounded by the fact that offenders residing in a CCC cannot access social services available to the general public (welfare, food banks, affordable transit pass programs, etc.). While CCC offenders who were employed were better able to manage their expenses, they reported difficulties in purchasing clothing/materials for particular jobs (i.e. hard hats, steel-toed boots and tools for construction jobs or aprons and utensils for jobs as a cook/chef). Regardless of income, the maximum weekly contribution toward food and accommodation in CCC s which provide food is $57. In CCC s which do not provide food, the maximum contribution toward the cost of accommodation is $21 per week. ²⁵ 

Meeting Needs of Vulnerable Populations

The needs of some of the most vulnerable populations (e.g. mentally ill, aging, and palliative) are not being adequately met in CCC s across the country. Of those facilities that were visited for the investigation, only about half had a nurse or social worker onsite full-time while the other facilities either shared this resource with another CCC or with the local parole office. Parole Officers often reported feeling responsible for assisting offenders with everything from ensuring medications are taken, to consulting with pharmacies/doctors for possible drug interactions, supporting offenders with serious mental health issues or providing care for aging, palliative and terminally ill offenders. This occurs despite policy that states “non-health services staff are not responsible to identify specific requirements regarding prescription medication.” ²⁶ It was clear from interviews with staff and offenders that having a nurse or social worker at the CCC was a best practice. Some offenders reported that the nurse was pivotal in helping them learn to manage their own medications and they felt more confident that they could continue this practice on their own in the community. CSC staff also noted the importance of having a nurse's knowledge and experience readily available as many reported that they did not feel they were adequately trained or prepared to manage some of the most complex cases. While the objective of CCC s is independent living for offenders, it is clear that the current population includes vulnerable and poly-need individuals who are not getting the care or assistance they require. 
 

Lack of consistency

Recognizing that each CCC must adapt and adjust not only to the community but also to the offender population residing within it, this investigation found some important discrepancies between CCC s. While all CCC s either offered programming within the CCC or through the local Parole Office, programming was not always available to offenders in the evening. This is concerning given the importance of obtaining and retaining employment at the same time as continuing correctional programming. The services available to offenders also differed among the CCC s visited. For example, some CCCs had an Employment Coordinator, Volunteer Coordinator, Aboriginal or Police Liaison Officer working within the CCC , while others accessed these resources primarily through the local Parole Office. Having access to these services and supports within the CCC was a best practice. For example, the CCC with an Employment Coordinator on site had a large proportion of offenders working and one centre with a Volunteer Coordinator had forty volunteers (most had less than five).

The extent to which CCC staff was involved in community outreach varied greatly. Widespread consultations and partnerships with community groups emerged as a clear best practice in this investigation. The CCC that worked very closely with the community had the most offenders working, volunteering and participating in community. While it may be easier for CCC s to remain anonymous within the community, partnerships and connections are essential to successful reintegration.

Limited Capacity and Modest Budget

CCC s face significant resource pressures. Many CSC staff reported insufficient resources (both financial and human) for mental health care services, effective supervision and risk management in particular, but also for activities such as community outreach and the management of aging and palliative offenders. Despite limited resources, it was clear from interviews with both staff and offenders that there is a tremendous amount of good and important work being done by a very committed CSC team. All Parole Officers interviewed discussed several instances of going well beyond their “work description” to help offenders succeed. Many reported helping offenders with mental health challenges particularly in terms of managing medication and/or money, others had picked offenders up from jobs because they could not find a ride back to the CCC in time to meet curfew and still others reported organizing events involving key community members/groups on their own time and using their own resources to purchase items for the event. Likewise, virtually all offenders interviewed commended the work of community staff and provided numerous examples of their dedication, enthusiasm and determination.

As of April 1, 2014, as part of CSC 's contribution to the Government of Canada's Deficit Reduction Action Plan ( DRAP ), CSC will increase the ratio of Parole Officers to offenders from 1 to 8 to 1 to 13 and decrease the number of times a Parole Officer must meet with an offender each month from 8 to 4 for higher risk offenders and from 4 to 2 for those with a lower risk. Parole Officers expressed concerns regarding these changes particularly for those offenders who must be accompanied in the community as there would be considerably less time for these types of duties.

Discussion

The Office's investigation found that despite the successes observed in CCC s across the country, challenges remain in adequately and effectively meeting the needs of offenders residing there. CSC must ensure that a rigorous process is in place to ensure the smooth transition of offenders from institutions to the community. These measures could include increasing the use of unescorted temporary absences and work releases to CCC s to better acquaint offenders with the facility and the community ²⁷ and providing offenders with a comprehensive handbook, ²⁸ which includes not only the rules but also services available in their release location, as well as a comprehensive pre-release planning strategy.

Despite CSC efforts over the past few years to enhance staff training programs, challenges remain in ensuring they are relevant and appropriate. CCC staff need to be appropriately trained, on an ongoing basis, particularly in terms of managing the complex needs of the population that now reside within CCC s (e.g. mental health, palliative and aging). Moreover, CSC needs to ensure that those with specialized expertise and experience are readily available to offenders and staff at CCC s across the country. While sharing these resources with the local parole office may be necessary, employees in these positions should be required to spend time each week at the CCC .

There is a need for more and varied strategic partnerships with communities and groups (i.e. cultural groups, trades associations, educational organizations, service groups and other levels of government including municipalities). The services offered by these groups should be used to enhance and improve on the programs and services already available within the CCC . There is an urgent need for CSC to develop a national strategic partnership strategy for CCC s. This could include creating an inventory of services and partners that are available, an outreach strategy, identifying gaps in partnerships (e.g. cultural groups), a communications plan that educates and informs community members, and a timetable for monitoring and reporting on these activities.

Finally, the percentage of resources allocated to community corrections is declining. Delivering programs in the community can be done much less expensively than maintaining an offender in an institution and they are often more effective. CSC must ensure sufficient and sustained funding for community corrections including CCC s and ensure that it is a priority. As the United Nations Office on Drugs and Crime has reported: “Investments in prisons, without a complementary investment in rehabilitation and reintegration programs, do not produce a significant reduction in recidivism. They may in fact compound the problem.” ²⁹ 

Recommendations

1. I recommend that CSC develop a comprehensive pre-release planning strategy that includes mandatory meetings between offenders and their institutional and community parole officer, a process to ensure an offender's official documents (i.e. birth certificate and health card) are available prior to release, and a handbook identifying programs, services and supports available in the release community. 

2. I recommend that every CCC have consistent access to the necessary resources, including nurses, social workers and psychologists, to ensure access to appropriate services and care. 

3. I recommend that CSC develop a national training plan specific to employees working in CCC s. 

4. I recommend that CSC develop a national partnership strategy for CCC s which includes creating an inventory of services and partners that are available, identifying gaps in partnerships (e.g. cultural groups), a communications plan that educates and informs community members, and a timetable for monitoring and reporting on these activities. 

5. I recommend that CSC conduct an operational audit of resources allocated to community corrections and CCC s specifically. The outcome of this audit should help inform reallocation decisions and the development of renewed monitoring and reporting strategy for CCC s. 

6. I recommend that CSC establish a working committee with the Parole Board of Canada to examine best practices and guidelines regarding the appropriate use of residency conditions for offenders released on statutory release and offenders on a long-term supervision order. 

1. Access to Health Care

It is CSC 's legal duty to ensure an inmate's health and safety while they are in custody. Health care can often be an especially complex area of offender complaint. Individual health care complaints typically break down as concerns involving access to health care services, quality of care as well as decisions regarding medication use, including discontinuation or alternatives. Provision of and access to health care services in a prison setting is contingent upon other competing operational demands and priorities (population management, institutional routines, staffing, counts, rounds and patrols), not to mention availability of external health care providers, services and clinics. Unlike the rest of us, offenders do not choose their health care provider and they cannot shop around for service; they must accept what they get when they can get it. Most federal penitentiaries lack 24/7 health care staffing; access can be particularly challenging during the night shift and on weekends, especially in more isolated locations.

A. Physical Health

The physical conditions of confinement in today's federal penitentiaries are far from optimal. As a study of international prison health recently put it: “(Prisoners may be) …incarcerated in overcrowded, unsanitary, stressful and violent conditions, alongside others who share the same increased health vulnerabilities. As a result, the prison environment is one marked by disease transmission, environmentally exacerbated health decline and death, and heightened risks of mental illness.” ³⁰ Federally sentenced offenders often arrive in prison with chronic or unmet health conditions. Their health needs are complex and include a higher than average incidence and prevalence of infectious diseases, mental health illnesses, and chronic conditions. Overall, inmates consistently have poorer health than Canadians at large. Physical health conditions are frequently exacerbated by histories of trauma, substance abuse or addiction issues, co-morbidities that are common among those living on the margins of society. From a determinants of health perspective, it is a high-needs population that requires a wide variety of services and supports.

Obtaining baseline data of the overall prevalence of physical and mental health conditions among the federal inmate population is not easy. It is complicated by the fact that CSC does not have an automated medical records system or an electronically accessible records storage and retrieval capacity. Notwithstanding, it is possible to build a composite picture derived from existing research, admissions data, surveillance and test results as well as information extracted from individual case records and reviews.

• Based on testing and screening surveillance data, CSC reports that at year end 2012, the prevalence rate of infection among the inmate population was 18.5% for Hepatitis C, 16.6% for Latent Tuberculosis Infection and 1.2% for HIV. ³¹ 
• A 2009 manual review of health care records estimated that 6.9% of the inmate population was living with diabetes, close to 20% had a cardiovascular condition, 15% a respiratory condition and 6.5% an urological condition.
• Based on 2008 data, 30% of newly admitted federally sentenced women had previously been hospitalized for psychiatric reasons.
• An August 2013 snapshot indicates that 63% of federally incarcerated women were prescribed some sort of psychotropic medication.
• In 2012-13, 49% of the inmate population received at least one institutional mental health service. Approximately 75% of women offenders and approximately 51% of Aboriginal offenders received an institutional mental health service.
• 61% of newly admitted offenders screened for potential mental health problems in 2012-13 were flagged for a follow-up intervention.
• A January 2013 summary of 50 natural cause mortality reviews indicated that cancer is the leading cause of natural death among the inmate population. 20% succumb to cardiovascular disease, which is also the second leading cause of death among Canadians. The third leading cause of death among offenders is infection at 14% (compared to stroke for the Canadian population). Influenza and pneumonia infection were the 8 ^th leading cause of death for Canadians, while death by infection related to AIDS, Hepatitis, Sepsis ranks 3 ^rd among inmates. ³² 
• One-in-five federal inmates are aged 50 years or older.

Considering that one-quarter of the inmate population is serving an indeterminate or life sentence, more inmates will not only grow old(er) in prison, but they may eventually succumb to chronic or acute diseases associated with the aging process. We also know that deficits in literacy, education, housing, employment, support networks, income and social status are all associated with increased morbidity and mortality.

I am pleased to learn that CSC is conducting a prevalence study of chronic health care conditions based on a manual review of several hundred inmate health care records. In light of the demographic trends indicated above, this is an important if time-consuming initiative. The Service urgently requires an electronic offender health information system capacity. While prevalence, screening and surveillance data is recorded for certain infectious diseases such as Hepatitis and HIV, the clinical and pharmaceutical side is supported by sub-standard, mostly manual, platforms that lack the capacity to share information with one another. The Service is unable to reliably extract or account for essential health care services, up to and including what drugs are being prescribed and for what purpose. Equivalence and consistency of standards of care varies between regions, and even from one institution to another. Prevention and management of chronic health conditions is difficult in the absence of a reliable data management tool. A competent, efficient and accountable prison health care service requires a modern monitoring and reporting e-health information system.

7. I recommend that CSC move forward the completion date of the electronic offender health information system. This may require new or reallocated funds. 

8. I recommend that (CSC) 's review of chronic health conditions be integrated with and inform a comprehensive prevention strategy to reduce premature mortality. 

Harm Reduction

It is in the interest of individual and public health to ensure the proper treatment and prevention of disease within correctional environments. Prisons offer an important opportunity to treat and prevent the spread of disease. To its credit, CSC has fairly robust and regular immunization, surveillance and screening protocols in place for a range of infectious diseases such as Hepatitis, HIV and sexually transmitted diseases. These activities are complemented by public health awareness campaigns and literature on healthy living inside prison. Indeed, though the total public health expenditure for CSC is relatively modest ($13.3M annually against a total health care budget of $216.7M), the range of promotion activities is generally impressive and would appear to meet community standards.

Blood borne communicable diseases can spread rapidly in a prison environment. Inmates experience rates of HIV/AIDS seven to ten times higher than the general public. Rates of Hepatitis C infection in prison are 30 times higher. High rates of infection and transmission are concerning from both a prison and public health perspective. For example, research suggests that incarceration is associated with non-adherence to or discontinuation of highly active antiretroviral therapy ( HAART ) for HIV disease. The risk of transmitting HIV can be significantly reduced (one study reports by 96%) with appropriate HAART . ³³ 

9. I recommend that efforts to ensure identification, ongoing monitoring and treatment of HIV infection in CSC facilities be a priority and that relevant systems to ensure timely and effective diagnosis and treatment are put in place. 

Drug and alcohol addiction is also an ever-present concern among the offender population. Upon admission, 80% of federally sentenced offenders have a serious substance abuse problem. Over half reported that alcohol or drug use was a factor in the commission of their offence. According to the 2007 inmate survey, 17% of men and 14% of women injected drugs in prison. About half of those who injected drugs shared injection equipment, including with people who they knew had HIV, Hepatitis C, or unknown infection status.

In May 2012, 789 offenders (or 5.3% of the incarcerated population) were enrolled in Opiate Substitute Therapy ( OST ), more commonly known as Methadone Maintenance Treatment ( MMT ). For 2011-12, the cost of this program was just over $11M annually, most of which is accounted for in salaries. ³⁴ The objectives of the program are to:

• Decrease the number of intravenous injections
• Reduce relapse to opiate drug use
• Improve the state of health and quality of life of offenders
• Assist and motivate offenders to gradually disengage from an illicit drug use
• Decrease criminal behaviour and incidents of incarceration

Despite many positive attributes, as part of CSC 's contribution to the government's overall Deficit Reduction Action Plan ( DRAP ) OST funding will be reduced in 2014/15 and ongoing to $9.8M annually, representing a reduction of just over 10%. I question the appropriateness of reducing investment in a program that delivers sound public policy benefits from both a health and public safety standpoint.

B. Mental Health

In a series of Annual Reports and systemic investigations, my Office has pointed to some key directions for reform in mental health service capacity and delivery in federal corrections:

• Create intermediate mental health care units in federal penitentiaries.
• Increase efforts to recruit and retain more mental health professionals.
• Treat self-injurious behaviour as a mental health, not security, issue.
• Prohibit the use of long-term segregation of offenders at risk of suicide or serious self-injury as well as offenders with acute mental health issues.
• Expand the range of alternative mental health service delivery partnerships with the provinces and territories.
• Appoint independent patient advocates or quality of care coordinators to serve each of CSC 's regional psychiatric facilities.
• Provide for 24/7 health care coverage at all maximum, medium and multi-level institutions.

Significantly, many of these same measures were recommended in the Ontario Coroner's inquest verdict and recommendations into the death of Ashley Smith concluded in December 2013. I am more convinced than ever that these measures would have a beneficial impact on the Service's ability to more safely and humanely manage mentally ill offenders.

Mental Health and Addictions

Mental health disorders, alone or in combination with alcohol abuse or drug addiction, represent a major health care and public safety challenge. People living with concurrent disorders have the highest risk for harm, experience the poorest system outcomes, and incur the highest system costs. They are more difficult for service providers to reach, less accepting of treatment, more prone to relapse and at increased risk of coming into contact with the criminal justice system.

The implications and impact of concurrent disorders come into even sharper focus in the area of corrections where mental health issues are 2-3 times more common in Canadian prisons than in the general population. Though there are few studies that have conclusively established prevalence rates, an overwhelming majority of offenders diagnosed with a mental disorder, usually though not always, also struggle with substance dependency. According to recent CSC research study, ³⁵ on comparison offenders with concurrent substance abuse and mental disorders:

• Had the highest risk and need ratings (employment, attitudes, associates and community functioning)
• More extensive criminal histories
• Higher rates of admission to segregation
• More likely to reoffend.

These findings have important implications for how CSC responds to mental illness and substance dependence disorders.

More needs to be done to meet the unique needs and challenges posed by concurrently disordered offenders. For example, there is an unusually high correlation between prison suicide with those who struggle with both addiction and mental health problems. While there are some awareness, support and counselling interventions available to offenders to manage their mental health and/or substance abuse issues, these measures are typically delivered as one-off interventions with little integration, coordination or coherence over time. Within corrections, there is a need to change the lens through which prison drug use is predominantly filtered. Interdiction and suppression in the absence of a more comprehensive range of treatment, prevention and harm reduction measures will not eliminate the demand (or supply) of contraband drugs or alcohol. CSC 's anti-drug strategy and services must include a greater balance of measures that are better aligned to the needs of offenders whose criminal activity is linked to substance dependency.

10. I recommend that CSC develop a comprehensive integrated model to treat offenders with concurrent substance abuse and mental health disorders. 

Regional Treatment Centres

In 2012-13, there were 779 referrals, 631 admissions and 652 discharges from CSC 's five Regional Treatment Centres (psychiatric hospitals). 54% were new admissions. The average length of stay in a treatment center was 264 days for offenders receiving acute or assessment services and 288 days for those receiving intervention specific treatment. The total number of treatment centre beds available for male offenders is 665. ³⁶ There are an additional 20 inpatient beds for federally sentenced women in the Assiniboine Unit, which is a co-located unit at the Regional Psychiatric Centre ( RPC ), Saskatoon.

The Regional Treatment Centre for Ontario ( RTC Ontario) was formerly located within the Kingston Penitentiary complex. When Kingston Penitentiary was closed on September 30, 2013 inmates that were housed at the treatment centre were transferred to two separate institutions. Those with acute needs were moved to Millhaven Institution, a maximum security facility, while the remainder is housed, temporarily, at Collins Bay with a final destination of Bath Institution once construction there is completed.

Some of the most acutely ill male offenders in the federal correctional system are now held in the old segregation wing of Millhaven Institution. These cells are located on the first floor, underneath the current segregation unit and opposite the special needs unit. From a community standards and therapeutic perspective, this infrastructure is inadequate:

• The facility is basically a narrow corridor, not a standalone area within the institution or built to hospital standards.
• There is very little natural light and poor ventilation.
• There is no common area for inmates to congregate or eat their meals – offenders that prepare their food must return to their cell to eat.
• The exercise yard is exceedingly small and sterile.
• Dedicated program rooms are limited.
• Patient confidentiality issues have been identified.

During visits to the facility, staff reported that they were concerned with the lack of routine in the unit, noting that this is not conducive for treatment and highly problematic for a population that requires routine as part of their mental health care. Overall, staff are frustrated that the RTC was moved so early given the disruptions in routine, programming and treatment for these patients. These issues have yet to be resolved nearly a year following the RTC 's relocation. As a psychiatric facility, in-patient care at new RTC Ontario does not reflect community standards. Although the Service is responding to the concerns identified above and while I understand that the situation is one where the CSC is ‘doing the best that it can with the resources and facilities available,' it is simply inadequate.

It is of interest that Millhaven is the site of a new 96-bed maximum security unit expansion that is currently being constructed at a total project cost of $32.5M. Once the decision was made to close Kingston Penitentiary the unit being constructed at Millhaven could have been altered in design and purpose to become the new multi-level RTC Ontario facility. In hindsight, it appears that the immediate desire to close Kingston Penitentiary overtook a longer term perspective that might have better matched needs of the population with appropriate infrastructure and staffing models. Revising construction plans would likely have cost less and caused much less disruption than renovating the old and entirely inappropriate segregation range at Millhaven. Another opportunity to build a consolidated stand-alone treatment centre may still exist in the region as Bath Institution is undergoing a 192 cell expansion at a similar cost to Millhaven. My Office will continue to closely monitor RTC Ontario developments.

Concerns about RTC Ontario once again bring into sharp relief the dilemma that treatment centers function as hybrid facilities – a ‘penitentiary' under the Corrections and Conditional Release Act ( CCRA ) and a ‘hospital' under applicable provincial mental health legislation. All but one of the five regional treatment centres is co-located within the confines of other CSC penitentiary reserves. As of April 1, 2014, for accountability purposes, health care professionals working in the treatment centres now report to Health Services. Though realignment is a welcome change in terms of function and reporting structures, the underlying tensions remain.

Risky Business and Ashley Smith Inquest Updates

On September 30, 2013, the Office released “ Risky Business: An Investigation of the Treatment and Management of Chronic Self-Injury among Federally Sentenced Women. ” The report examined CSC 's response to the growing number of incidents of self-injury among federally sentenced women offenders. The report followed eight chronically self-injurious women over a 30 month period (January 2010 to June 2012 inclusively). It documented a range of concerns with CSC 's capacity to balance operational and treatment needs for women offenders who engage in chronic self-injury. The report called for, among other measures:

1. Enhanced training for staff working with chronic self-injurious offenders.
2. Strengthened monitoring and reporting on the use of physical restraints in the management of chronic self-injury.
3. Prohibition on placing self-injurious offenders in conditions of prolonged clinical seclusion or segregation.
4. Appointment of an independent patient advocate or quality care coordinator at each of the five regional treatment centres, inclusive of the (then) Churchill Unit, ³⁷ Regional Psychiatric Centre, Saskatoon.
5. Immediate transfer of the most chronic and complex cases of self-injury to external community psychiatric facilities.

CSC 's response to the 16 recommendations made in Risky Business is still outstanding. The response to five other recommendations dealing with related concerns in the Office's last Annual Report, which was released on November 26, 2013, are also outstanding. The Service has informed the Office that it will respond to recommendations in these two reports in “due course” and “under separate cover.” I have subsequently learned that CSC 's response is tied to its consideration of the 104 recommendations made in the Ontario Coroner's Inquest into the death of Ashley Smith, a verdict which was delivered in December 2013.

While I appreciate that the inquest covered a number of similar issues of concern and made several recommendations consistent with my Office's own investigation and follow-up to Ashley Smith's death, the delay in response is increasingly untenable and unacceptable. It is now nearly seven years since Ashley's death in October 2007. The individual and systemic failings in Ashley's case do not need to be repeated here as they have long been part of the public record. Suffice to say, there remains considerable work to be done in terms of improving the operations and accountability of the federal correctional system to safely house, treat and manage the most profoundly mentally dis-ordered offenders. This work should not be further delayed.

I am advised that a Deputy Minister's steering committee has been established to oversee the government's response to the Ashley Smith jury's recommendations and that a final consolidated response is expected in December 2014. The interim announcement made by Public Safety Minister Steven Blaney on May 1, 2014 that a few beds will be made available to federally sentenced offenders in outside treatment centres is an important, if modest step, in the right direction. By the Service's own admission there are at least 20 other seriously mentally disordered offenders who are being closely monitored for the challenges they pose to safe and humane custody. Alternative in-patient care is needed now for these individuals. I encourage the Service to move quickly to expand external treatment options.

The final recommendation (#104) of the Ontario Coroner's inquest into Ashley Smith's death directly calls on my Office to “monitor and report publicly, and in writing, on the implementation of the recommendations made by this jury annually for the next ten years.” I have corresponded and also met with the Minister to discuss how my Office can best meet this requirement. I have reiterated my concern that it is highly unusual that the Service's response to recommendations made by my Office should be tied to or made contingent upon responses to a provincial inquiry. We have sensibly agreed to an arrangement that my Office should have an opportunity to review CSC 's response in advance before committing to the extent and nature of any further involvement by my Office.

Unreasonable delays are inconsistent with the Service's legal responsibility to respond to my recommendations and the expectation that it meaningfully address the important findings of my Office. A full, timely and constructive response to health care recommendations can prevent future or further harm and is a good indicator of an open and accountable organization.

2. Deaths in Custody

CSC has a legal obligation to preserve life in custody. It has a statutory obligation to investigate all in-custody deaths regardless of cause. The Office independently reviews CSC 's investigations into the factors and circumstances that contribute to natural and unnatural (suicides, overdoses, homicides) fatal incidents in federal penitentiaries.

Natural Cause Deaths in Custody

As indicted, suicide is not the only or even the leading cause of mortality in federal correctional institutions. The leading cause of death – surpassing any and all other “unnatural” causes of mortality combined (suicides, homicides, accidents, overdoses) – is death from “natural” causes. In any given year, about two-thirds of all in-custody deaths are attributed to natural causes, including cancers (lung and liver), cardiovascular disease and infection.

The average age of offenders who succumb to natural causes either in custody or under sentence in the community is far below national life expectancies. In a January 2013 review of 50 individual mortality reviews, the average inmate age at death was 60 years, ³⁸ much younger than the Canadian life expectancy of 78.3 years for males and 83 years for females. This trend holds consistent for offenders who die prematurely from natural causes in the community where the average age of death is just 62.5 years. In fact, more federally sentenced offenders die each year under community sentence than in prison.

While it is difficult to ascertain the specific natural mortality rate for offenders under federal sentence, these numbers raise some red flags given an incarcerated population of over 15,200 and a community supervision population of about 8,500. They take on added significance given that one in five inmates is 50 years of age or older and that one-quarter of the incarcerated population is serving a life or indeterminate sentence, with periods of parole ineligibility set anywhere between 7 and 25 years. With the stacking effect that results from an accumulation of long sentences over time, the math suggests that an increasing portion of the in-custody population will age and live out their natural life behind bars. At present, the system is poorly equipped and not taking the necessary steps to better prepare itself to care and provide for the demographics of this aging and ailing population.

Prompted by these concerns and after noting the paucity of critical findings and recommendations in how natural cause deaths are reviewed by the Correctional Service, on February 17, 2014 the Office released the findings of its investigation into CSC 's mortality review process. To facilitate this investigation, the Office retained the services of a senior medical practitioner who was asked to conduct an independent and expert review of the quality and adequacy of medical care provided in a sample of fifteen deceased offenders. The fifteen cases that the contracted expert was asked to review were not randomly selected. All of the deaths had raised some level of concern upon initial review. All of the deceased were male inmates, and all but one death was “anticipated” by CSC . The average age at death for the sample was 60. The physician consultant reviewed the same medical charts, files and records that were part of CSC 's mortality review exercise.

The findings of this investigation were disturbing. The review raised serious compliance issues concerning the quality and adequacy of health care provided: questionable diagnostic practices; incomplete medical documentation; quality and content of information sharing between health care providers and correctional staff and; delays and/or lack of appropriate follow-up on treatment recommendations. These are serious findings, particularly considering that in all fifteen of the individual mortality reviews conducted by the CSC , the care provided to the deceased inmates was determined to be “congruent” with “applicable” health care standards and policy.

The Office's investigation also found significant problems with respect to the mortality review process itself. For instance, the time between a fatality and the convening and completion of the mortality review often exceeded two years. This timeframe does not respect the legislative obligation for CSC to investigate an inmate fatality “forthwith.” Just as troubling, the individual reviewer is not asked to establish, reconstruct, validate or otherwise probe the facts or circumstances that contributed to the fatality beyond recording cause of death as either “expected/anticipated” or “unexpected/sudden.” Most mortality reviews simply conclude with a Closure Memo stating “no further action required.”

Given these deficiencies, it is perhaps not surprising to find that the mortality review process has failed to generate findings, recommendations, lessons or corrective measures of any national significance. Even when compliances issues are noted, there is no way of determining whether the death was potentially preventable or premature. There is little in the way that the process is currently structured that advances knowledge, generates lessons learned or leads to sustained corrective action over time.

To enhance the quality, accountability and transparency of CSC 's investigation of an inmate death by natural cause(s), the report made these key recommendations:

1. “Sudden” or “unexpected” fatalities, regardless of preliminary cause(s), should be subject to a National Board of Investigation.
2. The convening of a board of investigation should normally be within 15 working days of the fatality.
3. All mortality reviews, regardless of cause of death, should be led by a physician.
4. Mortality reports in their entirety should be shared, in a timely manner, with the designated family member(s) who request it.
5. The mortality review exercise should be subject to a quality control audit chaired by an outside medical examiner.

The Service responded to these recommendations on March 31, 2014. It rejected them all. Instead, it proposes to strengthen the existing mortality review process by increasing the involvement of the Senior Medical Advisor and conducting a six-month pilot in an effort to shorten the time it currently takes (up to two years as the Office found) to complete an individual mortality review.

This response falls short on many levels. It amounts to making modest reforms to a flawed and inadequate process. It is not nearly responsive enough to the core of the Office's concerns, namely that the current mortality review process is not carried out in a timely or rigorous manner to satisfy its statutory obligations, and it fails to meet basic investigative standards such as independence, thoroughness and credibility.

11. I recommend that CSC reconsider its response to the Office's report on the mortality review process to more specifically address the concerns about the lack of rigour, independence, credibility and timeliness in how the Service currently investigates natural cause fatalities. 

Balancing Justice and Compassion Interests

One of the issues that the mortality review process assesses is how and whether consideration of alternatives to incarceration, prior to death, were examined and documented in cases involving palliative or terminally ill offenders. Very few federal inmates, even those who are about to succumb to terminal illness, are ever in fact granted mercy (through the Royal Prerogative of Mercy) or exceptional release (Section 121 provisions of the Corrections and Conditional Release Act ). Parole Board of Canada statistics indicate that in the last five years between 2008/09 and 2012/13, the Board reviewed a total of 11 requests under Section 121. Of these requests, 7 were granted and 4 were denied.

As documented in the Office's investigation of the mortality review process, a recent review of 35 “expected” deaths CSC reported that 14 inmates were considered for Section 121 release, but none were in fact granted – 6 died before the paper work and release planning could be finalized; 6 cases were reported to have been brought before the Parole Board where 5 were denied; the other died during the adjournment of a hearing. Two others were considered under Royal Prerogative of Mercy requests but the risk was considered too high in both cases. As these outcomes demonstrate, there is a need for the CSC and the Parole Board to work together to review and streamline case management practices, procedures and policy requirements to ensure Section 121 applications are brought forward to the Board for decision in an expeditious manner.

Balancing justice and humanitarian concerns in cases involving palliative and/or terminally ill offenders is not easy. It is instructive that other jurisdictions facing an increasing number of offenders requiring expensive end of life prison care have responded in innovative ways including contracting with community nursing homes to secure assisted living and/or palliative beds. The US Bureau of Prisons, for example, has expanded its guidelines for compassionate release allowing for consideration of a reduction in sentence to inmates who have been diagnosed with a terminal, incurable disease and whose life expectancy is 18 months or less. Even elderly prisoners who are not terminally ill or disabled can apply for early release under the new rules.

12. I recommend that CSC issue a Request for Proposal to secure palliative community services and accommodations to allow terminally ill offenders to die with dignity in the community. 

3. Conditions of Confinement

During the reporting period, the daily federal incarcerated population count consistently topped 15,000 inmates, averaging 15,200 incarcerated (+10% increase in the last 5 years). In FY 2013-14, the national double-bunking rate (placing two inmates in a cell designed for one person) averaged 19.2% (+93% increase in the last 5 years). Through the reporting period, in-custody medium security counts were higher than rated cell capacities except for Pacific region. Across the country, there were 8,328 administrative segregation placements, with an average segregation count of 850 offenders on any given day (+6.4% increase in the last 5 years). Other significant trends in 2013-14 include:

• 1,293 inmate assaults and fights (+17% increase in the last 5 years)
• 1,683 use of force incidents (+6.7% increase in the last 5 years)
• 1,951 involuntary transfers (+33% increase in the last 5 years)
• 29,291 internal complaints and grievances (+3.6% increase in the last 5 years)
• 1,010 incidents of reported self-injury involving 295 offenders (+56% increase in the last 5 years)
• 182 inmates incurred serious bodily injury (+19% increase in the last 5 years)

Reflecting these overall trends, the Office conducted a total of 1,740 use of force reviews, the most ever recorded in a single reporting period. The Office also conducted 185 mandated reviews of serious incidents in 2013-14, including 66 assaults and 17 suicides. ³⁹ 

Last year, issues linked to conditions of confinement surpassed health care as the number one category of offender complaint to the Office. This is a significant development indicative of a deteriorating prison environment as population management pressures intensify. A range of concerns were observed, brought forward or investigated by the Office through the reporting period:

• Hygiene and cleanliness, including access to showers and functional toilets
• Lack of care, concern or complacency about daily living and working conditions (broken appliances not replaced, cell furniture not supplied, common areas not tidy or clean, garbage left to accumulate outside cells or at the end of ranges)
• Too much time spent locked up in cells (lack of programming, recreation or group association)
• Prolonged wait times to start or enroll in correctional programs
• Visits that were cancelled due to population management concerns or lack of staffing
• Use of non-accommodation space, including Private Family Visit facilities, to “temporarily” manage population challenges
• Involuntary transfers to another region due to lack of cell space.

In one case, a segregated inmate complained that one or two inmates in the unit were regularly flooding the range by clogging their toilet. While the inmate understood that the institution was not to blame, his complaint centred on the fact that other inmates on the range were not allowed to mop up their floors or wear shoes in their cells. The investigator assigned to the institution had to write a formal recommendation for the Warden to provide cleaning products for the segregation range. In another complaint, the only shower that can accommodate a physically disabled inmate was clogged for more than three weeks, apparently because of “an administrative oversight as a result of paperwork not being submitted.” ⁴⁰ 

Other cases involved more significant breaches of retained life and liberty interests. The Office reviewed a number of cases in which the security classification of an offender was based almost exclusively on the “nature and gravity” of the offence with little weight given to individual risk or actuarial evidence. In other words, in these cases CSC decision-makers relied too heavily on the crime itself (or sometimes the notoriety or public profile of the offender or the offence) to set the custody rating, which in turn determines security classification and ultimately penitentiary placements. Upon review, this kind of decision making, which is not based on the principle of managing risk in the least restrictive (“necessary and proportionate”) manner, can lead to unfair, arbitrary and/or unreasonable outcomes. In some cases, upon review of the full case file it became clear that CSC decision makers did not adequately consider professional risk assessments which, had they been followed, would have resulted in a placement at a lower security level.

These kinds of cases are increasing in frequency. They appear linked to a misapplication or misinterpretation of legal language that was added to the principles of the Corrections and Conditional Release Act in March 2012. It bears reminding that while the Service is now expected to take into account the “nature and gravity of the offence” as well as the “degree of responsibility of the offender,” these are additional case management responsibilities; they do not over-ride the constitutional imperative of managing individual and public safety risk in the least restrictive manner possible. It is decidedly not the responsibility of CSC decision makers to arbitrarily add to the severity of the detention conditions or the sentence imposed by the courts.

CSC 's Internal Review and Investigative Process

Beyond the increase in serious and reportable incidents, my Office continues to raise concerns regarding the manner in which CSC investigates itself and how it reviews and reports on significant incidents. Recent changes to the use of force review process have significantly reduced both the number and scope of use of incidents subject to national review. Only “level 3” events involving the most severe violations of law or policy are now routinely reviewed nationally. National Headquarters also randomly reviews 5% of all uses of force incidents, 20% of interventions involving self-injurious offenders and all incidents where the Emergency Response Team is involved for the purpose of involuntary medical injections. ⁴¹ While the rationale for the new process was to focus limited resources on situations of greatest significance, the Office continues to be concerned that other serious incidents are falling through the cracks and not being flagged for regional or national review.

There were other significant changes to CSC 's reporting and review procedures through the reporting period. As part of a pilot project, the criteria and resources for conducting local or institutional investigations were streamlined to allow for a single national level investigator to conduct the review. These investigative reports would not normally be forwarded or shared with national authorities, unless subject to a quality assurance review process. In a recent local review of a self-harm incident, serious deficiencies were noted in the investigative process and report: the review failed to assess compliance with Commissioner's Directive 843 – Management of Inmate Self-Injurious and Suicidal Behaviour ; the only staff member interviewed (by telephone) was the institutional Security Intelligence Officer (the investigator did not communicate with the institution's psychologist or mental health nurse). While the Office appreciates that investigative models will differ depending on the type and seriousness of the incident under review, it is not appropriate to use a streamlined model to review incidents involving self-harming or suicidal behaviours.

Another pilot project would extend the timeframe for the production of warden situation reports from the current 72 hour standard to five working days. New guidelines on the classification of “serious bodily injury” were also promulgated in an effort to promote more consistency in how incidents that have “the potential to endanger life, or which results in permanent physical impairment, significant disfigurement or protracted loss of normal functioning” are reported.

At a time when serious and significant incidents such as self injury, attempted suicides and use of force are increasing it seems unwise to reduce and dilute scrutiny or extend the timeframes that have been established to review these events. The initiative to extend the timeframe for production of the warden's situation report to five working days is particularly concerning given that the Office often relies on these preliminary reports to inform investigative staff and decide whether follow-up inquiries are warranted. From an investigative perspective, it is inappropriate to have to wait for up to seven days before information about an incident is shared. This change could well infringe upon the investigative mandate of my Office. Collecting evidence, corroborating information and interviewing witnesses as soon as practical after an incident occurs are critical. Even raw preliminary information is useful in assessing response and determining whether corrective measures are necessary.

These various “streamlining“ initiatives appear driven by administrative convenience. The thoroughness, timeliness or even appropriateness of the Service investigating itself does not seem to be an abiding concern of the internal assurance process. Use of force reviews and other incident investigations are rarely, if ever, released publicly which give rise to yet another set of concerns involving transparency and accountability in corrections.

One case reviewed by my Office during the reporting period raised a significant (and frequent) concern as to why Boards of Investigation rarely interview inmates in the course of establishing their findings, corroborating evidence or verifying the factual record, such as the timing of emergency cell calls and staff response. In this case, a number of inmates contacted the Office after the death of an offender on their range. They raised serious questions about the quality of health care monitoring in this case. Allegations were also made that the deceased inmate had requested help for hours. CSC 's investigative report provided critical findings and recommendations about the quality and responsiveness of health care provided, but it did not interview any of the inmates who had witnessed the incident, nor did it offer an explanation as to why they were not interviewed. Although there may be circumstances when inmates will refuse to cooperate or where, for valid reasons, their testimony could be partial or even irrelevant, CSC investigations should be encouraged to explain why this is so. Otherwise, the factual and investigative record remains incomplete.

Use of Force Involving Mentally Disordered Offenders

Mentally disordered offenders continue to be at increased risk of being involved in use of force interventions due to increased propensity to engage in self-injurious behaviour, unpredictable behaviour and decreased capacity to function as compliant, rule-abiding inmates. As CSC 's use of force policy directs, when circumstances permit the Service is to videotape every planned use of chemical or inflammatory agent and consult with a health care professional before their use to ensure the inmate has no prior known medical condition that would be aggravated by their application. According to CSC , mental health concerns were identified in nearly 30% of all use of force interventions. Incidents involving self-injurious behaviour represented 19% of all use of force interventions reviewed by this Office in 2013-14. The use of pepper spray in nearly 60.4% of all use of force incidents reviewed suggests an increasing reliance on inflammatory agents to respond to behaviours associated with mental illness.

A number of the Office's concerns are highlighted in the case summary (overleaf). Significantly, this incident first came to the attention of the Office when it was reported in the daily Situation Report (or SITREP ). It was not initially regarded by either institutional or regional authorities as a reportable use of force purportedly on the grounds that no physical handling was used to gain compliance. Even when the use of force package (including the video-recording of the incident) was forwarded to national headquarters on the initiative of this Office, it was still not deemed a reviewable use of force on preliminary assessment. Although this decision was eventually reconsidered, the case serves as a cautionary reminder of the gaps and silos that have developed in the Service's approach and review of post-use of force measures involving mentally disordered offenders. The fact that this incident occurred at a regional treatment centre is all the more disturbing considering the serious violations of law and policy caught on video and audio recordings.

Meantime, a series of recommendations brought forward by this Office to strengthen CSC 's use of force review framework for cases involving mentally disordered offenders have either been dismissed or are still awaiting response. For example, the Office's recommendation that the Service conduct a mandatory review of all use of force interventions involving offenders with mental health concerns has not been adopted. It still has not responded to recommendations calling for enhanced scrutiny and new training protocols for interventions involving mentally disordered offenders made in last year's Annual Report, measures the Service is said to be considering in its consolidated response to the Ashley Smith inquest that is now not expected until December 2014.

Once more, these are not new concerns for the Correctional Service. To its credit, while nearly all of CSC 's front-line officers have now received the mandatory two-day awareness session in the fundamentals of mental health, they are not health professionals and prisons are not treatment centres. CSC 's front-line population management approach to challenging inmate behaviour continues to rely almost exclusively on compliance and behavioural inducement methods. In managing a rising number of high risk interventions with offenders who may be suicidal, engaged in chronic self-injurious behavior or suffering from acute psychiatric illness, the Service is increasingly under-equipped and vulnerable. It appears mired in a cycle of behaviour and response that too often and too quickly escalates into a threatened or actual use of force intervention. More de-escalation training is required for front-line officers, but so too is the realization that some seriously disordered inmates simply do not belong in a correctional setting, and that force, no matter how judiciously applied, will not resolve underlying behaviours rooted in mental illness.

Follow Up Investigation at Kent Institution

In January 2014, the Office completed a follow-up review of a series of ongoing challenges at Kent Institution, a maximum security facility in the Pacific Region that has seen more than its share of violent incidents and unrest. ⁴² This was a particularly challenging investigation because one of the underlying issues was the behaviour of some front-line correctional officers who were known to engage in unprofessional conduct. Over time, this contributed to strained working and living conditions for both staff and inmates. It was also a precedent setting investigation as it looked at how workplace culture and labour relations can negatively influence conditions of detention for the inmate population.

The review led to a number of recommendations focused on the selection, promotion, training, mentoring and coaching of front-line staff. It called on CSC to adopt psychological screening methods and practices in selecting front-line recruits who exhibit desirable personal attributes and characteristics. It further recommended that CSC 's core training program should be updated and strengthened in the areas of dynamic security, de-escalation techniques, mental health in corrections, as well as personal and organizational leadership and accountability.

Overall, I was pleased that the review was considered constructive by Kent officials and CSC management. A number of developments can be linked to the review – disciplinary actions were taken against some staff; a concerted effort was initiated to address too much time spent in cells; there has been a reduction in the number of lockdowns and their duration, and; a renewed resolve to foster a more healthy and constructive approach to labour management issues and inmate-staff relations. This follow-up investigation provided insight and opportunity to assess the moral performance ⁴³ of a maximum security facility, a powerful and practical conceptual tool that could be adopted and applied to other maximum security institutions across the country.

Younger Offenders

In my 2005 – 06 Annual Report, I pointed out that the Correctional Service does not meet the special service and program needs of younger (under age 25) inmates. These younger offenders are often in vulnerable situations within federal penitentiaries. Segregation placement, abuse by other inmates, limited access to and success in programming, gang recruitment and delayed conditional release are often hallmarks of their correctional experience.

The CSC does not provide special housing, programming or other services for younger offenders. It does not have dedicated and trained staff to provide specialized support and services to young adults. The Correctional Service's position is that programs and interventions available to all inmates can be adapted to meet the needs of younger offenders. (The same reason offered for refusing to develop more specialized responses to the needs of older and elderly offenders). The reality is that these young men and women continue to endure difficult conditions that threaten their safety and undermine humane custody.

In March 2014, my Office conducted a comparative assessment of younger offenders aged 18 to 25 years with offenders aged 26 and older. We found that younger offenders are:

• more likely to be released later in their sentence, for example, 55% of younger offenders are released at the 2/3 point of their sentence (Statutory Release) compared to 37% for all other offenders
• more likely to be held in maximum-security institutions (19% versus 12% respectively)
• two times more likely to be gang affiliated (14.2% versus 7.5% respectively)
• more than twice as likely to be in administrative and disciplinary segregation (7.1% versus 3.7% respectively)
• more likely to be double-bunked (37.6% versus 31.3% respectively)
• twice as likely to have their parole revoked (less than 10% of the supervised population is aged 18-25, yet they receive 20% of all revocations)
• more likely to be of Aboriginal decent than older offenders (36.6% versus 21.5% respectively)
• more likely to be Black than older offenders (15.5% versus 9% respectively)
• less likely to be educated than older offenders (52.5% versus 40.6% respectively enter federal corrections with a grade 8 or lower education).

This situation needs to be acknowledged and rectified. We must invest in young adults to ensure that they leave the penitentiary system with the skills, insight and experience that will best assist them in the community. Harsher conditions of confinement and lack of tailored and responsive programs and services will continue to lead to poor correctional outcomes for this group.

The experience of Ashley Smith, who entered the federal penitentiary system at age 18 and died less than a year later, serves as a tragic reminder of how corrections can fail young adults. I echo the concerns of the Ashley Smith Coroner's jury and endorse their numerous recommendations related to making the CSC more responsive to the unique needs of young adults incarcerated in penitentiaries.

13. I recommend that the Correctional Service develop and implement a National Strategy for Younger Offenders in collaboration with external stakeholders with expertise in service delivery to young adults. The Strategy should address the need for policies, programs and services tailored specifically to meet the unique needs of offenders aged 25 and under. 

Inmate Pay

As part of CSC 's contribution to the federal government's Deficit Reduction Action Plan, as of October 2013 most offenders will now see more money from their gross inmate pay as well as other sources of income deducted to cover expenses related to food, accommodation and telephone use. These payments are not to exceed a maximum of $90 per week. These changes appear punitive when applied to inmates who already have limited means to meet family support obligations, save for release and pay for basic daily living requirements such as personal hygiene products, buying postage stamps and make a mandatory contribution to the Inmate Welfare Fund. ⁴⁴ The Office estimates that, after mandatory deductions, the pay for a typical offender employed 40 hours a week in a prison industry amounts to about 40 cents an hour. While 10% of earnings are directed to an inmate's savings account, such meagre amounts do not go very far in making a meaningful contribution to assist safe reintegration.

Most offenders that I come into contact with do not disagree that they should contribute to offsetting the costs of meeting their basic daily living, food and accommodation expenses. The difficulty arises when the actual ability to pay is out of balance with the requirement to pay. During the reporting period, changes to inmate pay have been met by a slew of protests and work stoppages at a number of institutions suggesting that the new pay rules and deductions are adding to the tension behind bars.

Clustered Institutions

Effective April 2014, CSC is amalgamating 22 separate institutions into 11 “clustered” sites. Clustering will bring the total number of federal penitentiaries to 43. The move, part of the Service's contribution to the government's Deficit Reduction Action Plan, is expected to generate efficiencies and cost-savings as some services and programs are brought together. Each of these new clustered institutions will be under the leadership of one Institutional Head and will operate as one facility, but with separate units of differing security levels. In practical terms, this means existing minimum security institutions physically located next to a larger institution will be managed by the same institutional head and adopt the name of the parent institution. For example, Frontenac Institution and Collins Bay Institution will be merged into one clustered site known as Collins Bay Institution with a single Warden.

The Office's primary concern regarding this initiative is how the minimum security environment will be preserved within the clustered site. In the past, staff posted to minimum security institutions worked there exclusively; the workplace culture was much more focused on dynamic, as opposed to static, security. As well, the minimum sites had a warden and dedicated management team who would take operational decisions informed by that very different context. With clustered sites, the environment or culture of the larger, parent site (medium or maximum) may spill over into the minimum setting, resulting in a “hardening” of that environment. These concerns have been raised with regional and national authorities and the Office will continue to closely monitor developments as this initiative continues to unfold.

4. Aboriginal Corrections

CSC recently released the results of a research study looking at a sample of Aboriginal offenders enrolled in the Aboriginal Offender Substance Abuse Program. Based on self-reported data for 316 Aboriginal offenders, the study presents a very familiar if troubling profile: ⁴⁵ 

• Half of the sample indicated that they had been in the care of the child welfare system – 71% had spent time in foster care and 39% in a group home.
• 61% had family members who had spent time in prison.
• 73% reported a familial history of involvement with the residential school system; 18% said they themselves were residential school survivors.
• Almost all (96%) indicated that substance use was related to their current offence; 85% reported they were under the influence at the time of their offence.
• 88% reported they had a family member struggling with alcohol or drug addiction issues.
• Significantly nearly one-third of the sample indicated they were first introduced to Aboriginal cultural teachings in prison.

As these numbers indicate, the factors and circumstances that bring Aboriginal people into disproportionate contact with the federal correctional system defy easy solutions. The gap in outcomes between Aboriginal and non-Aboriginal offenders is widening as the most significant indicators of correctional performance continue to trend downward. Aboriginal people under federal sentence tend to be younger, less educated, and more likely to present a history of substance abuse, addictions and mental health concerns. They are more likely to be serving a sentence for violence, stay longer in prison before first release and more likely to be kept at higher security institutions. They are more likely to be gang-affiliated, over-involved in use of force interventions and spend disproportionate time in segregation. Aboriginal offenders are more likely denied parole, revoked and returned to prison more often.

The situation is compounded by the fact that the proportion of Aboriginal people under federal sentence is growing rapidly. Since March 2005, the federal inmate population increased overall by 2,203 offenders (or 17.5%). Over the same period, the Aboriginal inmate population grew by 1,088 (or 47.4%). Today, Aboriginal people comprise 22.8% of the total incarcerated population, although they comprise just 4% of Canada's population. The Prairie region now manages 51% of the national Aboriginal offender population.

The news is not all bad. For example, there is some positive progress being reported in the areas of Escorted and Unescorted Temporary Absences for Aboriginal offenders to participate in cultural activities and to maintain community contact, as well as higher program enrolment and completion rates in Aboriginal-specific programs and interventions. The Correctional Service is creating more Aboriginal-specific positions such as Aboriginal Community Development, Programs and Community Liaison Officers. The number of Aboriginal offenders returning to their communities is finally beginning to turn slightly upward after years of steady decline.

Consideration of individual and social histories that have formed the Aboriginal experience in Canada – e.g. effects of the residential school system, negative experience in the child welfare or adoption system, family histories of substance abuse, poverty and poor living conditions, lack of formal schooling – are beginning to be more widely incorporated in CSC 's policy and decision-making frameworks. Even still, progress and compliance with integrating this 2008 policy standard is still far too slow and inconsistent. To be most effective Aboriginal Social History factors need to be considered at crucial points in the case management process – custody rating scale, security classification, penitentiary placement, and conditional release decision making. While mindful of some progress, there are still too many Aboriginal offenders whose initial custody rating scale is overridden to higher security, too many day and full parole waivers, suspensions and revocations, and statutory releases. There are reported disconnects between front-line staff and those involved in managing the rather unwieldy performance measures contained in CSC 's Aboriginal Corrections Accountability Framework. There is definite room for enhancing Aboriginal cultural competence in the areas of health promotion, peer education and inmate employment. More effort needs to be directed to supporting Elders in delivering culturally appropriate services, spirituality and ceremony inside federal institutions.

While I have been concerned with the lack of responsiveness to my reports and recommendations on Aboriginal corrections I sense that there is deep concern about these issues at the local community level. Through the reporting period, I have met with a number of Aboriginal leaders representing local bands, provincial, territorial and national Federations and Grand Councils. Among local and national leaderships, there is both engagement in and concern about how to best address the disproportionate rates of crime, victimization and incarceration among Canada's Aboriginal peoples. There appears to be renewed interest to use Aboriginal specific provisions of the law to better support safe and timely release of Aboriginal offenders who want to return to their home communities. CSC is encouraged to engage this interest.

14. I recommend that CSC conduct an audit to assess whether Aboriginal Social History factors are being adequately considered in case management records and decisions. 

5. Federally Sentenced Women

Federally Sentenced Women ( FSW ) make up a very small portion of the total offender population (4.9%), yet are among the fastest growing sub-populations in federal corrections today. Over the last decade, the number of women offenders (incarcerated and in the community) increased by 30%. The growth in the FSW population has been largest within the incarcerated population. Since 2004-05, the number of women in custody has increased by 66.8%. More than one in three women inmates are of Aboriginal ancestry. While their relative proportion within the total incarcerated population has remained stable over the past decade, the total number of Aboriginal women inmates has more than doubled since 2004-05. Reflecting this growth, the number of complaints to the Office by women offenders increased by 41.37% (from 336 to 475) over the last five years.

A recent CSC study of mental health prevalence among FSW found that 94% of women in the sample experienced symptoms consistent with a diagnosis of a psychiatric disorder, and eight in ten women had had a history of substance or alcohol abuse. ⁴⁶ As of August 2013, 62.6% of incarcerated women were prescribed some form of psychotropic medication to manage mental health symptoms.

The number of self-injury incidents among federally sentenced women is increasing at an alarming rate, essentially doubling in the past few years. In 2013-14, there were 559 incidents of self-injury among women offenders. Fully one-quarter were met with a use of force intervention. ⁴⁷ By comparison, in 2011-12 there were 243 incidents of self-injury and only 15% involved a use of force intervention. Over the same two year period, the number of women engaging in incidents of self-injury increased by almost 40%. The resort to prolific and at times near lethal self-injurious behaviour among a handful of federally sentenced women reinforces the need to move these women to outside treatment centres.

An April 1, 2014 snapshot of incarcerated women found:

• seven out of ten women inmates are single ⁴⁸ 
• more than 60% are between the ages of 20 and 39
• almost half (45%) are classified as medium security
• 52.4% are serving a sentence between 2 and 4 years
• most are classified as high need and risk
• women inmates tend to demonstrate higher levels of motivation and reintegration potential compared to their male counterparts.

In addition to being young, serving relatively short sentences and demonstrating high levels of need, three in four incarcerated women are also mothers to children under the age of 18. At the time of their arrest, almost two-thirds of women offenders were single caregivers and over half reported having had experiences with Children's Aid – often due to substance abuse, mental health concerns or issues of abuse/ neglect. ⁴⁹ Maintaining family relationships between women and their children throughout their incarceration increases the chances of a woman's successful reintegration following her sentence, but presents a number of challenges in the correctional environment. Often, women report that visits are difficult to coordinate with the current primary caregiver and that long distance visits and telephone calls are not practical or affordable.

To address some of these issues, CSC has piloted an initiative called CHILD LINK which allows women inmates to maintain remote contact with their children via WebEx. The Office supports the implementation of this initiative across all sites, and encourages the CSC to examine and address the challenges faced by women from remote areas or who are not located in their home province to maximize participation.

15. I recommend that CSC implement CHILD LINK at all regional women's facilities. 

Independent Review of Assaults in Secure Units

In its 2011-2012 Annual Report, the Office recommended that CSC convene an investigation into all assaults that occurred in the Secure Units (i.e. maximum security) in FY 2011-2012. The resulting Independent Review of Assaults in the Secure Units (2011-2012) was provided to my Office in November 2013. It confirms a number of recent trends and concerns identified by the Office:

• Erosion of “Creating Choices” principles in the regional women's facilities. ⁵⁰ 
• Gaps in dynamic security.
• Non-compliance with use of force reporting and preservation and retention of video recordings.
• Infrastructure deficiencies limiting direct lines of sight onto living units and ranges. ⁵¹ 

Although the Independent Review did not address double bunking assessments/assignments in the Secure Units, the Office remains concerned that these placements are not being adequately monitored or assessed. A recent visit to a women's institution found that Double Bunking Assessments ( DBAs ) ⁵² for the Secure Unit were improperly completed in the case of all of the women currently double-bunked. The DBAs on this unit were not appropriately updated to reflect changes in the needs/ risks of individual women or to determine compatibility in cases where there were changes to the individuals placed in a shared maximum security cell. The Office is of the view that diligence is required to ensure the safety of offenders and staff members alike in the Secure Units.

16. I recommend that CSC conduct a review of double-bunking assessments and assignments in the Secure Units. 

Release and Reintegration Considerations

Over the last decade, there has been a reversal in the ratio of the proportion of the women population that is incarcerated and in the community. In FY 2004-2005, 57% of the total federally sentenced women population were in the community, compared to 43% incarcerated. Today, 57% of FSW offenders are incarcerated and 43% are in the community.

Despite these trends, the number of FSW released on conditional release (Day Parole and Full Parole) has increased, and outcomes have remained largely unchanged over the last decade. Compared to male offenders, federally sentenced women are:

• less likely to be revoked for an offence (non-violent or violent)
• have more successful completion rates (averaging more than a 90% success rate for Day Parole and Full Parole in FY 2012-2013)
• less likely to be revoked for breach of conditions.

Recognizing the comparative success of women released to the community, CSC has made a number of investments in its community strategy over the last several years. Stand-alone minimum security units are under construction outside of perimeter fences at four of the five regional women's facilities and are scheduled to be operational in FY 2014-2015. Since 2008, three additional Women's Supervision Units ⁵³ (for a total of 9) were created to support women released to the community. In the five year period between FY 2008-2009 and 2012-2013, the number of beds available in women-only facilities in the community increased by 18% (from 194 beds to 229). The number of beds in co-ed facilities (i.e. the bed can be designated for men or women depending upon need) more than doubled over the same period (from 89 to 233 beds). Most additional bed spaces for women were created in community-based residential facilities ( CRF ), though a number of beds were also made available in hostels (11.3%), treatment centres (4.9%) and private home placement facilities (2.2%). ⁵⁴ 

An increase in the number of beds to accommodate women in the community is encouraging, but is only helpful if the beds are distributed according to demonstrated need, and actually ‘filled'. In FY 2012-2013, the average number of beds ‘in use' was only 64.7%, and usage rates varied across regions.

Source: Glube and Panel Recommendation and Review, 2013. 

For women released with addictions or substance abuse needs the number of treatment beds available is still quite low, with a service capacity of only 13% of the population. Responding to needs and capacity is not always easy. For women from Nunavut, Whitehorse and Yukon territories, the closest community beds are located in Ottawa, ON , Edmonton, AB and Prince George, BC , respectively. The challenge for CSC in coming years is to ensure that the location and types of beds available are responsive to the needs of ex-inmates returning to the community. I encourage the Service to carefully assess these needs and adjust its resource allocation accordingly.

Correctional Investigator's Outlook for 2014-15

I fully expect another busy and challenging year ahead for my Office and the Correctional Service. Funding of CSC 's budget is set to decrease again in 2014-15 by $262.9M representing an overall reduction of 10.1% from the previous year. Substantial reductions are expected in correctional interventions and community supervision program activities. The Office will monitor the impact of these and other deficit reduction and cost containment measures on activities to support timely reintegration and safe community corrections.

Other CSC initiatives that require attention in the coming year include:

1. Streamlining of case management activities
2. Completion and opening of new cells and units across the country
3. Response to the Ashley Smith inquest and recommendations
4. Regional Treatment Center (Ontario) developments

The Office also intends to look more closely at the issue of offender employment and employability within institutions and Corcan industries. We will focus on the capacity of the Service to deliver meaningful work and “job ready” vocational training opportunities that directly support community reintegration. The Office will investigate the use and management of prescription drugs in CSC facilities in light of high rates of psychotropic use among federally sentenced women offenders. Finally, the Office intends to look more closely at the issue of prison suicides in segregation and observation cells.

Recently, the Supreme Court of Canada ( SCC ) has made two significant decisions that will have an impact on federal corrections going forward. In Khela , the SCC ruled that the decision to transfer an inmate to a higher security penitentiary must, among other requirements, be procedurally fair. At issue in this case was whether federal prisoners should have access to the provincial superior courts. The SCC ruled unanimously that they do. Whaling dealt with offenders who would have been eligible for Accelerated Parole Review prior to coming into force of the Abolition of Early Parole Act . As a result of this decision, CSC is required to review and bring retroactive cases to the Parole Board for decision in a timely manner. We will watch how the Service responds to these decisions.

Internally, how the Office responds to Aboriginal offenders appears to require further focus and attention. The number of Aboriginal offenders making formal contact with the Office through our complaint process has actually declined in recent years suggesting that there may be some real or perceived barriers in accessibility, communication, effectiveness and engagement. My Office will look to see if improvements are required in how we interact with Aboriginal offenders.

Finally, in the coming year, I look forward to some tangible improvement in terms of how the Service assesses and responds to systemic concerns brought forward by my Office. In a short period of time the Office has completed a series of in-depth investigations into matters involving prison self-injury, diversity in corrections, mental health, Aboriginal corrections and prevention of deaths in custody. The Service's response has often been found to be lacking and delayed. On too many occasions I have had to formally remind or request the Service's response well after a reasonable period of time had passed. Though I accept there are times when our two organizations will “agree to disagree,” I continue to expect a full, thoughtful and timely response to all recommendations. Timeliness, responsiveness and respect are in our mutual interests.

I want to close by offering my sincere thanks and gratitude to the staff who carry out my Office's challenging mandate with professionalism and excellence. Ten years into this position and I am still impressed on a daily basis by the quality and commitment of my staff to make a meaningful and lasting contribution to public safety in Canada. Thank you!

Ed McIsaac Human Rights in Corrections Award

The Ed McIsaac Human Rights in Corrections Award was established in December 2008, in honour of Mr. Ed McIsaac, long-time Executive Director of the Office of the Correctional Investigator and strong promoter and defender of human rights in federal corrections. It commemorates outstanding achievement and commitments to improving corrections in Canada and protecting the human rights of the incarcerated.

The 2013 recipient of the Ed McIsaac Human Rights in Corrections Award was Graham Stewart, former Executive Director of the John Howard Society of Canada. The award was presented in Ottawa on October 24, 2013.

Annex A 
Summary of Recommendations

1. I recommend that CSC develop a comprehensive pre-release planning strategy that includes mandatory meetings between offenders and their institutional and community parole officer, a process to ensure an offender's official documents (i.e. birth certificate and health card) are available prior to release, and a handbook identifying programs, services and supports available in the release community. 
2. I recommend that every Community Correctional Centre have consistent access to the necessary resources, including nurses, social workers and psychologists, to ensure access to appropriate services and care. 
3. I recommend that CSC develop a national training plan specific to employees working in Community Correctional Centers. 
4. I recommend that CSC develop a national partnership strategy for Community Correctional Centres which includes creating an inventory of services and partners that are available, identifying gaps in partnerships (e.g. cultural groups), a communications plan that educates and informs community members, and a timetable for monitoring and reporting on these activities. 
5. I recommend that CSC conduct an operational audit of resources allocated to community corrections and Community Correctional Centres specifically. The outcome of this audit should help inform reallocation decisions and the development of renewed monitoring and reporting strategy for CCC s. 
6. I recommend that CSC establish a working committee with the Parole Board of Canada to examine best practices and guidelines regarding the appropriate use of residency conditions for offenders released on statutory release and offenders on a long-term supervision order. 
7. I recommend that CSC move forward the completion date of the electronic offender health information system. This may require new or reallocated funds. 
8. I recommend that CSC 's review of chronic health conditions be integrated with and inform a comprehensive prevention strategy to reduce premature mortality. 
9. I recommend that efforts to ensure identification, ongoing monitoring and treatment of HIV infection in CSC facilities be a priority and that relevant systems to ensure timely and effective diagnosis and treatment are put in place. 
10. I recommend that CSC develop a comprehensive integrated model to treat offenders with concurrent substance abuse and mental health disorders. 
11. I recommend that CSC reconsider its response to the Office's report on the mortality review process to more specifically address the concerns about the lack of rigour, independence, credibility and timeliness in how the Service currently investigates natural cause fatalities. 
12. I recommend that CSC issue a Request for Proposal to secure palliative community services and accommodations to allow terminally ill offenders to die with dignity in the community. 
13. I recommend that the Correctional Service develop and implement a National Strategy for Younger Offenders in collaboration with external stakeholders with expertise in service delivery to young adults. The Strategy should address the need for policies, programs and services tailored specifically to meet the unique needs of offenders aged 25 and under. 
14. I recommend that CSC conduct an audit to assess whether Aboriginal Social History factors are being adequately considered in case management records and decisions. 
15. I recommend that CSC implement CHILD LINK at all regional women's facilities. 
16. I recommend that CSC conduct a review of double-bunking assessments and assignments in the Secure Units. 

Annex B 
Annual Statistics

Table A: Complaints (1) By Category

Complaints - see Glossary (1), Internal Response - see Glossary (2), Investigation - see Glossary (3)

Table B: Complaints By Institution / Region

Table C: Complaints and Inmate Population by Region

Table D: Disposition of Complaints by Action

Table E: Areas of Concern Most Frequently Identified by Offenders

^[**] Case Preparation, Financial Matters and Security Classification received 12 complaints each.

Annex C 
Other Statistics

A. Mandated Reviews Conducted in 2013-14

As per the Corrections and Conditional Release Act (CCRA) , the Office of the Correctional Investigator reviews all CSC investigations involving incidents of inmate serious bodily injury or death.

Mandated Reviews by Type of Incident

^[*] Deaths due to ‘natural causes' are investigated under a separate Mortality Review process involving a file review conducted at National Headquarters.

^[**] Investigations convened under S. 97 & 98 of the CCRA, including disturbances, sexual assault, etc.

B. Use of Force Reviews Conducted by the OCI in 2013-14

Per policy, the Correctional Service is required to provide all pertinent and relevant use of force documentation to the Office. Use of force documentation typically includes:

• Use of Force Report,
• Copy of incident-related video recording,
• Checklist for Health Services Review of Use of Force,
• Post-incident Checklist,
• Officer's Statement/Observation Report; and,
• Action plan to address deficiencies.

OCI Use of Force Statistics for 2013-14

Use of force measures applied

Indicators of concerns

Injuries

C. Toll-Free Contacts in 2013-14

Offenders and members of the public can contact the OCI by calling our toll-free number (1-877-885-8848) anywhere in Canada. All communications between offenders and the OCI are confidential.

Number of toll-free contacts received in the reporting period: 18,867

Number of minutes recorded on toll-free line: 85,380

D. National Level Investigations in 2013-14

1. Deaths in Custody (Mortality Review) – An Investigation of the Correctional Service's Mortality Review Process – Released December 18, 2013.
2. Chronic Self-Injury Among Women Offenders – Risky Business: An Investigation of the Treatment and Management of Chronic Self-Injury Among Federally Sentenced Women – Released September 30, 2013.
3. Follow-up to Unauthorized Force: An Investigation into the Dangerous Use of Firearms at Kent Institution between January 8 and January 18, 2010 – Letter to Commissioner and CSC official response posted on OCI website.
4. Community Correctional Centres ( CCC s) – Special Focus in 2013-2014 Annual Report.