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


March 25, 2010

Dear Commissioner:

My Office has completed its third quarterly assessment of the Correctional Service of Canada's ( CSC ) progress in preventing deaths in custody.

I am encouraged by the range of initiatives that have been launched since our last review in December 2009. In the interest of public accountability and transparency, I especially welcome those commitments that incorporate elements of external and independent review, including the examination of the use of long-term segregation of offenders with mental health concerns and the external review of the offender complaints and grievances system.

My Office also commends the Service's initiative to establish a national verification team to audit, at the operational level, whether resources are being deployed effectively to support national-level commitments to prevent deaths in custody. I encourage the commitment to establish an independent review group to assess CSC 's actions and responses to preventing deaths in custody on an annual basis as this initiative would complement ongoing work associated with regular internal audits and periodic verification and inspection reviews.

As I have stated publicly, establishing key performance indicators and benchmarks for monitoring and assessing progress in this area of corrections is a particularly encouraging and important development. My Office concurs that reduction in the number of suicides, serious self-injury, drug overdoses, days spent in segregation and use of force interventions involving those with serious mental health issues should be part of the public record, and we look forward to being consulted in determining the specific set of performance indicators that will eventually become the Service's accountability framework.

We welcome the Service's intention to more closely monitor placement of offenders with mental health problems in segregation for risk of suicide, self-harm or self-protection. However, my Office remains concerned with the overall lack of capacity, resources and options to manage a growing and vulnerable population. I do not accept that confining mentally ill offenders to prolonged periods of isolation in austere conditions with limited social and physical interaction meets the test of the "least restrictive" option, nor is it effective or safe corrections. While I appreciate the fact that intermediate care is not currently a funded component of the Service's continuum of care model, I cannot avoid comment on practices that run contrary to the Corrections and Conditional Release Act . In the absence of meaningful custody alternatives to segregation for mentally ill offenders, those at risk of suicide and serious self-injury should not be held in conditions of confinement that are contrary to their well-being. Resources will continue to be scarce, but this cannot be used as an excuse for a lack of action.

Finally, as mentioned in our Second Quarterly assessment, I remain concerned about the circumstances associated with so-called "natural" cause deaths. In that respect, my Office awaits response to correspondence outlining a series of concerns with the Service's "alternative" investigative process (Mortality Review) for all natural cause deaths. We continue to investigate inmate deaths that call into question the timeliness and appropriateness of the Service's initial response to medical emergencies, including unexpected and rapid deterioration in physical health. The flow of information between mental health care professionals and front-line staff who have the most direct contact with offenders at risk of suicide or self-injury also continues to be problematic in some cases.

While even the most vigilant efforts may not avert the most determined individual from ending life, the point of establishing verification teams, initiating external reviews and creating an accountability framework is to demonstrate that everything that could have been done to preserve life was in fact done. I look forward to continuing to work with the Service to achieve the goal of preventing deaths in custody.


Howard Sapers 
Correctional Investigator of Canada

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