Correctional Service of Canada Challenged to Apply Lessons Learned and Prevent Deaths in Custody


For Immediate Release 

OTTAWA, September 8, 2010 - The Correctional Investigator of Canada, Mr. Howard Sapers, today issued his fourth and final assessment of the Correctional Service of Canada's ( CSC ) progress in preventing deaths in custody.

"The Correctional Service has taken some concrete steps toward improving its performance in relation to the prevention and reduction of deaths in federal correctional facilities," said Mr. Sapers. "Yet many of the same issues continue to arise because CSC has not moved on key accountability and governance issues that have the potential to significantly impact on preventable deaths in custody."

Since the death of Ashley Smith in October 2007, more than 130 offenders have died in federal custody. The final Office of the Correctional Investigator ( OCI ) assessment reviews nine deaths that occurred in federal custody between April 2008 and April 2010. The cases show recurring problems regarding first response, accountability and compliance issues in federal corrections.

The nine cases reviewed in the final assessment found common deficiencies in the following areas:

  • Response to medical emergencies;
  • Sharing of information between clinical and front-line staff;
  • Monitoring of suicide pre-indicators;
  • Quality and frequency of security patrols, rounds and counts;
  • Management of mentally ill offenders; and
  • Quality of internal investigative reports and processes.

"Measurable progress is not yet where it should be," said Mr. Sapers. "The preservation of life is an integral part of the mandate of the Correctional Service. I expect this principle to be embedded in policy, reflected in the culture of the organization and orient its day-to-day interactions with offenders."

In making his final recommendations, the Correctional Investigator placed emphasis on the requirement for the timely implementation of corrective measures.

He recommended that CSC strengthen its internal investigative framework to ensure principles of independence, accountability and transparency by appointing external health care professionals to chair reviews of suicide and serious self-injury, and to make reports of the investigations public. He called for CSC to create a senior management position responsible for promoting and monitoring safe custody practices.

In addressing other systemic deficiencies, the Correctional Investigator recommended that:

  • the practice of placing mentally ill offenders, or those at risk of suicide or serious self-injury, in prolonged segregation be prohibited
  • the Service provide round-the-clock health care coverage at all maximum, medium and multi-level institutions;
  • the quality of security patrols be enhanced by introducing audit and accountability measures to ensure rounds and counts are conducted in a manner consistent with preservation of life principles; and
  • basic information and instructions for managing offenders at risk of self-injury or suicide be shared with front-line staff to ensure that adequate monitoring, crisis response strategies and prevention protocols are made easily and readily accessible.

"There is no denying the initiative and direction that CSC has taken to address factors related to preventable deaths in custody," said Mr. Sapers. "But, as I have stressed in a number of recent reports and investigations, correctional authorities need to maintain public trust and confidence in what they do behind the closed prison gate. It is critical that CSC translate findings, recommendations and lessons learned into demonstrable and sustainable progress on the ground."

The intent of the quarterly public reporting and review exercise was to assess CSC 's progress in responding to recommendations stemming from the Office of the Correctional Investigator's ( OCI ) 2007 Deaths in Custody Study and the 2008 report into the death of Ashley Smith, A Preventable Death , as well as CSC 's own National Board of Investigation into Ms. Smith's death. OCI issued an Initial Assessment of CSC 's Response in September 2009, followed by two other quarterly assessments in December 2009 and March 2010.

The Correctional Investigator is mandated by an Act of Parliament to be an independent ombudsman for federal offenders. This work includes ensuring that systemic areas of concern are identified and addressed. OCI reports cited in this release are available at .


For further information contact:

Ivan Zinger, LL.B., Ph.D.  
Executive Director and General Counsel  
Office of the Correctional Investigator  
(613) 990-2690 or 

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