The Office of the Correctional Investigator (OCI) has released the fourth and final assessment of Correctional Services of Canada’s (CSC) response to preventable deaths in federal custody, including recommending improved monitoring of inmates with mental health issues in Canada’s prison system.
The report examines nine cases involving deaths in federal custody that occurred between April 2008 and April 2010. Five of the deaths involved suicide, and one death resulted from medical complications arising from chronic self-injurious behaviour. In two of these deaths, the deceased was of Aboriginal descent. Another inmate who committed suicide was a young, first-time federal offender serving a two-year sentence.
Some of the deaths involved offenders with mental health issues. According to the report, these cases reveal recurring problems in federal corrections institutions that relate to first response, accountability and compliance, including deficiencies in: responding to medical emergencies; sharing of information between clinical and front-line staff; monitoring individuals at risk of suicide; quality and frequency of security patrols, rounds and counts; management of offenders with mental illnesses; and quality of internal investigative reports and processes.
The OCI has recommended that CSC develop a comprehensive public accountability and performance framework to help prevent deaths in custody, and create a senior management position exclusively responsible for promoting, monitoring and ensuring safe custody practices. Other recommendations include:
- Providing 24 hours a day, seven days a week health care coverage at all maximum, medium and multi-level institutions;
- Increasing information sharing with front-line staff regarding offenders at risk of self-injury or suicide to ensure effective monitoring, crisis response strategies and prevention protocols;
- Enhancing the quality of security patrols by introducing audit and accountability measures to ensure rounds and counts are conducted in a manner consistent with preservation of life principles;
- Prohibiting the practice of placing offenders with mental illnesses, who are at risk of suicide or serious self-injury, in prolonged segregation; and
- Increasing the accountability and transparency of National Boards of Investigation inquiries into cases of suicide or serious self-injury by having an external health care professional chair the investigations and making their reports available to the public.
Since the death of Ashley Smith, a mentally disordered offender who died in custody at the Grand Valley Institution for Women in Kitchener in 2007, the OCI has conducted several investigations and provided recommendations for addressing preventable deaths in custody. Since Smith’s death, 130 inmates have died in federal custody across the country.
See “Final Assessment of the Correctional Service of Canada’s Response to Deaths in Custody,” September 8, 2010, available at www.oci-bec.gc.ca.
Also, see the press release “Correctional Service of Canada Challenged to Apply Lessons Learned and Prevent Deaths in Custody,” Office of the Correctional Investigator, September 8, 2010, available at www.oci-bec.gc.ca.
See the related Mental Health Notes story “Correctional Investigator Calling for More Mental Health Services in Prisons,” December 10, 2009.