Correctional Investigator Releases Report on Federal Inmate Suicides


For Immediate Release 

Ottawa, September 10, 2014 – Today, on World Suicide Prevention Day, the Correctional Investigator of Canada, Mr. Howard Sapers, released a report that reviews thirty suicide deaths that occurred in federal penitentiaries in the three year period between April 2011 and March 2014.  Suicide is the leading cause of un-natural death in federal prisons, accounting for approximately one-in-five in-custody deaths in any given year.

In releasing his report, Mr. Sapers drew attention to the fact that 14 of the 30 suicides reviewed by his Office occurred in segregation cells under conditions of close monitoring and supervision. “I am concerned that the Correctional Service of Canada continues to rely on long-term segregation placements as a means to manage symptoms or behaviors associated with mental illness, suicidal ideation or self-harming. This practice is unsafe and should be expressly prohibited.”

In nearly all (27 of 30) of the suicides reviewed by the Office, the inmate died by asphyxiation (25 by hanging). The report concludes that there are still a number of dangerous in-cell suspension points accessible to inmates, including in segregation units. “It is concerning that these individuals were able to find the means to end their lives in an area of the prison where safety, security and surveillance protocols are elevated. Despite a 2010 directive, there is still no coordinated national effort to ensure potential suspension points in segregation cells have been systematically identified and removed.”

To put a human face on a problem that is often considered to be inevitable or beyond prevention measures, the report includes case histories for ten inmates who took their life behind bars. In most of these cases, there were either known precipitating events or risk factors that indicated suicidal intent, including a history of psychological disorder, previous suicide attempts or a history of self-injurious behaviour. The report raises the possibility that some of these deaths could have been averted through more rigorous screening procedures, better information sharing or more timely access to mental health services. “Preventing deaths in custody is challenging work, but it is not beyond the reach of a comprehensive prison suicide awareness and prevention program,” observed Sapers.

Although the Correctional Service investigates all deaths in custody, the report points to a number of deficiencies in its post-incident investigative process.  “ CSC staff investigating other CSC staff members lacks both functional and organizational independence,” stated Sapers.  “It is rare for CSC investigators to go the extra step to identify how the death might have been averted had staff acted or decided in a different manner.  Lessons learned and corrective measures from even a single suicide should have a lasting impact on the organization.”  To ensure transparency and accountability, the report recommends that CSC investigative reports of suicides should be shared with designated family members and routinely made available to provincial and territorial Coroner’s offices.

The review led to 11 new recommendations and called for more action on two recommendations from previous investigations into deaths in custody.  The full report cited in this release and background information 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 

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