Summary of Major Investigations, Findings and Recommendations
OVERVIEW
The 2023-24 Annual Report of the Office of the Correctional Investigator (OCI) was tabled in Parliament on October 29, 2024, and includes:
-
The Correctional Investigator’s Message, which focuses on the groundbreaking nature of this year’s national investigations, and the importance of effective engagement and working relationships with CSC in advancing a shared goal of safe, effective, and humane care and custody.
Several updates on issues of national concern, including: risk assessment and classification of Indigenous Peoples since Ewert v. Canada (2018), a review of CSC’s internal complaints and grievances system, the examination of Quality of Care Reviews for natural cause deaths in federal custody, population pressures in women’s institution, and a review of the impact of the Engagement and Intervention Model (EIM) on use of force incidents.
A case study into the death of an incarcerated individual at a Regional Treatment Center.
Two national-level investigations:
An Investigation of the Standalone Male Maximum-Security Penitentiaries in Federal Corrections
Hope Behind Bars: Managing Life Sentences in Federal Custody
Correctional Investigator’s Outlook for federal corrections in 2024-25.
Correctional Service of Canada’s Responses to Recommendations.
Statistical Annexes.
This year’s report contains 28 recommendations, all directed to the Correctional Service of Canada.
CASE STUDY - Death at the Regional Treatment Centre (Millhaven)
Purpose and Context
On December 17, 2021, Mr. Stéphane Bissonnette, a 39-year-old man serving his first federal sentence died in an observation cell while on modified suicide watch at the Regional Treatment Centre (RTC) Millhaven. Following his death, CSC’s National Board of Investigation (NBOI) was convened to examine the incident, and, upon recommendation of this Office, an Independent Observer was appointed to oversee and evaluate the impartiality and thoroughness of CSC’s internal investigation.
Our review sought to identify, confirm, and contextualize the systemic factors, gaps and compliance issues that contributed to this tragic incident.
Findings
Through the course of his federal incarceration, Mr. Bissonnette was placed in administrative segregation on 22 separate occasions, cumulatively spending 461 days in solitary confinement. He also spent a combined total of 158 days in Structured Intervention Units, was often physically restrained for prolonged periods of time, and had an extensive history of suicidal and chronic self-injurious behaviour. Mr. Bissonnette was an individual with significant mental health needs who CSC failed to manage safely and humanely.
This incident needs to be understood in the context of significant, persistent, cumulative, and recurring issues that continue to lead to tragic and preventable deaths in CSC custody. These contributing and precipitating factors include:
Inadequate quality of security patrols and wellness checks (systemic failure to verify a living, breathing body or signs of medical distress). Security patrols, counts and nursing rounds failed to assess and verify signs of life despite the patient exhibiting some genuinely concerning symptoms.
Critical lapses in the continuity of care, including gaps in reporting, communication, assessment and monitoring of suicidal and self-injurious behaviour.
Highly restrictive placements and inappropriate conditions of confinement with security-driven and punitive responses to behaviours associated with mental illness. For example, even though it was specified to allow Mr. Bissonnette out of his cell for exercise, phone and showers every day, this almost never occurred. For security staff, getting patients out of observation cells for leisure or exercise did not seem to be considered a priority. This likely significantly impaired the quality of care that Mr. Bissonnette received.
The tendency to regard and operate RTC Millhaven, an accredited multi-level psychiatric facility, as an extension of the maximum-security Millhaven complex.
The prevailing and deficient physical infrastructure at RTC Millhaven is not conducive to the management of complex mental health cases. It is based on a repurposed maximum-security unit with notable limitations that hinder staff’s ability to ensure quality, timely, safe, and effective inpatient care.
Inappropriate suitability, selection and training of security staff working in an RTC setting, with individuals presenting significant mental health needs.
Problematic oversight and confounding governance structures lead to role confusion, particularly with senior-level decision-making practices, and created conflicts and barriers between health care and operational staff (dual loyalties).
The governance structure does not seem to respect the principles of professional autonomy and clinical decision-making required to operate an accredited psychiatric facility.
The boundaries separating clinical and operational authority at RTC Millhaven are highly blurred, leading to confusion, role conflicts and an overreach of correctional authorities at the expense of health care.
The Office also noted recurring issues in how CSC deals with and responds to families who have lost a loved one behind bars. Consistent with previous findings, CSC did not actively share information with Mr. Bissonnette’s family, nor did it apprise or follow-up with them during the investigative process. The family waited more than two and a half years to get answers regarding the death of their loved one.
Recommendations to CSC
Immediately release the Independent Observer’s evaluation of the impartiality, thoroughness, and professionalism of this National Board of Investigation.
Prepare and release a Case Summary of the facts and findings of this NBOI including recommendations, learnings and corrective measures that have been implemented at RTC Millhaven to date.
Ensure an independent and external mental health expert conducts a full compliance review of patient safety at RTC Millhaven.
Evaluate the suitability and feasibility of installing in-cell vital sign remote monitoring technologies in all high(er)-risk placement areas of federal prisons.
Re-issuing of previous recommendations
Ensure security staff working in a Regional Treatment Centre be carefully recruited, selected, properly trained and fully competent to carry out their duties in a secure psychiatric hospital environment.
Expand alternatives to incarceration options and increase bed space to facilitate the transfer and placement of federally sentenced individuals with significant mental health needs in external community psychiatric facilities.
NATIONAL SYSTEMIC INVESTIGATIONS
An investigation of the Standalone Male Maximum-Security Penitentiaries in Federal Corrections
Purpose and Context
Despite decades of various tasks forces, working groups, federal commissions, reports and recommendations, including from this Office, significant problems with the functioning of maximum penitentiaries in Canada persist today. This Office has repeatedly found male maximum-security institutions to be highly restrictive and depriving to the point of undermining most other correctional objectives.
The purpose of the investigation was to assess and compare the functioning of the six CSC maximum-security facilities for men to identify deficiencies, best practices, and determine if the maximum environment effectively balances public safety requirements with rehabilitative and reintegrative objectives.
Findings
Profile
At the time of writing of this report, there were 1,409 individuals incarcerated at these six institutions. The standalone maximum-security population is diverse, and institutions see significant over-representation of Indigenous peoples and Black individuals. Across the institutions, the majority of individuals have been assessed as high need (95%) and high risk (90%)
Most of the standalone maximum-security institutions regularly find themselves considerably under capacity, ranging from approximately 57% to 86.5% capacity at the time of this report.
Although the maximum-security population only represents just over 10% of individuals serving a federal sentence, they account for a larger portion of the assaults on staff (40%) and inmates (33%) across all federal institutions.
There has been a steady increase in use of force incidents, and rising numbers of self-inflicted injurious ehaviour and attempted suicides in the facilities over the past several years.
Thematic Findings
The federal correctional system lacks a clearly articulated statement of purpose for maximum-security institutions, making it difficult to assess whether any correctional aims are being achieved. Nevertheless, findings are summarized under four areas:
The overreliance on creating and managing subpopulations to address perceived security risks has adverse effects. Subpopulations can include Security Threat Group (STG) affiliation, incompatibility issues, offence-type, mental health concerns, or profiles such as “Integrated” or “Non-Integrated”.
Although there was a range of subpopulations across the institutions (less than five, up to a dozen), all institutions experienced similar access and movement challenges.
Restrictions on movement due to subpopulations increased range and unit confinement and precluded prisoners from accessing significant areas of the institutions such as recreation spaces, libraries, and program spaces. Management of subpopulations also consumed an inordinate amount of staff time and resources.
The emphasis on security, control, and confinement hinders staff engagement with the population, limits dynamic security practices, and restricts opportunities for group movement, assembly, and recreation.
Time out of Cells: routines are highly restrictive and seemingly designed to isolate and contain individuals whenever possible. Access to common areas is significantly limited and most shared spaces are barren and do not promote constructive use of time.
Restrictive Infrastructure: the dated and restrictive institutional infrastructure severely impedes proper movement and functioning and does not foster a dynamic security environment.
Access to Recreation and Fresh Air: institutions have taken to relegating many prisoners to small, restrictive unit-based yards for their daily access to fresh air. These spaces are inherently depriving and dehumanizing.
The creation and implementation of the Structured Intervention Unit (SIU) have led to an inordinate consumption of institutional resources and staff attention, often at the expense of other units and resulting in population management issues on a national scale.
Many incarcerated individuals find SIU conditions more favourable than the mainstream maximum-security prison population because of their greater access to services and interventions, daily visits by nurses and wardens, more opportunities to engage with non-security staff, and the possibility of greater out-of-cell time.
Interregional SIU transfers, often taking precedence over other transfers, put a further strain on resources and delay other incarcerated individuals from progressing through their own correctional plans.
Persons incarcerated in maximum-security facilities are poorly prepared to cascade to medium-security institutions and/or be released directly into the community due to a lack of meaningful employment, multiple barriers to programs and education, and poor case management and release planning.
Data provided by the Service from two recent fiscal years revealed that each year, there were more than 500 individuals released directly from the six maximum security institutions into the community via statutory release. There is a minimal interaction between case management staff and incarcerated persons and a notable lack of discharge planning for individuals released directly from maximum security institutions.
Beyond the current investigation, the Office also examined use of force cases in maximum-security institutions as a national update, looking specifically at the impact of the Engagement and Intervention Model (EIM, implemented in 2018). Findings for the standalone maximum-security institutions demonstrated:
Use of force incidents account for 46% of all use of force incidents nationwide, even though these facilities house approximately 10% of all individuals in federal custody.
The rate of unique use of force incidents has increased from 441 per 1,000 incarcerated individuals in 2018-19 to 651 per 1,000 in 2023-24.
In the six years following the introduction of the EIM, 58% of cases of inflammatory spray and chemical agent use in the federal correctional system took place in standalone male maximum-security institutions.
Acts of self-harm remain the third most common incident type where force is used.
The investigation concludes that the overall lack of reintegrative and rehabilitative purpose has turned maximum-security facilities into places of incapacitation and containment. In their present form, their primary function appears to be simply holding prisoners long enough to secure a transfer to medium-security, or worse yet, reach their statutory release date without any sort of meaningful preparation for community release.
Recommendations to CSC
Devise and implement a national subpopulation management strategy by the end of the fiscal year, with the goal of reducing the number of subpopulations within maximum-security institutions.
Ensure institutional routines are established to allow all incarcerated persons have access to primary large yard spaces daily; all living units at standalone maximum-security institutions are equipped with basic amenities and seating; and, policies related to institutional movement be reviewed to ensure that they no longer limit individuals from engaging in their Correctional Plan.
Develop a national policy surrounding complex SIU cases to make SIU transfer processes more efficient and equitable.
Increase availability of meaningful employment and apprenticeship opportunities at these institutions, while mandating basic oversight of these jobs.
Provide consistent access to Indigenous services, programs and supports, including establishing and maintaining Pathways programs, at each of these institutions without delay.
Assign dedicated Release Coordinators at each standalone maximum-security institution and bolster related policy to establishing clear responsibilities surrounding discharge planning.
Develop policy establishing a minimum frequency of in-person contacts between Institutional Parole Officers and incarcerated persons on their caseloads.
Hope Behind Bars: Managing Life Sentences in Federal Custody
Purpose and Context
This investigation examines some of the key issues in case management, security reclassification, and sentence planning for individuals sentenced to a mandatory minimum of life in prison under section 745 of the Criminal Code (i.e., Life-Min) at medium-security institutions.
As of February 18, 2024, there were approximately 3,600 federal prisoners with indeterminate sentences (i.e., when the term of imprisonment does not have an end date), also known as “Lifers,” representing 26% of the total in-custody population.
Findings
The current investigation revealed several serious issues with case management and sentence planning:
A biased Security Reclassification Scale (SRS) and inadequate assessments of risk disadvantage Lifers in several ways:
Temporary absences serve as an important correctional tool in the rehabilitative process, facilitating the safe and timely movement of sentenced individuals to lower security levels and, eventually, their release and reintegration. However, Lifers in medium security facilities struggle to access temporary absences, undermining their ability to demonstrate readiness for lower security, directly impacting their SRS score.
Correctional Plan (CP) Updates play a major role in the security reclassification review. However, CP updates for Lifers are rarely completed on a timely basis and do not always reflect the actual progress a person has made.
Individuals with Life-Min sentences are waiting longer than all others for CP updates, with one quarter waiting between 2 and 5 years and 7% (n = 198) waiting between 5 to 13 years.
Given these timeframes, security reclassification reviews are often based on outdated events and assessments that overshadow recent progress made by these individuals.
Escape risk assessments, which are another component of security reclassification reviews, appear to be arbitrary. Investigators found that CSC staff use justifications that are not actually indicators of risk to assess likelihood of escape. Lifers were maintained at “higher risk to the public” primarily due to their indeterminate sentence and a dated CP.
Psychological risk assessments (PRA) are required, in certain cases, before transfers can be approved. This investigation noted several issues with PRA timeliness resulting in additional delays in transfer-related decisions, including decisions regarding Lifers waiting for transfers to minim-security.
Federal Lifers are expected to comply with unreasonable behavioural standards, with non-compliance often being interpreted as indicative of higher risk.
Inadequate Integration of “Four Phases of a Life Sentences” (adaptation, integration to the prison environment, preparation for release, reintegration into the community) into Correctional Plans.
According to policy, individuals in medium security must be in the third or fourth phase to be eligible for placement in or transfer to minimum security. There is little else written into policy to guide the integration of the four phases into case management and sentence planning.
Overprogramming and Inappropriate Use of Correctional Interventions
While maintenance programs are not mandatory for transitioning to lower security facilities, it has become a “checklist item” for decision-makers in determining support for transfers of Lifers.
Many Indigenous lifers with distant day parole eligibility dates are placed in Pathways to keep them ‘engaged’, despite there being no prospect of support for minimum-security in the short term. Pathways has become another “checklist item.” However, progress made in Pathways is hardly considered in the overall assessment of risk, neither is the consideration for Indigenous Social History.
Languishing in Medium-Security Well Past Parole Eligibility Dates
For individuals with indeterminate sentences, 59% are past their Day Parole eligibility date (49% for Life-Min) and 49% are past their Full Parole eligibility date (39% for Life-Min).
The cumulative effect of these shortcomings in policy and practice is that Lifers are kept at higher security levels for longer periods with no clear rehabilitative or reintegrative purpose.
Recommendations to CSC
Review and revise security reclassification processes to provide more support to staff preparing risk assessments and recommendations.
Reduce delays and discontinue the imposition of unreasonable behavioural expectations.
Review the Sentence Planning process and provide support to staff in developing individualized sentence plans for Lifers.
Draw on the experience and expertise of national voluntary organizations to provide support to Lifers from intake to community release.
Review the requirement for Psychological Risk Assessments for individuals seeking transfers to minimum security, with the aim to reduce delays that impede timely decision-making.
Ensure the National Lifer Strategy integrates these findings, is responsive to the experiences of Lifers, draws from consultations with a range of voices, is made public with specific timelines.
