For Immediate Release

ARCHIVED - Federal Prison Ombudsman Releases
Study on Deaths in Custody: Report Finds Some Fatalities Could Have Been Averted

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Backgrounder: Deaths in Custody Study

OTTAWA, June 27, 2007 - A report into federal inmate fatalities has found some deaths of prisoners while in custody could have been averted through improved risk assessments, more vigorous preventive measures, and more competent and timely responses by the Correctional Service of Canada (CSC). The study, commissioned by the Correctional Investigator of Canada, examined all reported deaths in Canadian penitentiaries due to factors other than natural causes from 2001 to 2005.

The Deaths in Custody Study examined 82 reported suicides, homicides, and accidental deaths of prisoners while in custody of the Correctional Service during the five year period. "The findings are disturbing and indicate that the Correctional Service has not rigorously fulfilled its mandate to keep all inmates safe and act on recommendations related to inmate deaths," said the Correctional Investigator, Mr. Howard Sapers. The report found the Correctional Service has failed to incorporate lessons learned and implement corrective action over time and across regions, with the same errors and observations being made incident after incident. The study found the Correctional Service of Canada resists or fails to reasonably act on a large proportion of Coroners'and Medical Examiners' findings and recommendations.

"This report confirms my Office's own assessment that similar observations and recommendations are made year after year by the Correctional Service's national investigations, provincial coroners, and medical examiners. Although the Correctional Service says it takes corrective action to ensure similar situations do not occur again, the same problems are repeatedly occurring, resulting in the tragic loss of human lives," said Mr. Sapers. "In order to reduce the number of fatalities, a timely and systematic follow-up on corrective actions is required to ensure that preventive measures are implemented", he added.

The Correctional Service has indicated a willingness to address many of the Deaths in Custody Study's findings. The Office of the Correctional Investigator is now working with the Correctional Service in an attempt to ensure that existing procedures and requirements are adhered to. While the Correctional Investigator characterized CSC's response to the study's findings as "encouraging", citing the Correctional Service's commitments to improving the timeliness of its investigation process, enhancing mental health services and better responsiveness to incidents - he also noted his Office would be monitoring the actions of CSC for tangible signs of real progress in the coming months.

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. The Deaths in Custody Study, as well as the latest Annual Report 2005-06, are on the Correctional Investigator's Website at

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For further information:

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