Correctional Investigator Releases Investigation into Natural Cause Deaths in Federal Penitentiaries


For Immediate Release 

Ottawa, February 17, 2014 – Between 2003 and 2013, more than 500 inmates have died in federal penitentiaries. The majority of in custody deaths are by natural cause(s). The investigative report released by the Office of the Correctional Investigator today raises significant issues about how the Correctional Service of Canada ( CSC ) meets its legal obligation to investigate the factors and circumstances that led to death regardless of cause. Mr. Howard Sapers, Correctional Investigator of Canada, stated in releasing his report: “The CSC ’s mortality review process is flawed and inadequate. It is not carried out in a timely and rigorous manner as required by law. It fails to thoroughly establish, reconstruct or probe the factors that may have contributed to the fatality under review.”

The Office contracted with a senior medical practitioner to assess the quality and adequacy of end of life care provided in a sample of fifteen deceased offenders. The expert review raises significant quality of care issues: 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.

Despite these critical findings, all fifteen individual mortality reviews conducted by CSC assess the care provided to the deceased inmate(s) as “congruent” with “applicable” health care standards and policy.

The review found that the time between a fatality and the convening and completion of the mortality review often exceeds two years. Moreover, the mortality review process has yet to generate a single finding, recommendation, lesson learned or corrective measure of any national significance. “Even when quality or standard of care issues are noted, they appear to be not acted upon. In some cases, there is simply no way of determining whether the death was potentially preventable or premature,” added Mr. Sapers.

The full report and backgrounder is available at: .

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.


For more information, please contact:  
Ivan Zinger, J.D., Ph.D.  
Executive Director and General Counsel  
(613) 990-2690 

Date modified  


Banner Image
OCI News Releases