Second Quarterly Assessment of the Correctional Service of Canada's Response to Deaths in Custody Reports and Investigations


December 18, 2009

Dear Commissioner:

The Office of the Correctional Investigator ( OCI ) has completed its second quarterly assessment of the Correctional Service of Canada's ( CSC ) Response to addressing the findings and recommendations of our Deaths in Custody Study (February 2007) and report into the death of Ashley Smith, A Preventable Death (June 2008),as well as the CSC 's National Board of Investigation into the Death of an Offender at Grand Valley Institution (February 2008).

In our second quarterly report, we have principally relied on assessing initiatives set out in your Progress Report , which is an updated version of the Service's Response that was originally released on August 14, 2009. In the interests of transparency, these documents, as well as our Initial Assessment (September 2009), are part of the public record, including this correspondence.  We appreciate the responsiveness of the Service in the advance production and sharing of these documents in order that we can keep the Minister of Public Safety and all Canadians informed of progress in this important area of corrections.

We acknowledge the activity and initiative of the Service, particularly in its commitment to move forward with separate external reviews of long-term segregation and the inmate complaint and grievance system. We also welcome the development of the September 2009 " Guidelines: Process for Managing Offenders Who Self-Injure ," which we hope will eventually become an integrated and comprehensive approach for managing the rising numbers and incidence of serious and chronic self-harming behaviours in federal prisons. While self-injurious behaviour does not necessarily equate to an intention to end life, my Office is increasingly concerned by the frequency, seriousness and cumulative impact of these injuries (e.g. head-banging, slashing, self-mutilation) on physical 
and mental health in a prison setting. We are encouraged by the range of undertakings the Service has committed to in regard to improving the quality of and timely access to mental health services.

My Office has welcomed the Service's commitment to report annually to Parliament on its efforts to prevent deaths in custody. We note that CSC 's 2009-10 Report on Plans and Priorities commits to a 5-year reduction in the rate of offender deaths by other than natural causes.  However, the latest available figures note that the number of inmate deaths by other than natural causes (e.g. suicide, accident, homicide, overdose) actually increased from 10 in 2007-08 to 17 in 2008-09. In other words, contrary to expected results, the rate of non-natural deaths in federal custody has not been reduced. Just as concerning is the fact that there are no actual performance indicators or detailed plans in the RPP or the current Progress Report that specifically sets out the actions the Service will take to reverse this trend.

My Office urges the Service to pay much closer attention to performance indicators and results that would demonstrate sustained and measurable progress over time. Accordingly, I recommend that the Service closely monitor the following indicators and report positive performance gains in the following areas:

  • Segregated inmates with significant mental health issues that have been moved into alternative custody arrangements.
  • Comprehensive clinical treatment plans (integrating clinical, security and program needs) developed and implemented by institutional inter-disciplinary teams, and shared with front-line staff as appropriate.
  • Comprehensive clinical treatment plans developed by MTAC (Mobile Interdisciplinary Treatment Assessment and Consultation Team), fully implemented by institutional inter-disciplinary teams.
  • Improvement in vacancy rates for mental health professionals and reduction in the number of under-filled positions.
  • Increased direct (e.g. face-to-face) contacts between mental health professionals and segregated inmates.
  • Reduction in the use of force interventions involving offenders with serious mental health problems.
  • Policy compliance regarding notification to and response of health care staff or other emergency responders to medical emergencies, including initiation of CPR and use of Automatic External Defibrillators ( AED ).

In each of these areas we need to see clear target dates, identified resources, national and regional "champions," expected results, as well as detailed evaluation and feedback plans.

While most of the current focus is on non-natural cause deaths, I have a growing concern about so-called "natural" cause deaths. These deaths may be linked to other issues – e.g. aging, access to health care, timeliness and appropriateness of first response to medical emergencies, changes in the drug formulary.  I encourage the Service to incorporate these factors into its next Report on Plans and Priorities and Progress Report .

I look forward to seeing the above captured in the 3 rd quarterly review exercise as these are the issues of highest risk and concern impacting on the Service's capacity to reduce preventable deaths and preserve life.


Howard Sapers 
Correctional Investigator of Canada

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