BACKGROUNDER - 2020-2021 Annual Report of the Office of the Correctional Investigator



The 2020-21 Annual Report of the Office of the Correctional Investigator (OCI) was tabled in Parliament on February 10, 2022. Major sections include:

  • Correctional Investigator’s Message, which contains a summary of Office reporting and recommendations concerning Correctional Service of Canada’s (CSC) response to the COVID-19 pandemic. 

  • Summary of significant cases and updates on major files, including sexual coercion and violence behind bars. 

  • Six national investigations in areas of systemic concern. 

  • Assessment of mandatory reporting requirements imposed on small and micro-agencies, like the OCI. 

  • Twenty recommendations – including four outside the direct responsibility of the CSC. 

  • Correctional Investigator’s Outlook for federal corrections in 2021-22. 

  • Four Annexes – Summary of Recommendations, Annual and Other Statistics (e.g. Mandated Reviews and Use of Force Reviews conducted in 2020-21) and Corporate Reporting Information


1. Uses of Force Involving Federally Incarcerated Black, Indigenous, Peoples of Colour (BIPOC) and Other Vulnerable Populations

Purpose and Context 

This investigation examines the intersection of race and involvement in use of force incidents in federal penitentiaries over a five-year review period (2015 to 2020).

General Findings 

  • Use of force incidents have been steadily increasing over the last five years, despite an overall decline in the prison population, and the introduction of major changes to incident management (i.e., implementation of the Engagement and Intervention Model) that was expected to result in fewer uses of force. 

  • Inflammatory spray (pepper spray) continues to be over-utilized and is the most common type of force used, accounting for more than 40% of all incidents. 

  • A significant proportion of individuals involved in use of force incidents had a history of suicide attempt(s), self-injury, and/or other mental health needs. More than one-quarter (27%) of all use-of-force incidents involving federally sentenced women were in response to self-injurious behaviour.

Specific Findings 

  • Race was found to be uniquely associated with over-representation of Black, Indigenous, and Peoples of Colour (BIPOC) in use of force incidents in federal prisons. Specifically, BIPOC persons accounted for 60% of all uses of force, while representing 44% of the federally incarcerated population. 

  • Regardless of risk level, security level, age, sentence length or gender, identifying as Indigenous or Black was associated with a greater likelihood of involvement in a use of force incident. Specifically, Black and Indigenous individuals accounted for 51% of all individuals involved in uses of force over the last 5 years, while representing 37% of the federal prison population. This trend line is getting worse. 

  • Indigenous peoples in particular are vastly over-represented in uses of force, accounting for 39% of individuals involved in uses of force over the last 5 years, while representing 28% of population (on average) during the same period. 

  • In addition to being over-represented, Black and Indigenous individuals experience more uses of force on average per person, and this is particularly the case for Indigenous persons. 

  • BIPOC women account for more than two-thirds of all women involved in uses of force. These high numbers are driven by the increasing proportion of Indigenous women in federal custody, who, over the period of the study, accounted for 60% of all women involved in a use of force incident, while comprising 40% of incarcerated women. 

  • Use of force in federal corrections appears vulnerable to the influence of racial bias.

2.  Review of Women’s Corrections 30-Years since Creating Choices 

Context and Purpose 

This investigation examines progress made in women’s corrections over the last 30 years against the principles and problems identified in Creating Choices , the 1990 Report of the Task Force on Federally Sentenced Women.

General Findings 

  • Admissions to women’s federal correctional facilities more than tripled, from 170 in 1990-91 to 562 in 2019-20. 

  • The composition of the population has changed significantly. Indigenous women now comprise 43% of the federally sentenced women population, up from 23% in 1990-91.

Specific Findings 

  • Nearly all of the problems identified thirty years ago (inadequate infrastructure, over-securitization, lack of programming and services, poor community reintegration practices) remain significant areas of concern today and continue to contribute to poor correctional outcomes for many incarcerated women. 

  • Many of the progressive principles and ideas of Creating Choices – presumption of minimum-security classification at admission; no perimeter fencing; no maximum-security units; no segregation for incarcerated women; use of strip-searching – have been abandoned in favour of a framework that puts security and control at the forefront. Specific correctional practices, such as random strip searches, re-traumatize women, many of whom have histories of physical and/or sexual abuse. 

  • The Office continues to hear complaints about staff who discriminate or bully women on the basis of their race, sexual orientation, gender identity or expression.  This workplace culture in no way contributes to a healing environment. 

  • Programming, services, and interventions remain problematic. While we heard from some women that they have had positive experiences in programs, correctional programming is not resulting in better community outcomes for many others. Indigenous women have limited access to specialized programming, and to Elders and Indigenous Liaison Officers. Job training for women is often grounded in gendered roles and expectations, offering few marketable skills. 

  • The Office concludes that a security-driven approach pervades nearly every aspect of contemporary women’s corrections, preventing CSC from fully realizing the vision in Creating Choices .

3. Structured Intervention Units(SIUs)

Purpose and Context : This investigation makes preliminary observations related to the introduction of SIUs in penitentiaries, which replaced solitary confinement (administrative segregation) in November 2019. These early findings are based on in-person interviews, analysis of complaints from individuals in SIUs, reviews of Independent External Decision Maker (IEDM) decisions and response to questionnaires sent to CSC staff and individuals working or housed in SIUs.

Preliminary Findings 

  1. As of May 2021, 46.8% of persons housed in an SIU self-identified as Indigenous. 

  2. Problems with data collection, accountability and transparency limit the ability to assess SIU compliance with mandated measures and safeguards – out of cell time, “meaningful” human contact, reason for placement. 

  3. No public records regarding compliance with Independent External Decision Maker (IEDM) removal orders from SIUs. 

  4. SIUs purportedly have more favourable conditions of confinement and better access to services compared to other areas of maximum-security facilities. As a result, prisoners often refuse to voluntarily leave these units.

4. Medical Isolation in Federal Corrections

Context and Purpose : This investigation examines the use of medical isolation (quarantine periods) in context of reducing COVID-19 transmission in federal prisons.


  • CSC’s approach to medical isolation has the potential to violate or degrade residual liberties and minimum standards guaranteed in law (e.g. access to fresh air exercise, out of cell time, access to programs and services). 

  • CSC lacks capacity to track medical isolation stays beyond 14 days. 

  • Use of medical isolation in CSC facilities appears to exceed the need, potentially going beyond quarantine periods or clinical relevance criteria recommended by public health authorities.

5. Suicide in a Maximum-Security Facility

Context and Purpose 

This investigation examines a series of cumulative failures that contributed to the tragic suicide of a young Indigenous man ( M ) in a maximum-security facility.


  • Early into his incarceration, M was the victim of a serious assault carried out by a group of prisoners. From that point forward, M expressed fear for his life and safety. He requested a “voluntary” placement in segregation and refused to be returned to mainstream population. M was maintained in segregation or other restricted confinement up until his suicide six months later. 

  • M was subject to three involuntary transfers across the country to alleviate his administrative segregation (solitary confinement) status, which was used to manage his disruptive, assaultive and self-injurious behaviours. With each transfer, M became increasingly isolated and withdrawn, disengaging with his correctional plan, mental health and cultural supports. M’s mental health needs should have effectively ruled out involuntary transfers and placements in solitary confinement.


  • CSC’s internal investigation documented 6 suicide attempts, 12 incidents of self-injurious behaviour and 22 expressions of suicidal ideation. Despite a clear and escalating pattern in the severity and frequency of M’s suicidal and self-injurious behaviour, a comprehensive assessment of M’s suicidal risk was never completed. 

  • Acts of self-injury were considered instrumental or wilful in nature, and were often met with force. 

  • No coordinated mental health continuum of care was present among the various transfer sites. Clinical progress notes and concerns were not forwarded from one site to another. 

  • There was little regional or national oversight of this case, despite M’s complex mental health needs. 

  • M’s Indigenous status, which should have informed his care and treatment plans, was not taken into account in sentence administration. 

  • CSC’s investigation concluded that “there were no pre-incident indicators that could have predicted M’s death,” which seems at odds with several immediate, documented and known suicide risk factors: 

    • M refused his noontime meal, then hanged himself a few hours later. 

    • M had accrued prison debts and paid them off the before his death. 

    • M had fashioned a noose and hung it on the back of his window the week before his suicide. 

    • M spoke of the loss of family members immediately preceding his own death.
  • Lessons learned from other preventable deaths, particularly in relation to suicides in solitary confinement, do not seem to be applied from one incident investigation to the next.

6. Canada’s Ratification of the Optional Protocol to the Convention against Torture (OPCAT)

Issue : Despite persistent appeals by this Office and many others, and successive government promises to do so, Canada has yet to ratify the Optional Protocol to the Convention against Torture (OPCAT). Ratification would create a framework for independent national and international inspection of all places of detention in Canada.

  • Canada lacks a coordinated and proactive framework of monitoring and inspection of places where citizens are deprived of their liberty. 

  • The OPCAT would create a single mechanism for inspection of detention facilities under federal authority (penitentiaries, immigration holding centres, Canadian Forces Service Prisons and Detention Barracks and RCMP holding cells). 

  • More broadly, the OPCAT would extend to all places and persons deprived of liberty regardless of cause, circumstance or context.


Reporting Burden on Micro Agencies

  • As a micro-agency of 40 employees, the OCI has the same mandatory reporting requirements as the Correctional Service of Canada (19,000 employees). 

  • The Office is required to complete 40 corporate reports each year, many of which are redundant or duplicative. 

  • The burden to produce these reports constrains delivery of the Office’s core mandate. 

  • Essential elements of public reporting (transparency, results for Canadians, performance, accountability, stewardship and value for money) can be condensed into a single 12-page report, which is appended to this year’s Annual Report.


The 2020-21 Annual Report makes 20 recommendations. Key recommendations include:

  1. CSC promptly develop an action plan in consultation with stakeholders to address the relationship between use-of-force and systemic racism against Indigenous and Black individuals and publicly report on actionable changes to policy and practice that will effectively reduce the over-representation of these groups among those exposed to uses of force. 

  2. CSC should return to the basic principles identified in Creating Choices and develop a long-term strategy to ensure that all women are prepared at their earliest date possible to return to the community and that significant resources be reallocated to the community supervision program and community correctional programming to support women back in the community. 

  3. CSC should publish forthwith a quarterly record of SIU placement authorizations under section 34 (2) of the CCRA, including the reasons cited for granting authorization. This record should also include the number of instances where individuals were subjected to Restricted Movement under section 37.91 (1) of the CCRA. 

  4. CSC should discontinue the practice of labeling non-suicidal self-injurious behaviour in prisons settings as ‘instrumental, ‘willful’ or ‘deliberate’ in nature or intent. A comprehensive mental health assessment of self-injurious and suicidal persons should be completed, and clear guidance provided to front-line staff in how to manage and de-escalate incidents of self-injurious and suicidal behaviour. 

  5. The Prime Minister of Canada should fulfill the Government’s commitment by signing the Optional Protocol to the Convention against Torture and taking concrete steps within the next four years to ensure that this important human rights instrument is ratified.

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