BACKGROUNDER - 2024-2025 Annual Report of the Office of the Correctional Investigator

Body

Summary of Systemic Investigations, Findings, and Recommendations

OVERVIEW

The 2024-25 Annual Report of the Office of the Correctional Investigator (OCI) was tabled in Parliament on October 30, 2025, and includes the following:

  1. The Correctional Investigator’s (CI) Message, which provides a high-level summary of the findings from six investigations examining systemic issues related to the quality and accessibility of mental health care in federal correctional facilities. Beyond the recommendations presented throughout the report, the CI outlines two substantive recommendations directed to the Correctional Service of Canada (CSC) and Public Safety Canada, specifically concerning the operation and oversight of regional treatment centres. The message also highlights key achievements during the CI’s tenure and notes the CI’s upcoming retirement.

  2. Six national-level investigations, including:

    1. Regional Treatment Centres in Crisis: The Erosion of Mental Health Care in Federal Corrections
    2. Falling Through the Cracks: Federally Sentenced Individuals with Cognitive Deficits
    3. Community’s Burden: The Discontinuity of Post-Release Mental Health Services
    4. An Update on Therapeutic Ranges and Intermediate Mental Health Care
    5. Assessing and Addressing Trauma in Federally Sentenced Women
    6. Mental Health Needs and Services for Indigenous Peoples in Federal Corrections
  3. A total of 425 interviews were conducted with federally-sentenced individuals, making this the most comprehensive investigation this Office has ever completed on mental health in federal corrections. Further to these investigations, 21 recommendations were issued: 19 directed to the Correctional Service of Canada and two to the Minister of Public Safety. The corresponding responses to each recommendation are integrated throughout the report.
  4. The Correctional Investigator’s Outlook for federal corrections in 2025-2026.
  5. Statistical Annexes.

NATIONAL SYSTEMIC INVESTIGATIONS

Regional Treatment Centres in Crisis: The Erosion of Mental Health Care in Federal Corrections

Purpose

Conduct an in-depth review of CSC’s Regional Treatment Centres (RTCs), including, but not limited to, the governance structure, staff selection and training, the dynamic between security and health care, the quality of mental health care, infrastructure, challenges of the ‘hybrid’ model, deaths in custody and related National Board of Investigations (NBOIs), and examples of promising practices.

Findings

  • Outdated and inappropriate infrastructure for a psychiatric and therapeutic hospital setting.
  • RTCs have become holding centres for the growing number of aging and infirm persons behind bars.
  • Security responses take precedence over the delivery of physical and mental health care.
  • Over-reliance on the use of force on patients, including the concerning use of OC (oleoresin capsicum) spray to interrupt self-injury.
  • Weak governance structure and absence of national policy lead to role confusion and the undermining of clinical decision-making by mental health professionals.
  • Poor recruitment, selection, and training of staff, who lack specialization for a mental health setting.
  • The ‘stabilization’ of behavioural symptoms of mental health appears to be the overriding objective of co-located RTCs.
  • Per a review of NBOIs, CSC has systematically failed to learn from or prevent numerous serious incidents and deaths.
  • The marked absence of dedicated patient advocates in RTCs infringes on patients’ rights and needs.

Recommendations

The OCI recommends that:

  1. CSC’s RTCs be redefined and formally recognized as Intermediate Mental Health Care facilities, with limited capacity to manage emergency psychiatric cases. Individuals diagnosed with serious mental illness should be transferred to community-based psychiatric hospitals better suited to meet their needs.
  2. The Government of Canada/Minister of Public Safety reconsider its recent $1.3 billion investment in a replacement facility for RTC Atlantic. Instead, efforts and funding should be redirected to facilitating the transfer of individuals with serious mental illness to provincial psychiatric hospitals. This includes supporting the creation or expansion of bed space in provinces facing capacity constraints.

Once the RTCs are reprofiled as Intermediate Mental Health Care facilities, the OCI recommends that:

  1. CSC work with mental health professionals to see how the current RTC infrastructure could be significantly improved in order to become more therapeutic.
  2. The Minister of Public Safety review and assess release options for older and long-serving patients who do not pose undue risk to public safety and advance legislative amendments to the Corrections and Conditional Release Act accordingly.
  3. CSC develop a policy specific to the governance and operation of the RTCs, in consultation with external experienced mental health professionals.
  4. CSC review the implementation of the Engagement and Intervention Model and end the use of inflammatory sprays as a first response to incidents of self-harm, in favour of health care-driven, de-escalation, and therapeutic responses and techniques.
  5. CSC develop a governance model for RTCs that includes an autonomous reporting and governance structure so that all matters related to health are decided by clinicians, not Wardens or operational staff.
  6. CSC develop training, onboarding, policies, procedures and directives specific to the function and purpose of RTCs and the welfare of patients.
  7. CSC develop a specific mandate and mission statement that reflects the purpose, goals, and methodology around which staff across disciplines can collectively unify their efforts to achieve a common goal.
  8. CSC develop practices to ensure that the NBOI process balances investigation of compliance-driven issues with issues of quality, nature, and frequency of interventions provided to individuals with mental health concerns to prevent further deaths and serious injury.
  9. CSC immediately introduce, at minimum, one Patient Advocate in each RTC to support patient-centred care and provide independent advocacy for patients in navigating the medical system in a correctional context.

Falling Through the Cracks: Federally Sentenced Individuals with Cognitive Deficits

Purpose

Review CSC’s approach to identifying, supporting, and tailoring services and interventions for individuals with cognitive deficits (with a focus on intellectual developmental disorder, fetal alcohol spectrum disorder, autism spectrum disorder, and traumatic brain injury).

Findings

  • Outdated, vague, high-level, and brief policies provide little guidance to staff.
  • There is growing evidence to suggest that prevalence of cognitive deficits is underestimated and that these individuals are overrepresented in correctional settings.
  • Individuals with cognitive deficits face multiple challenges of stigma, increased risk of victimization, bullying, and difficulties navigating the institutional environment.
  • Ineffective and inconsistent screening and assessment tools lead to individuals being overlooked.
  • CSC lacks a systematic and effective approach to addressing the diverse responsivity needs of individuals with cognitive deficits in programming, education and vocational training.
  • Inadequate staff training and insufficient resources compromise the quality of care.

Recommendations

In partnership with external, community organizations with expertise on cognitive deficits, the OCI recommends that CSC:

  1. Review and update Guideline 800-10: Intellectual Disability and the Mental Health Guidelines to provide more comprehensive policy and guidelines for the management and supervision of individuals with cognitive deficits by the end of fiscal year 2025-2026.
  2. Identify and implement a consistent, comprehensive, timely and standardized approach to the screening and assessment of individuals with cognitive deficits.
  3. Ensure adapted correctional programs are available at all sites, facilitators are properly trained, and admission criteria are broadened to increase access.
  4. Implement new mandatory training on working with individuals with cognitive deficits in a correctional environment for all staff by 2026-2027, including more comprehensive materials for correctional officer training.

Community’s Burden: The Discontinuity of Post-Release Mental Health Services

Purpose

Examine the continuity of mental health services for federally sentenced persons assessed by CSC as having high mental health needs and requiring additional support upon release into the community.

Findings

  • There has been a gradual decline in funding and an overall erosion of CSC’s Community Mental Health Services.
  • There is a clear disconnect between policy and the realities faced by community staff.
  • Flawed mental health assessment tool excludes many who need community support.
  • Poor engagement and information sharing between institutions and the community hinder effective discharge planning and continuity of care for offenders.
  • Individuals face significant barriers to accessing mental health services upon release due to the abrupt termination of CSC-provided care and the lack of personal identification.
  • Significant impediments to accessing housing create additional challenges for individuals in the community with mental health needs.

Recommendations

The OCI recommends that CSC:

  1. Double the budget allocation to community-based residential facilities, Community Correctional Centres (CCCs), and community mental health services, over the next five fiscal years, to meet the changing mental health profile of parolees; appropriately compensate external partners and service providers; and ensure that community mental health and transitional services are resourced adequately.

  2. Implement changes to discharge planning and community mental health by the end of fiscal year 2025-2026, including the following:

    • Update and streamline national policies and tools
    • Implement a mental health needs assessment tool that enables reintegration planning
    • Improve training, education, and policies around information sharing
    • Ensure compliance with policies around releasing individuals with government identification
    • Remove barriers to accessing government funded health and mental health care on release by focusing on improving collaboration with provincial and territorial health authorities as well as community partners.

Update on Therapeutic Ranges and Intermediate Mental Health Care

Purpose

Conduct a follow-up review of the Therapeutic Ranges and investigate Intermediate Mental Health Care (IMHC) more broadly.

Findings

Findings were consistent with concerns raised in CSC’s IMHC Working Group Report (2023).

  • Overall progress in Therapeutic Ranges, which operate only in name, remains stagnant 5 years later.
  • Lack of a standardized approach results in inconsistent care and competing demands and resources.
  • Inadequate infrastructure, including deficiencies in the units’ look and feel, hinders a therapeutic environment and renders them indistinguishable from other areas of the prison.
  • Lack of dynamic security and trained staff compromises the quality of care.
  • Discontinuity in mental health care during transitions from IMHC to the general population or to the community are leading to a revolving door effect, where individuals return due to a lack of adequate support.

Recommendations

The OCI recommends that CSC:

  1. Immediately respond to the recommendation and issues previously raised by the OCI regarding Therapeutic Ranges and the provision of IMHC.
  2. Immediately respond to and action each of the 38 recommendations outlined in the IMHC Working Group report titled, “Review of Intermediate Mental Health Care Services in Correctional Service Canada Mainstream Institutions and Associated Recommendations” (January 11, 2023).

Assessing and Addressing Trauma in Federally Sentenced Women

Purpose

Explore how trauma is assessed and treated in the federal correctional system, and whether current approaches are gender-responsive, culturally relevant, and trauma-informed.

Findings

  • The prison environment as a source of trauma – incarceration and institutional practices (e.g., strip searches, lockdowns, recounting personal histories) often retraumatize women.
  • Without proper trauma assessment and screening tools, CSC is inadequately prepared to effectively and safely work with women on the root causes of trauma.
  • Inadequate staff training related to trauma and trauma-informed approaches compromises the quality of care.
  • Few dedicated psychological services, the prioritization of acute needs, and an overreliance on staff who are not trained in trauma interventions, leave many women without proper trauma care in prison.
  • There is a need for culturally specific trauma interventions for Indigenous women.

Recommendation

The OCI recommends that CSC:

  1. Work closely with an external, expert mental health organization to develop and implement an evidence-based, comprehensive strategy for trauma-informed services and trauma-specific treatment for federally sentenced women by June 2026.

The new strategy should be fully implemented by June 2026. The new model should then be evaluated by CSC, and a similar approach extended to male institutions nationwide.

Mental Health Needs and Services for Indigenous Peoples in Federal Corrections

Purpose

A review of the mental health needs, current approaches to services offered, as well as the gaps and barriers to addressing mental health for Indigenous prisoners.

Findings

  • Discrimination and unconscious bias in mental health care create unique challenges for Indigenous prisoners.
  • Availability and access to culturally-informed and trauma-informed mental health services for Indigenous peoples are lacking.
  • Continuity of mental health care for Indigenous peoples upon release to the community setting is poor.
  • Decolonization of mental health care in the prison system is required to achieve equity for Indigenous peoples serving federal sentences.

Recommendation

The OCI recommends that CSC:

  1. Reallocate and increase resources to fund additional Section 81 healing lodges and increase funding of existing Section 81 healing lodges within the 2025-2026 fiscal year, to provide Indigenous-led, holistic mental health and wellness services that better meet the needs of Indigenous individuals with mental health issues, in ways that are culturally- and trauma-informed, and free of discrimination and unconscious bias.

The 2024-25 Annual Report and a comprehensive backgrounder are available at www.oci-bec.gc.ca.

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