Annual Report of the Office of the Correctional Investigator 2012-2013

June 28, 2013

The Honourable Vic Toews
Minister of Public Safety
House of Commons
Ottawa, Ontario

Dear Minister,

In accordance with section 192 of the Corrections and Conditional Release Act, it is my privilege and duty to submit to you the 40th Annual Report of the Correctional Investigator.

Yours respectfully,

Howard Sapers
Correctional Investigator

“It is said that no one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens, but its lowest ones.”
- Nelson Mandela

Table of Contents

Correctional Investigator's Message

Executive Director's Message

Special Focus on Diversity in Corrections

Case Study of Diversity in Corrections

I. Access to Health Care

II. Deaths in Custody

III. Conditions of Confinement

IV. Aboriginal Issues

V. Access to Programs

VI. Federally Sentenced Women

Transparency and Accountability in Corrections

Correctional Investigator’s Outlook for 2013-14

Ed McIsaac Human Rights in Corrections Award

Annex A: Summary of Recommendations

Annex B: Annual Statistics

Annex C: Other Statistics

Correctional Investigator's Message

On June 1, 1973, then Solicitor General of Canada, the Honourable Warren Allmand, announced the appointment of the first Correctional Investigator for federally sentenced inmates. The Office of the Correctional Investigator (OCI) was created in response to the Report of the Commission of Inquiry into Certain Disturbances at Kingston Penitentiary, which had identified the need for an independent body to review and provide redress to legitimate inmate grievances. The Commission summarized the conditions of confinement that prevailed at Kingston Penitentiary (KP) in April 1971 as “repressive and dehumanizing.” Inmates had rioted and rampaged for four days, events which included six staff taken hostage, brutal violence, two inmate murders and the near total destruction of a section of the facility. As shocking as these events were, the KP riot was not isolated, but part of an escalating series of violent institutional disturbances in the late 1960s and early 1970s.

Importantly, the Commission of Inquiry reported on the “recourse to violence as a means of redressing long-standing grievances and of calling those grievances to the attention of the public.” It found that the Canadian Penitentiary Service (as the Correctional Service of Canada was known at the time) lacked a transparent and impartial outlet for inmate complaint: there was no effective system to air or redress legitimate grievances; no recourse to review the actions or decisions of institutional authorities; no mechanism to bring public attention to prison conditions; and treatment was callous, abusive or degrading. Though 40 years removed from the circumstances that gave rise to one of the most infamous prison riots in the history of Canadian corrections, the Commission’s assessment of its causes remains remarkably relevant and prescient:

We have already noted a number of causes for Kingston’s failure: the aged facilities, overcrowding, the shortage of professional staff, a program that had been substantially curtailed, the confinement in the institution of a number of people who did not require maximum security confinement, too much time spent in cells, a lack of adequate channels to deal with complaints and the lack of an adequate staff which resulted in the breakdown of established procedures to deal with inmate requests. These facts were established beyond doubt by the testimony heard by the Commission.1

As the Commission saw it, the system fundamentally failed because there was inadequate focus on the rehabilitative (or “correctional”) purpose to imprisonment. Today, as my report makes clear, many of the same problems that were endemic to prison life in the early 1970s – crowding; too much time spent in cells; the curtailment of movement, association and contact with the outside world; lack of program capacity; the paucity of meaningful prison work or vocational skills training; and the polarization between inmates and custodial staff – continue to be features of contemporary correctional practice.

Population management pressures inside federal penitentiaries continue to mount. More than 20% of the inmate population is double-bunked, confined to cells originally designed for one. As penitentiaries become more crowded, they also become more dangerous and unpredictable places for both staff and offenders. Inmate assaults with injuries and the rate of violent institutional incidents increased again last year. Inmate complaints and institutional charges remain high, as do the number of segregation placements and use of force interventions where a mental health concern is identified. This environment is particularly difficult on the growing complex needs populations in corrections – federally sentenced women, mentally ill, Aboriginal, visible minority and aging offenders.

Reflecting these internal realities, the rate at which offenders are granted parole continues to set new historic lows. The trend lines are clear – a greater percentage of offenders are spending longer and more of their sentence behind bars in increasingly volatile and hardening conditions of confinement. At a time when more offenders are remaining longer in custody, a renewed focus on CSC’s rehabilitation obligations and a stronger commitment to community reintegration are as urgently required today as they were four decades ago. The 40th Anniversary of the creation of the Office of the Correctional Investigator reminds us that Canadian correctional history is marked by a pattern of crisis and retrenchment followed by reform and progress. As the 1971 Commission of Inquiry found, the prison operating environment had masked unfairness, inequity and even brutality from public view. In a democratic society, outside intervention by independent oversight, the courts, Commissions of Inquiry and Parliament have been necessary to build a safer, more humane and effective correctional system. As an independent Ombudsman, our focus on fair and reasonable decision making, viewed through a human rights lens, keeps accountability at the forefront of federal corrections.

There are very sound reasons why the rule of law follows an offender into prison and why legality does not end at the prison gate. Even while deprived of liberty, the Supreme Court of Canada has affirmed that an incarcerated person is still a Canadian citizen, still a bearer of Charter rights and freedoms. The Corrections and Conditional Release Act (CCRA) puts it this way: “offenders retain the rights of all members of society except those that are, as a consequence of the sentence, lawfully and necessarily removed or restricted.” Imprisonment does not mean total deprivation or absolute forfeiture of rights. By law, prisoners maintain the right to be treated with dignity and respect, they have the right to safety and security of the person, to be treated humanely, to not be discriminated against on the basis of ethnicity or religion and to be free from degrading, cruel and/or inhumane treatment or punishment.

Legal compliance, however important, is not the sole test of CSC’s conduct. CSC staff makes thousands of discretionary decisions each year. Good decision making is about more than legal compliance. Complying with the law is the floor, not the ceiling, for setting the standard in regard to administrative fairness. Good and best practices are about more than just doing the minimum.

Canadians expect their correctional authority to both uphold and model the principles and values of a free and democratic society – transparency, accountability, equality, respect for human rights and fairness. It is not without purpose that I continue to call on the Correctional Service to respond publicly (and therefore openly and transparently) to my concerns and recommendations. This means more than simply meeting government reporting requirements. It means being proactive to make sure quality information is readily available and reasons for decision are clearly and fully stated. What happens behind prison walls is a reflection of the health and vitality of Canadian society. In my view, the matters that are brought forward in my Annual Reports – use of force, treatment of mentally ill persons in prison, deaths in custody, prison crowding and violence, access to rehabilitative programs – are of significant public interest and concern. Most offenders will eventually return to their home communities upon release. Conditions of confinement should support their preparation for community reintegration. After all, the point of prison is not to make model inmates, but to aid them to become better citizens.


Howard Sapers - Correctional Investigator of Canada.  Description follows.

Howard Sapers
Correctional Investigator of Canada
June 30, 2012

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In this year’s Annual Report, I call special attention to the increasing diversity and complexity of prison demographics. In the 10 year period between March 2003 and March 2013, the incarcerated population has grown by close to 2,100 inmates, which represents an overall increase of 16.5%. During this period, the Aboriginal incarcerated population increased overall by 46.4%. Federally sentenced Aboriginal women inmates have increased by over 80% in the last 10 years. Visible minority groups (Black, Hispanic, Asian, East Indian and other ethnicities) behind bars increased by almost 75% over this period. As a subgroup, Black inmates have increased every year, growing by nearly 90% over the last 10 years. Meantime, Caucasian inmates actually declined by 3% over this same period.

When combined, the number of Aboriginal and visible minority inmates now exceeds 6,000 of a total incarcerated population of approximately 15,000. In other words, 40% of the 40% of the inmate count on any given day now comes from a non-Caucasian background. Recent inmate population growth is almost exclusively driven by absolute and relative increases in the composition of ethnically and culturally diverse offenders.

A more complex and diverse offender population profile mirrors larger demographic trends and patterns in Canadian society. As Statistics Canada reports, one trend consists of a younger, pluralistic and multicultural population whose diversity has been shaped over time by newer immigrants and foreign-born Canadians. Another trend reflects the increasing number of Canadians from Aboriginal heritage, while a third pattern reflects an aging, largely Caucasian majority, which is declining in both relative and absolute terms. On quite another level, disproportionate rates of incarceration of some minority groups, including Black and Aboriginal Canadians, reflect gaps in our social fabric and raise concerns about social inclusion, participation and equality of opportunity. Emerging demographic trends and patterns will shape and define who occupies federal penitentiaries for generations to come.

During the reporting period, CSC’s contribution to the government’s overall fiscal agenda has had an impact on a number of service delivery and program areas, including Inmate Welfare, Employment and Correctional Programming. Cost-saving and revenue-generating measures announced in FY 2012-13 will mean charging more for inmate telephone calls, an increase in room and board deductions, elimination of incentive pay for work in prison industries, cancellation of inmate social events (which help bridge the gap between prison and the outside world) and the closing of or reduced access to some inmate libraries.

The decision to not renew part-time prison chaplain contracts, primarily affecting non-Christian inmates, was particularly controversial, running contrary to the rising proportion of offenders from different cultures, nationalities, beliefs and religious affiliation in CSC facilities. Similarly, the end of funding for Lifeline, a program that provided inreach and outreach services and support to life sentenced offenders, appears unwarranted and contrary to long-established practice. Considered together, these measures reflect a narrowing of the rehabilitative potential of corrections.

Executive Director's Message

The tempo and volume of work continues to remain high for the Office of the Correctional Investigator. From April 1, 2012, to March 31, 2013, the Office’s team of 32 staff members (which includes corporate, policy, executive and investigative streams) spent more than 330 cumulative days visiting federal facilities, interviewed 1,309 offenders in institutions, responded to more than 5,400 offender complaints and answered 18,259 toll-free telephone calls. In addition, the Office’s use of force team reviewed more than 1,400 uses of force incidents in CSC facilities.

The number of calls received or files opened are not the only, or even the best, measures of workload. The complexity of issues addressed and the compound nature of many complaints must also be considered. Moreover, the Office continues to identify, invest and address systemic issues of concern in an attempt to reduce the overall number of individual offender complaints.

During the reporting period, the Office continued to focus on system-wide concerns: a case study examining the treatment of chronic self-injurious women offenders; a review of practices at a maximum security penitentiary; and an investigation of “natural” cause deaths in federal custody. In addition, the summary results of a review of the Black inmate experience in federal corrections are featured in this year’s Annual Report, part of a larger thematic focus that the Office has undertaken on diversity in corrections.

For a small agency, investigations of this nature are intense and demanding, involve significant reassignment of personnel, sharing of workload and juggling of priorities while maintaining focus on the Office’s core mandate to respond to individual offender complaints. The Office remains committed to investing in thematic reports and case studies that bring matters of substantive concern to the attention of CSC, the Minister of Public Safety, Parliamentarians and Canadians.

In terms of other accomplishments in 2012-13, the Office launched its revamped website (which last year recorded nearly 2 million visitor ‘hits’), developed a new Mission Statement and implemented a new Code of Conduct inspired by the values and principles of its role and mandate – independence, accessibility, confidentiality and fairness.

Ivan Zinger, J.D., PhD
Executive Director and General Counsel

A Special Focus on Diversity in Corrections

The face of Canadian corrections is changing, mirroring an increasingly diverse, multi-ethnic and pluralistic society. The visible minority2 offender population (community and incarcerated) has increased over the past 5 years by 40%. Visible minorities now constitute 18% of the total federally sentenced offender population (those incarcerated and in the community), which is largely consistent with representation rates in Canadian society. In 2011-12, Caucasians continued to make up the largest proportion of the federal offender population (62.3%). By comparison, Aboriginals represented 19.3%, Blacks 8.6%, Asians3 5.4%, Hispanics4 0.9% and other visible minority groups 3.4% of the population respectively.5

Focusing on the last five years, the total offender population (community and incarcerated) increased by 1,539 offenders or 7.1%. All new net growth in the offender population can be accounted for by increases in Aboriginal (+793), Black (+585), Asian (+337) and other visible minority groups. By contrast, during the same time period, the total Caucasian offender population decreased (- 466 or 3%).

Figure 10 Year Offender Population Trends: (Incarcerated and Community

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Diversity Within Diversity

While the tendency is to group all visible minority offenders together into one category, they are in fact a very diverse population. Nearly one-in-four visible minority inmates are foreign-born, coming from countries from all over the world, many of which have very different cultures, traditions and customs. Facilitating institutional adjustment and community reintegration for these offenders poses considerable challenges.

The Corrections and Conditional Release Act (CCRA) provides that correctional policies, programs and practices respect, among other things, ethnic, cultural and linguistic differences. CSC faces increasing pressure to accommodate a wide range of needs with respect to language, culture, religious identification, diet and ethnicity. Religious diversity within correctional facilities reflects what is now seen within the Canadian population. While the majority of inmates affiliate with Christianity, several other religious faiths are represented, for example Muslim (6%), Native Spirituality (6%), Buddhist (2%) and Sikh (1%). Different religious diets, clothing, medicines, books and worship practices adhered to by the faithful must be accommodated by the CSC.

Approximately 6% of the inmate population reports that the language spoken in their home is other than English or French.6 The CSC is required to provide interpreters for offenders who do not speak Canada’s two official languages for any formal hearing or for the purpose of understanding materials provided to the offender. While this ensures that inmates will be accommodated in formal proceedings, it does not address the challenges they have in day-to-day communications with correctional staff or for completing correctional programs.

Correctional Outcomes

Taken as a whole, visible minority inmates appear to have better correctional outcomes than the total offender population. Over the last 7 years, on average, less than 5% of visible minority inmates have been readmitted within two years of their warrant expiry date. However, grouping visible minorities together masks important differences in these very distinct groups. For example, the case study of the experience of Black inmates under federal custody demonstrates that correctional outcomes are not as encouraging for this visible minority group when compared to others.

When looking at diversity in corrections, it is important to understand what is happening in both relative and absolute terms. For example, the total number of institutional charges decreased by 5,731 in the last 4 years, which can be entirely attributable to the decrease in the number of charges against Caucasian inmates (- 6463). Meantime, institutional charges involving visible minority (+510) and Aboriginal (+222) inmates increased over the same period, even after accounting for increases in these populations. Black inmates are over-represented in use of force incidents, and, overall, visible minority inmates are over-represented in segregation placements.


A Case Study of Diversity in Corrections: The Black Inmate Experience in Federal Penitentiaries

In the 2011-12 Annual Report, the Office committed to a review of the experiences and outcomes of Black inmates in federal custody. A case study was completed over a 4-month period (November 2012 – February 2013) which included a literature review, data analysis and qualitative interviews with Black Inmate Committees, Black inmates, CSC personnel, Audmax (an organization currently on contract with CSC to provide ethno-cultural services in the Ontario region) and community volunteers. Site visits were also conducted in institutions in the Ontario, Quebec and Atlantic region, recognizing that the majority of federally sentenced Black inmates (86%) are incarcerated in these regions.

The Chair of the Black Inmate Committee at each institution was contacted informing them of the case study and requesting their participation and assistance in consulting with members of the Committee to identify issues to bring forward as part of the case study. Notices were also posted on all ranges informing all Black inmates of the study and the opportunity to voluntarily participate. The Chair of the Black Inmate Committee was interviewed at each institution. Voluntary interviews were also conducted with interested Black inmates in one of three ways: individually, in small groups (2-3 participants) or in larger focus groups (15-20 participants). In total, 73 Black inmates (30 women and 43 men), were interviewed. Interviews were also conducted with 24 CSC personnel representing a variety of positions (e.g. Wardens, Correctional Officers, Program Managers), 2 community volunteers and Audmax. In addition, the OCI contracted with the Afrikan Canadian Prisoner Advocacy Coalition (ACPAC) to provide a literature review, expertise and analysis of Black Canadians in conflict with the law7.

Sites Visited for Case Study
Institution Region Security level # of Black inmates in 2011/12  Black inmates as a
proportion of the overall institutional population
Joyceville Ontario Medium 137 37%
Collins Bay Ontario Medium 109 27%
Grand Valley Institution for Women Ontario Multi-level 43 23%
Archambault Quebec Medium 35 10%
Dorchester Atlantic Medium 30 8%


Black inmates are one of the fastest growing sub-populations in federal corrections. Over the last 10 years, the number of federally incarcerated Black inmates has increased by 80% from 778 to 1,403. Black inmates now account for 9.5% of the total prison population (up from 6.3% in 2003/04) while representing just 2.9% of the general Canadian population.8

Population Management and Conditions of Confinement

Black inmates are disproportionately incarcerated in specific institutions in the Ontario and Quebec regions. While there are five medium security facilities in Ontario, nearly 60% of Black inmates are incarcerated in just two of those institutions (Joyceville and Collins Bay). Likewise, in Quebec, there are five medium security institutions, two of which house 60% of all Black inmates in the province (Cowansville and Archambault). This practice persists despite CSC’s Population Management Strategy, which supports the integration of various populations in support of maintaining diverse institutions. CSC staff reported that ethno-cultural diversity reduces violence and contributes to an environment that is less prone to discrimination and cultural stereotyping.

Issues in Focus


While many Black inmates reported interactions with other inmates and staff that were considerate and respectful, nearly all Black inmates interviewed for the case study reported experiencing discrimination by correctional officials. The use of racist language, while present in all institutions, was not reported to be pervasive by those interviewed. More concerning to Black inmates was some of the behaviours exhibited by many staff members. As the literature indicates, the ways in which discrimination and prejudice are displayed or expressed have changed over time from more overt forms (e.g. racist language and behaviour) to more covert and subtle forms (e.g. ignoring, shunning) often making it difficult to recognize and counteract.9 Much of what inmates reported to the Office falls within what the literature describes as covert discrimination.

For example, many talked about being ignored when asking questions: one inmate commented that correctional officers “…look right through me and say nothing. They just look right through me like I am not standing right in front of them.” Their needs did not appear to be a priority; their concerns were often ignored and many felt as though there were a ‘different set of rules’ for Black inmates. While feelings of being ignored or disregarded by correctional staff are no doubt common to many inmates, this behaviour particularly resonates with Black inmates, as it reinforces their lived experiences with racism and discrimination on a daily basis. In prison, it increases feelings of marginalization, exclusion and isolation.

Numerous examples of stereotyping were also reported by Black inmates, primarily in terms of being characterized as a “gang member,” “trouble-maker,” “drug dealer” or “womanizer.” The gang member label was particularly troubling and deemed to be pervasively applied to Black male inmates. They felt as though everything they did or said was viewed through a “gang lens.” Body language, manner of speaking, use of expressions, style of dress and association with others were often perceived as gang behaviour by CSC staff. Many CSC personnel agreed that stereotypes were regularly employed by some staff, viewing everything Black inmates did through bias and prejudice. This label impacts decision making in regard to security classification, program enrollment, work assignment and conditional release recommendation.

Black inmates reported feeling targeted with respect to institutional charges, particularly those that were more discretionary or requiring judgment on the part of correctional officers. The expressive nature of many Black inmates was often viewed by correctional staff as aggressive or disrespectful, while Black inmates felt as though it was “just part of our culture.” In 2011/12, Black inmates were over-represented in many of the categories of charges that could be considered discretionary. For example, Black inmates were disproportionately charged for disrespect toward staff (13%), disobeying an order (20%), and jeopardizing the safety/security of the institution or another person (23%). On the other hand, Black inmates tend to be under-represented in categories that required proof of an infraction, for example possession of stolen property (5%) or unauthorized items (8%).

A review of data over the previous five years reveals that Black inmates are consistently over-represented in administrative segregation, particularly involuntary and disciplinary placements. In 2012-13, Black inmates were disproportionately involved in use of force incidents.

Gang Affiliation

While Black inmates are twice as likely as compared to the overall population to have a gang affiliation, the majority (80.7%) are not a member of a gang. Despite this, the gang affiliation label is the one issue that seems to both distinguish and define the Black inmate experience in federal penitentiaries. Prejudice and bias have been well documented in other studies and inquiries of the Canadian criminal justice system.10 Canadian research suggests that racial profiling exists where Black people are much more likely to experience police stop and search procedures.11 Being subject to greater police surveillance has not only resulted in a greater likelihood of being caught when the law is broken but it also “…serves to further alienate Black people from mainstream Canadian society and reinforces perceptions of discrimination and racial injustice.”12 It is little surprise that this community experience follows Black Canadians into prisons.

On the surface, gang affiliation as identified, assessed and defined by CSC appears to be based on objective criteria: reliable source identification (informants, community or institutional sources); tangible written or electronic evidence (e.g. pictures); common and/or symbolic identification (e.g. scars, marks and tattoos or criminal organization paraphernalia); and observed behaviour that by its nature or association gives reasonable and probable grounds to believe that the offender has a gang affiliation.13 In practice, these criteria are discretionary and prone to confirmation bias, the tendency to interpret information or behaviour in a way that confirms preconceptions and subjective judgments. Once applied, the validity and reliability of the gang label appear to be rarely questioned, particularly among those in operational positions working with Black inmates. This kind of labelling is particularly questionable when it relies on internal security intelligence information or prison informants, which are not always corroborated by external law enforcement, court or judicial authorities.


Despite being rated as a population having a lower risk to re-offend and lower need overall,14 Black inmates are 1.5 times more likely to be placed in maximum security institutions where programming, employment, education, rehabilitative and social activities are limited. They are also less likely to have their Custody Rating Scale score overridden in favour of a placement in a medium or even minimum security institution.

Issues in Focus



Black inmates consistently reported difficulties finding employment, especially jobs of ‘trust’ or in positions which provide training in a particular trade (e.g. manufacturing, construction). The official prison unemployment rate in 2012-13 was 1.5%; however, for Black inmates this rate was 7%. Black inmates were also considerably less likely to be employed in a CORCAN industry – 32% of inmates worked in a CORCAN enterprise compared to only 25% of Black inmates.15 For those employed, Black inmates are essentially on par with the general inmate population with respect to inmate pay levels.


In 2011-12, the top three categories for all inmate grievances were conditions of confinement/institutional routine (27%), interaction (24%) and health care (10%). Black inmates were most likely to file a grievance related to interaction (29%), conditions of confinement/institutional routine (22%) and visits/leisure (13%), highlighting that the quality of staff-offender relations is a particular concern for Black inmates. When the sub-categories of “interaction” are examined more closely, it is clear that Black inmates are over-represented in filing grievances for reasons of discrimination. Black inmates accounted for 25% of all inmate discrimination grievances. Black inmates were also over-represented in staff performance grievances.

Cultural Programming and Services

While Black offenders felt that CSC programs provided them with important tools and strategies, they did not feel that they adequately reflected their cultural reality. Black inmates reported that they could not see themselves reflected in program materials and activities and they felt these were not rooted in their cultural or historical experiences. Moreover, many initiatives and services which serve as important complements to CSC programming also fell short of expectations. Our review revealed:

  • Inconsistent support for cultural events at the institutional level. Some Black Inmate Committees had sufficient guidance in planning events while others reported little to no assistance, to the point that very few events had ever taken place within the institution.
  • A lack of community support. Many Black inmates had never seen, spoken with or met anyone from a Black community group while incarcerated, though most expressed a strong desire to develop and maintain these community linkages. (Importantly, this form of support is a key component of CSC’s Strategic Plan for Aboriginal Corrections.)
  • A need for better access to and availability of hygiene products specifically designed for their hair/skin type and cultural food items through the canteen.
  • Lower grant rates for temporary absences, day and full parole. Programs that offer gradual, supervised release have been shown to reduce re-offending.

Concerns of Federally Sentenced Black Women

In 2011-12, there were 55 Black women inmates serving time in a federal penitentiary, representing 9.12% of the incarcerated women population. Over the past 10 years, the number of incarcerated Black women fluctuated very little between 2002 and 2010, at which point the number increased by 54% and then again by another 28% between 2010 and 2012. The number of incarcerated Black women appears to be rising quickly.

The majority of Black women inmates (78%) are held at Grand Valley Institution (GVI) in the Ontario region. Black women were most likely to be incarcerated for Schedule II (drug) offences16 (53%). Interviews with Black women at GVI revealed that most were incarcerated for drug trafficking. Many indicated that they carried drugs across international borders primarily as an attempt to rise above poverty. There were some who reported/ indicated being forced into these activities with threats of violence to their children and/or families.

Most Black women interviewed were foreign nationals. Many indicated that the high cost of calling home from prison meant that they rarely spoke with family members. CSC policy does not allow for the use of considerably less expensive calling cards. (The Office will be more fully examining inmate telephone cost over the coming year). Restricted contact with home and family presents huge reintegration challenges, particularly because many face deportation upon completion of their sentence.

There were other concerns noted by the women in group and individual interviews: the lack of availability and access to special medicated creams and ointments for skin and hair care; lack of appropriate skills training (rather than laundering, folding, ironing and sewing of clothes); and, cuts to part-time chaplains, reflecting a concern that their spiritual needs could not be met by Christian chaplains. Finally, though many Black women at GVI were incarcerated for drug trafficking, conviction for this type of offence does not necessarily translate into having a drug addiction or substance abuse problem. Several women could not understand why they were required to complete these programs in the absence of an identified need.

Correctional Outcomes

As a group, Black inmates fare relatively well once released from prison. Over the last five years (2007/08 – 2011/12), successful completion rates for both federal day and full parole and statutory release supervision were consistently higher for Black offenders. Moreover, over the long term (for sentences completed between 1996/97 to 2000/01), of offenders who completed their sentences on full parole, statutory release or at warrant expiry, Black offenders were generally less likely to be readmitted on a new federal sentence.17

Conclusion: What Does Diversity Mean for CSC?

The Office’s review of diversity in corrections and the case study of the experience of Black inmates in federal custody finds that, to its credit, CSC has implemented a number of measures to better identify and meet the needs of a more ethno-culturally diverse inmate population and it has implemented an organizational structure to support this work: diversity committees (e.g. national and regional ethno-cultural advisory committees, National Advisory Council on Diversity, National Diversity Committee); cultural programs and awareness activities; sensitivity and diversity training; and staffing initiatives aimed at increasing the representation of employment equity groups (e.g. targeted recruitment, Diversity and Employment Equity Committee, mentorship and leadership programs).

However, challenges remain to reflect, respond to and accommodate diversity. CSC must first ensure that its diversity training, recruitment efforts and retention policies and practices are consistent across all regions, integrated within the overall training framework and followed-up with ongoing practical training, experiences and support. A national diversity awareness training plan that begins at employee orientation and is continuous throughout a staff member’s career would enhance cultural awareness and cultural competency within CSC ranks. This training should be rooted in practical operational experience and target front-line correctional officers as a matter of priority.

While CSC meets and often exceeds workforce employment equity targets on a national basis, this is not well reflected at the institutional level. Not surprisingly, Black inmates cited more positive inmate-staff relations in one institution where the proportion of visible minority staff more closely reflected their numbers. Recruitment and retention strategies need to prioritize and target front-line institutions (not just Regional or National Headquarters) which house the greatest proportion of ethno-cultural offenders. Correctional officers who can speak languages other than English or French are increasingly important assets in improving interactions and communication with the rising number of foreign-born inmates.

The Office’s review of diversity in corrections also yields some important findings with respect to the content, delivery and relevance of correctional programming. For example, ethno-cultural programs are often available in only one institution per region. This program delivery practice gives rise to population management strategies that run contrary to integrative practices and principles. It is also clear that core correctional programs need to be reviewed, revised and updated from a diversity perspective to incorporate more modules, examples and components drawn from lived ethno-cultural experience. More visible minority program facilitators would help ensure relevance, uptake and retention, potentially resulting in higher program completion rates.

Finally, as the results of the 2012 Ethical Climate Survey clearly demonstrate, there is much room for improvement in how CSC staff value and model respect, fairness, inclusiveness, accountability and professionalism in the workplace.18 The voluntary staff survey collected information on abuse of power, discrimination, harassment, inappropriate behaviour and other rude and degrading treatment. Overall, close to 25% of respondents indicated that they had experienced discrimination on at least one of the prohibited grounds (race = 45%, gender = 43.6% and age = 36.3%) over the past year. Of those having experienced discrimination, over 60% reported that the source of discrimination was other co-workers senior to them in the department, including managers.19 Of the sample reported, 31.8% have been harassed in the workplace in the past year, mostly by others senior to them, immediate supervisor(s) or colleagues in their own work unit. These results contribute to what was labelled in the survey as an unhealthy, even “toxic” workplace. On the basis of how poorly CSC staff report they treat one another, it is an important question as to how offenders of different cultures, nationality, religion, creed or race are treated behind penitentiary walls.

The Office’s review and case study of diversity in federal corrections suggests a number of areas for improvement. In terms of the way forward on these matters, I make two substantive recommendations:

1. I recommend that CSC develop a National Diversity Awareness Training Plan that provides practical and operational training in the areas of diversity, sensitivity awareness and cultural competency. This Training Plan should be integrated within the overall training framework.

2. I recommend that CSC establish an Ethnicity Liaison Officer position at each institution responsible for building and maintaining linkages with culturally diverse community groups and organizations, ensuring the needs of visible minority inmates are met and facilitating culturally appropriate program development and delivery at the site level.

I. Access to Health Care

Issues in Focus

Canada’s correctional authority continues to face increasing costs and challenges in managing a higher proportion of the offender population with mental health concerns. The most recent data available indicates that the Correctional Service delivered at least one institutional mental health service to 48.3% of the total inmate population, with 47% of Aboriginal offenders and 75% of women offenders receiving services in FY 2011-12. Just over 90% (or 4,065) of newly admitted offenders were comprehensively screened for potential mental health problems last year; nearly two-thirds were flagged for follow-up mental health interventions. The Service also delivered Fundamentals of Mental Health training to 2,438 staff in fiscal year 2011-12.20

Since 2005, the Service has invested approximately $90M in new funds to strengthen primary institutional mental health care service delivery, implement mental health screening at admission, train front-line staff in mental health awareness and enhance community partnerships and discharge planning for offenders with mental health disorders. These initiatives are part of CSC’s five-point mental health strategy.

Health care remains the number one category of offender complaint to the Office. Staff visits to CSC facilities across the country confirm that access to health care, particularly mental health services and acute or complex care, remains fragmented and variable, especially in more remote penitentiaries.

As I have reported previously, in terms of inmate access to health care that meets professional and community standards of care, the CSC faces important staffing, recruitment and retention challenges. The Service employs a total of approximately 1,200 health care professionals, including nurses, psychologists, pharmacists, medical doctors and social workers. For FY 2011-12, the national vacancy rate for all health care positions in CSC was just over 8.5%. The psychologist vacancy rate in 2011-12 was 16% or 51 positions. The psychologist vacancy rate was highest for the Ontario region, at 29% or 23 positions. Fifty of 329 psychologist positions (or 15%) were filled by incumbents who are non-licensed staff (or “under-fills”) and cannot deliver the same level or range of services as licensed psychologists. In other words, nearly one-third of CSC’s total psychologist staff complement is either vacant or “under-filled.”21 Complicating professional recruitment and retention efforts are concerns about scope of practice, inter-provincial licensing and accreditation issues, as well as issues related to pay, professional development, and terms and conditions of employment.

Intermediate Care

Nine years after launching its Mental Health Strategy in 2004, the intermediate care component for male offenders remains without a source of permanent funds22. The only male intermediate mental health care unit in the country, a pilot project at Kingston Penitentiary (KP) that began in November 2010, was to be terminated in March 2013.23 Like elsewhere in the system, common problems plagued the pilot project:

  1. Aging and inappropriate infrastructure lacking in therapeutic design or purpose.
  2. Persistent staff turnover related to funding and recruitment challenges.
  3. Resort to filling professional health care positions with unregistered (or “under-fill”) staff.
  4. Lack of 24-7 health care coverage (no dedicated clinical service delivery capacity to provide after-hours care or on the weekend).
  5. Lack of specialized mental health care training for new staff.

The cancellation of the intermediate care unit pilot is disappointing, but not entirely surprising given the context and challenges noted above. Unfortunately, it means that the majority of inmates requiring intermediate level interventions to manage their mental health needs will remain in general population or segregation in medium and maximum security facilities as a result of inadequate access to mental health care services and supports. They must rely on primary health care resources that are available in penitentiaries, unable to benefit from a more intensive level of services that intermediate care units could provide. These offenders do not have access to the services in the Regional Treatment Centres, as the admission criteria, rightfully so, screens them out.

Management of Chronic Self-Injurious Offenders

I reported last year that the number of self-injury incidents in federal prisons has more than tripled in the last five years. The number of Aboriginal inmates engaging in self-injurious behaviour is a particularly troubling dimension of this problem. Self-injurious offenders are often managed in maximum security segregation units or observation cells, where conditions of confinement, lack of external stimuli and limited association can result in further deterioration in mental health functioning, leading to an escalation in the frequency and seriousness of self-injury. In some cases, the resort to self-destructive behaviour provides a form of coping and relief from the monotony, negative emotions and deprivations associated with penitentiary life. The known protective/preventive factors for self-injury in prisons – less time locked in a cell; employment; meaningful association with others; engaging in correctional programs; regular and quality contacts with family – appear to conflict with security and incident-driven responses that, in chronic cases, are reduced to simply keeping an offender alive.

Self-Injurious Incidents Involving Women and Aboriginal Offenders

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The Office has documented a series of concerns with respect to the Correctional Service’s capacity and response to mental health service delivery:

  1. Over-reliance on use of force and control measures, such as physical restraints, and restrictions on movement and association to manage self-injurious offenders.
  2. Non-compliance with voluntary and informed consent to treatment protocols.
  3. Limited access to specialized acute services for federally sentenced women offenders.
  4. Inadequate physical infrastructure, staff, resources and capacity to meet complex mental health needs.
  5. Inappropriate monitoring and inadequate oversight in the use of physical restraints.

In my view, the lack of progress and noted gaps above in capacity and access, infrastructure and service delivery warrants consideration of a patient advocate or quality care coordinator model for federal corrections. Such models are becoming the standard of community mental health care practice in Canada and internationally. The legal, ethical and operational issues at play in CSC’s Regional Treatment Centres – e.g. informed and voluntary consent, the right to refuse or withdraw from treatment, legal certification under mental health regulations, among others – are complex. Though designated psychiatric facilities, CSC treatment centres are in fact “hybrid” facilities – both “hospitals” and “penitentiaries.” As a hospital, these centres are subject to provisions of the relevant provincial mental health legislation. As a penitentiary, they operate under federal statute.

Operationally, the interplay between these entities – patient vs. inmate, security vs. treatment, hospital vs. penitentiary – creates its own tensions and contradictions. Moreover, access and continuity of care can be an issue as offenders make their transition from prison to the community. A patient advocate capacity appears all the more urgent and required in light of the decision to cancel the 10-bed Complex Needs program for male inmates who chronically self-injure, a pilot project which had been running at the Regional Treatment Centre in the Pacific Region since November 2010.

3. I recommend that CSC appoint independent patient advocates or quality care coordinators to serve each of its five Regional Treatment Centres.

Alternative Mental Health Care Measures

In December 2012, the Commissioner and Minister of Public Safety were provided a summary of six cases of acutely mentally ill offenders who, in the Office’s opinion, cannot be appropriately managed or cared for in a federal penitentiary. All six of these offenders were subject to interventions by this Office recommending their transfer to an external psychiatric treatment facility. On some level, each of the case summaries raises disturbing parallels to Ashley Smith’s preventable death in October 2007. Like Ashley, these offenders have complex and acute mental health care needs well beyond the resources or capacity of the Service to safely or humanely manage.

The cases brought forward by the Office provide evidence that the sentence for these individuals needs to be medically managed and their serial and prolific self-injury warrants transfer to outside treatment facilities. Most have been involved in dozens of uses of force interventions to prevent or interrupt patterns of repetitive self-harming. Some are certified under provincial mental health legislation. Most have a protracted history of childhood physical, mental and sexual abuse. A few are “low functioning,” more child-like in their responses and emotional development. One is disfigured and permanently brain injured from repetitive and chronic head-banging. All have an extensive history and diagnosis of mental illness. One is a “dual status” offender following a previous finding of Not Criminally Responsible. Several have been the subject of reviews by National Boards of Investigation. These offenders can be disruptive, their behaviour causes significant staff stress and their care and management can be extremely expensive. Many have been managed on around the clock suicide watch, mostly in long-term segregation or observation cells largely devoid of stimuli.

As of the writing of this report, the Office has not yet received a full response to its December 2012 correspondence. CSC should and can provide mental health supports for the greater majority of federally sentenced offenders. But it should contract out services for the few that require highly specialized mental health care interventions and treatment. With respect to managing acute physical health conditions, the Service regularly moves offenders into community hospitals and external treatment centres. There is a corresponding and requisite need to do the same in managing acute mental health cases. Outside psychiatric hospitals provide a therapeutic environment where interventions are conducted by a team of health care professionals. This is not the case in federal penitentiaries, not even in the Regional Treatment Centres, where first responders are typically correctional officers who may or may not be accompanied by Health Services personnel. Segregation, pepper spray and restraints are not treatment for mentally ill individuals.

The management and treatment of mentally disordered individuals in correctional facilities is extremely challenging work. We should not expect the Correctional Service to do the impossible. The Office does not question the integrity, commitment or professionalism of CSC’s efforts. However, we should not be relying on facilities that were never designed to accommodate or care for individuals with serious mental health issues and those who seriously and chronically self-injure. I am increasingly of the opinion that modest and incremental reform of a system that is fundamentally flawed is not in the public interest. Some mentally ill individuals in federal penitentiaries do not belong there and should be transferred to outside treatment facilities as a matter of priority.

4. I recommend that the CSC immediately identify the most severely mentally ill male and female inmates for review by external mental health experts and formulate health-focused treatment and placement options.

II. Deaths in Custody

In 2011-12 there were 53 deaths recorded in CSC facilities, including eight prison suicides and 35 deaths from “natural” causes. These numbers in part reflect the fact that more offenders are serving longer sentences, more are sentenced later in life and more are growing old and dying behind bars. As the inmate population ages, the number of deaths attributable to “natural” causes far exceeds other types of death as the leading cause of death in federal custody.

Section 19 and Death in Custody Reviews

With respect to CCRA Section 19 review of deaths in custody, in FY 2012-13 the Office investigated a troubling case where next of kin notification procedures had gone very wrong. Based on this and other case reviews, the lack of information provided to families by CSC about the circumstances and causes of death of a loved one continues to be a matter of concern. There is little that is “natural” about dying in a federal prison. Few terminally ill inmates receive “compassionate release” to die with some semblance of dignity in the community. Meantime, the manner in which CSC chooses to inform the public of a death in one of its facilities suggests that there is more to be done to respect the dignity, privacy and confidentiality of all parties.

Of considerable concern is CSC’s relatively new streamlined Mortality Review Process (MRP) for investigating so-called natural deaths in custody. The MRP is a shortcut that appears to be unequal to the requirements of Section 19. These matters are currently under investigation, the findings of which will be issued in the coming year.

National Forum for Preventing Deaths in Custody

Canada lacks an independent, high-level review mechanism to review and help prevent deaths in custody. There is no Ministerial-level panel or Parliamentary Committee that looks into the number or rate of deaths in federal prisons, provincial and territorial jails, or law enforcement or immigration detention facilities.24 During the reporting period, the Office’s review of the circumstances contributing to inmate deaths in federal custody suggests that these events continue to be responded to episodically rather than systematically. Despite a number of draft attempts, CSC still has no consolidated or publicly available performance and accountability strategy focused on the prevention and reduction of preventable or premature deaths in federal custody.

Coroner and Medical Examiner reviews, inquests and reports continue to demonstrate scope for further learning in terms of applying lessons in assessing and managing the risk of suicide, overdoses and other deaths in custody. However, these reviews have had little sustained impact in part because there is no official body to share, let alone enforce their findings or recommendations. As a matter of practice, some provincial jurisdictions do not automatically review or probe a death in federal custody when it was “expected” or attributable to “natural” causes. Moreover, public fatality inquiries are often conducted long after the fact, raising serious concern about CSC’s capacity to identify and correct systemic deficiencies in a timely and responsive manner.

5. I recommend that the Minister of Public Safety create an independent national advisory forum drawn from experts, practitioners and stakeholder groups to review trends, share lessons learned and suggest research that will reduce the number and rate of deaths in custody in Canada.


III. Conditions of Confinement

Population Management

In the three year period between March 2010 and March 2013, the federal in-custody population increased by 1,214 inmates or 8.4%.25 When the numbers are broken down it is apparent that recent population growth is not evenly distributed across CSC’s five regions. The Ontario and Prairie Regions lead population growth, both in proportionate and absolute terms. Both regions continue to exceed rated capacities and have resorted to some extraordinary measures to manage rising inmate numbers, including inter-regional and involuntary transfers, which raise significant legal rights, due process and fairness considerations.

The system is exhibiting strains in safely managing an increasing population through daily routines and providing adequate access to programs and services. At the national, regional and local levels, there are policies and procedures in place limiting the number of offenders that may be associating on a range, outside in the yard or in the cafeteria for meals at a given time. It becomes increasingly difficult to coordinate daily prison routines that are compliant with legal, policy and procedural guidelines as populations increase.


As of March 31, 2013, the national double bunking rate, the practice of confining two inmates in a cell designed for one, was 20.98%. The Office has long raised concerns with this practice. In January 2013, the Office received a paper forwarded by the local UCCO-SACC-CSN Executive at Bath Institution, a medium security facility in Ontario, outlining its concerns about double-bunking. The following excerpt summarizes the issues at stake:

(T)here is a correlation between double bunking and an increase in serious institutional incidents. The act of double bunking creates problems by multiplying the offender population within limited infrastructure. When large groups of inmates are forced to live together in minimal space (they) begin to fight over such things as washrooms, televisions, phones, food, recreational areas and equipment … Therefore higher rates of aggression, violence, injury from other and self-injurious behaviours may increase … due to the increased anxiety and demands on stressed individuals. Inmates generally deal with this type of anxiety by withdrawal from programming, vocational and recreational activities, as they deal with feelings of depression and or aggression, which greatly diminish a chance to succeed with their correctional plan. The institutional overcrowding and lack of institutional employment also leads to an increasing number of institutional security incidents.26

Inmate views of double bunking are almost equally negative and pessimistic. Being locked up in a space about the size of an average bathroom with another person inevitably means diminished privacy and dignity, and increases the potential for tension and violence. Inmates describe the experience to the Office as demoralizing and degrading.

The Prairie Region exemplifies these pressures. Over the past five years, the number of incidents of assault (including assaults on other inmates, visitors, and staff; inmate fights; and sexual assaults) increased by 60% (from 366 in FY 2008-09 to 586 in FY 2011-12). The number of use of force incidents increased by 48% (from 265 to 393) over the same period. In the last three years, there have been five inmate murders in the Prairie Region, accounting for more than half of all inmate homicides in federal penitentiaries.

These violent events often translate into further disruptions to the prison routine resulting in a high number of lockdowns, searches, time spent in cells and staff refusals to work on occupational health or safety grounds. There were 428 lockdowns recorded in CSC facilities during FY 2012-2013. The response to these incidents negatively impacts on staff and offenders alike, and raises obvious personal safety and institutional security concerns. Other performance measures that speak to deteriorating conditions inside federal institutions – disciplinary and institutional charges, use of force interventions, incidents of self-harm, number of minor and major disturbances, segregation placements, offender grievances – suggest that many key indicators are trending in the wrong direction.

Issues in Focus


Issues in Focus


Inmate Accommodation Policy

In the reporting period, the Service finally promulgated its long-awaited revised policy standards on inmate accommodation. The new Commissioner’s Directive is seriously flawed and signifies a dramatic reversal in terms of principles and standards. Most significantly, the new policy direction removes two long-standing tenets of federal correctional practice: “single occupancy accommodation is the most desirable and correctionally appropriate method of housing offenders” and “double bunking is inappropriate as a permanent accommodation measure within the context of corrections.” These omissions normalize double-bunking as a response to population pressures rather than consider it an exceptional or temporary measure or as an option of last resort.

There are other problems with the revised policy. For example, the new policy continues to require correctional officers to complete the double-bunking assessment to ensure compatibility between cell mates. The Office has long considered this practice inadequate – particularly given the amount of information and level of assessment required (psychological profile, medical information, criminal history, compatibility, predatory/permissive behaviour and vulnerability) – to make informed judgments. In the Office’s view, this type of assessment is more appropriately carried out with the oversight of the Warden and should be subject to periodic review by regional authorities.

A recent CSC audit noted that of the 216 double-bunked offenders’ files reviewed only 56% (or 120 of 216) had a double-bunking assessment on file for their current cellmate.27 Even with new policy direction, front-line staff continue to report confusion regarding who is responsible for completing double-bunking assessments. These findings confirm the Office’s experience that these assessments are often missing, incomplete or superficial.

The new policy standard also removes reference to limits on the maximum number of inmates that an institution is permitted to hold by security level. The size and scale of a correctional facility is extremely important. Large facilities (in excess of 300 offenders) tend to reinforce an environment of anonymity and may promote individual feelings of powerlessness, isolation and embitterment, sentiments which are counterproductive to correctional programming and reintegration purposes. The removal of upper limits runs contrary to long-standing evidence, which suggests that smaller scale institutions are safer, better managed and deliver superior correctional outcomes.28

In response to these concerns, the Senior Deputy Commissioner stated in correspondence dated October 29, 2012, that the new inmate accommodation standards “must not be interpreted as a change in direction as CSC recognizes that single occupancy accommodation is the most desirable and appropriate method of housing offenders.” If this is indeed the case, it begs the question why seemingly “desirable” and “appropriate” single cell occupancy standards and physical limits on the size of CSC institutions were removed from the accommodation policy framework in the first place. A recent CSC research report evaluating the effects of prison crowding concedes that “the literature does suggest a relationship exists between crowding and psychological and physiological stress for offenders,” and, furthermore, there is an “effect of crowding on institutional misconduct.” The report concludes that “scholars and criminal justice organizations, including CSC, agree that double bunking should not become a common practice or a long-term strategy in correctional facilities.”29 CSC’s revised inmate accommodation policy runs contrary to the available evidence and experience, which indicates that without proper safeguards double bunking as a response to prison crowding is a practice that jeopardizes staff and inmate safety.

6. I recommend that CSC’s inmate accommodation policy reinstate the principle that single occupancy is the most desirable and correctionally appropriate method of housing offenders.

Issues in Focus


The Office has identified some serious gaps in CSC’s use of force review process which once again calls into question the system’s capacity to detect and correct deficiencies. As part of policy changes to the use of force review process that went into effect in April and June 2012, the number and types of incidents that are subject to a regional or national review have been significantly reduced. Under the new rules, “moderate” use of force incidents are now subject to regional (or level two) review in only 25% of cases. A national review involves a “selective” random sample of 5% of use of force incidents pulled from the regional review process. The Office is concerned that non-compliant or inappropriate uses of force are not making their way up the review and accountability chain as they should. There is still no clear national policy direction on how cases at the regional or headquarters levels are selected for the 25% and 5% reviews. Unless a use of force intervention is “flagged” at the regional level, it may never be brought to the attention of national authorities.

It is my view that it is inappropriate to leave review of use of force incidents to random selection. Experience and common sense dictate a need to both assure and ensure force is used appropriately, judiciously and proportionately in a correctional setting. Reliable mechanisms must be in place to record, review and report use of force incidents. Previously, national authorities reviewed all use of force events that occurred in CSC facilities across the country, but as a result of these new policy directives, they are now “randomly” reviewing just 5% of the over 1,200 reported incidents annually. Surely the point of having a use of force review process is to hold the organization to account by identifying areas of non-compliance and correcting deficiencies. It is simply not wise to dilute oversight or download accountability for this high-risk activity.

The Office has reported serious and long-standing compliance problems in meeting current use of force guidelines, including post-use of force health care assessments, videotaping and decontamination procedures. These deficiencies are of particular concern because close to 60% of all use of force scenarios involve the use of an inflammatory spray, 16% of incidents take place where a mental health concern is identified and nearly 10% did not meet the most reasonable, safest or least restrictive use of force option available. These already poor compliance rates would seem to require decidedly more attention and involvement by national authorities, not less.

7. I recommend that any use of force incident involving a mentally disordered offender be subject to a mandatory review at the institutional and regional levels. Issues of non-compliance should be submitted to National Headquarters for review and identification of corrective measures.

8. I recommend that regional authorities review all use of force incidents involving the use of Institutional Emergency Response Teams.

It is distressing to note that some front-line staff continue to insist that the drawing or display of a weapon (e.g. baton, pepper spray or even shotgun) should be reported differently from its actual use or discharging. In these matters, there is a long-standing discrepancy between incidents and reporting of what is deemed “reportable” (and therefore reviewable) and what is considered routine. The policy on these matters is perfectly clear: a “reportable” use of force includes the use and/or the threat, display, loading or charging of a weapon, including the display of a pepper spray canister.30 Among trained, certified and professional staff, there should be no room for ambiguity on these matters; similar regulations govern all law enforcement agencies in Canada. There are good legal and practical reasons why these procedures have been adopted and why they should be followed as a matter of both procedure and principle.

There are other troubling practices. Uses of force reviews systematically do not meet the review period timelines: it is not an uncommon occurrence for an offender to have been released, transferred or otherwise moved on with his/her life before the review of the incident is ever completed. There are some use of force packages that date back as far as 2009 that are still considered “pending” by CSC. In too many cases, by the time that the file is finally reviewed or makes its way through the review levels, the actors have changed and there is simply no opportunity to take meaningful follow-up or corrective measures. For CSC, a case status of “pending” often translates into “no further action required.”

This year, the Office reviewed a number of files subject to national level review that were little more than “cut and paste” reports involving minimal analytical effort and offering little in the way of value-added. The reviews were often superficial and perfunctory in both form and fashion. More significantly, the Office noted interference by National Headquarters in some of its requests to share information or files from regional authorities. Office notification of serious cases does not happen routinely in all regions or as a matter of policy, as it should. Cases that, in the Office’s view, merit proceeding directly to a national “priority” review can linger or languish interminably in procedural delays. That said, the Office is not a substitute (or “fail-safe”) for CSC’s administrative use of force review process. It is the Service’s legal obligation to ensure use of force interventions comply with the letter of the law.

Emergency Response Teams

In use of force files reviewed by the Office in FY 2012-13, Emergency Response Teams (ERTs) responded to over 10% of all use of force interventions in male facilities. While traditionally reserved for high-risk procedures (e.g. to quell disturbances or perform a cell extraction of a physically uncooperative inmate), ERTs are increasingly used in support roles such as escorts or internal population movements. In some institutions, “shadowing” of front-line staff by the ERT, to facilitate a range search for example, has become standard procedure. Fully outfitted in their protective gear, ERTs have even been used to “supervise” medical treatment. Under the new use of force review procedures, there is no policy obligation to report deployments of ERTs.

Use of force scenarios where mental health concerns are identified are increasing. ERTs may also be called in to manage a mentally disordered offender who is “acting out.” Use of force interventions involving “problematic” or non-compliant inmates often involves situations where a mental health issue is the underlying basis of the “bizarre” or “threatening” behaviour. In deployments involving mentally disordered offenders, the composition and comportment of a fully armed and equipped ERT does not normally allow for subtlety in purpose or action. The Office reviewed video evidence of some ERT actions that raise serious concern about the nature and appropriateness of the degree and level of force used in cases involving mentally disordered offenders. These are not isolated occurrences.

9. I recommend that Emergency Response Training be updated to include standards and protocols when responding to situations where a mental health concern is identified. Awareness training in mental health issues and self-injurious behaviour, including de-escalation techniques, should be mandatory components of this training.

Information and Privacy

The Privacy Act imposes certain obligations on federal departments and agencies with respect to the protection of personal information that it collects, stores, uses or disseminates. Given the amount and array of sensitive information that CSC collects and possesses, the Service is obligated to ensure there are practices and processes in place to safeguard against any potential privacy risk or unauthorized sharing of personal information.

On an annual basis, the Office of the Privacy Commissioner of Canada receives a substantial number of formal complaints – accounting for approximately one-third of its overall complaint caseload – from federally sentenced offenders. These complaints typically involve the inappropriate use, access or disclosure of personal information either held or collected by the CSC. In a prison setting, breaches of protected personal information, such as inmate medical records, security intelligence information or criminal history, can have serious consequences.

10.  I recommend that the CSC conduct an internal audit of its practices and procedures to protect personal inmate information.

Issues in Focus


IV. Aboriginal Issues

“To be clear, courts must take judicial notice of such matters as the history of colonialism, displacement, and residential schools and how that history continues to translate into lower educational attainment, lower incomes, higher unemployment, higher rates of substance abuse and suicide, and of course higher levels of incarceration for Aboriginal peoples.” (R. v. Ipeelee, SCC 13 2012)

The federal Aboriginal offender population is complex. As one of the youngest and fastest growing segments of Canada’s population, Aboriginal people are likely to continue to experience disproportionate rates of incarceration.31 The Aboriginal incarceration rate is already estimated to be 10 times higher than the national average.32 Today, 22% of the total federal inmate population claims Aboriginal ancestry. Aboriginal women represent 33.6% of all federally sentenced women in Canada. Current sentencing trends combined with a growing and youthful demographic indicate that the over-representation of Aboriginal people in Canada’s correctional system is likely to grow.

Some progress is being reported:

  • Aboriginal offenders access their first Nationally Recognized Correctional Program (NRCP) faster than non-Aboriginal offenders.
  • A greater percentage of Aboriginal offenders with an identified employment need receive vocation skills training or certification prior to Full Parole Eligibility Dates compared to non-Aboriginal offenders.
  • Aboriginal offenders access their first community-based NRCP faster than non-Aboriginal offenders.
  • The percentage of offenders with Educational referrals approved within 120 days of admission is greater for Aboriginal than non-Aboriginal offenders.

However, on many key indicators of correctional performance and outcome, the gap between Aboriginal and non-Aboriginal offenders continues to widen:

  • Aboriginal offenders are kept behind bars for longer periods and at higher security levels than their non-Aboriginal counterparts.
  • They are over-represented in segregation placements, maximum security populations, institutional charges and in use of force incidents.
  • Although conditional release grant rates are low for all inmates, they are far worse and deteriorating faster for Aboriginal men and women; indeed, most Aboriginal inmates are released on statutory release (two-thirds point of the sentence) or warrant expiry, not parole.
  • Aboriginal offenders accounted for 45% of all self-injury incidents in federal prisons last fiscal year.33

Since 2005-06, the Aboriginal inmate population has increased by over 40%. There are now more than 3,500 Aboriginal people behind bars in federal penitentiaries. More than half of the daily inmate count at several institutions in the Prairie Region is Aboriginal.

The over-representation of Aboriginal men and women entangled in Canada’s criminal justice system is not new. The social, cultural, historical and economic factors that give rise to incarceration rates that are 10 times higher for Aboriginal people have been extensively documented. In R. v. Gladue (1999) and R. v. Ipeelee (2012), the Supreme Court of Canada confirmed that the social history of an Aboriginal offender (also known as Gladue factors) is to be considered when the interests of an Aboriginal offender are at stake:

  • Effects of the residential school system.
  • Experience in the child welfare or adoption system.
  • Effects of the dislocation and dispossession of Aboriginal people.
  • Family or community history of suicide, substance abuse and/or victimization.
  • Loss of, or struggle with, cultural/spiritual identity.
  • Level or lack of formal education.
  • Poverty and poor living conditions.
  • Exposure to/membership in, Aboriginal street gangs.

Despite incorporation into CSC’s policy framework, there is little evidence to suggest that Gladue principles are routinely applied by CSC authorities or making a tangible difference in the lives of Aboriginal people under federal sentence.

Spirit Matters

This was the context in which the Office released, on March 7, 2013, a systemic investigation into how CSC has responded to Parliament’s direction to share care and custody of Aboriginal offenders with Aboriginal communities under Sections 81 and 84 of the CCRA. The report entitled, Spirit Matters: Aboriginal People and the Corrections and Conditional Release Act,34 marked only the second time in the history of the Office that Section 193 provisions of the CCRA – Special Report to Parliament – have been used. In the Office’s assessment, the issues facing Canada’s Aboriginal people in the federal correctional system are both significant and urgent, and demanded a comprehensive and immediate response.

There were a series of unforeseen procedural delays leading up to the report’s eventual tabling in Parliament. The final report was submitted to the Commissioner on October 22, 2012. As per standard Office practice, the Commissioner was asked to respond to the report’s 10 recommendations by November 12, 2012. Despite a number of follow-up requests, by the end of December I still had not received the Commissioner’s response. On January 7, 2013, I asked the Minister to intervene. In response, on January 30, 2013, the Minister invited me to submit my report to him for the purpose of tabling in Parliament pursuant to Section 193 (Special Report) provisions of the CCRA. In light of the importance and urgency of the issues under consideration, and given that I still had not received CSC’s response, I decided to have the report released through tabling under Section 193. Spirit Matters was finally tabled in Parliament on March 7, 2013, four months after it had been sent to the Commissioner for his response.

I expected a meaningful and comprehensive response, consistent with the extraordinary measures that were taken to have Spirit Matters laid before Parliament. In the end, the Correctional Service’s response was neither. In correspondence sent to the Commissioner on March 8, 2013, I stated that CSC’s response lacked “substance, meaning and clarity.” On some matters, for example my recommendation to appoint a Deputy Commissioner for Aboriginal Corrections, the response simply recycled previously held CSC positions. My conclusion then, as it is now, is that CSC’s response did not meet the urgency, immediacy or importance of the issues that my Special Report to Parliament warranted. My concerns about CSC’s response were subsequently shared with the Minister.

11. I recommend that the Correctional Service of Canada publish a public accountability report card summarizing key correctional outcomes, programs and services for Aboriginal people, to be tabled annually in Parliament by the Minister of Public Safety.

12. I recommend that in the coming year, the Correctional Service of Canada publish an update to its response to Spirit Matters in collaboration and consultation with its National Aboriginal Advisory Committee.

13. I recommend that the Correctional Service of Canada audit the use of Gladue principles in correctional decision making affecting significant life and liberty interests of Aboriginal offenders, to include penitentiary placements, security classification, segregation, use of force, health care and conditional release.

V. Access to Programs

Prison Work and Vocational Skills Training

Approximately three in five offenders have employment needs at intake to a correctional facility. CSC research has confirmed a number of positive associations between offenders engaged in prison work and vocational skills training during incarceration:

  • Lower rates of admission to segregation
  • Fewer institutional charges
  • Higher parole grant rates
  • More likely to attain and hold a job in the community

Moreover, offenders employed in the community were almost three times less likely to be revoked due to a new offence than were those who were not employed.35

As encouraging as these results are, several barriers to vocational skills training remain. The single largest barrier to effective participation in work and vocational skills programs is not inmate disinterest, but rather the shortage of meaningful work and training opportunities. The use of work releases has declined by nearly 39% in the last decade; only 363 inmates benefited from a Warden-approved work release in 2011-1236. Though work in CORCAN production industries is considered a rehabilitation program by CSC and does offer some limited skills training and certification, there is concern that the jobs themselves – primarily in laundry and textiles, manufacturing and construction – are not well aligned with current labour market realities or requirements.

Although women offenders are engaged in a number of skills and vocational training activities (including food preparation, customer service, hair styling, pet grooming and computer skills), many continue to express a desire to learn skills other than those related to “domestic” work (washing, sewing, ironing and folding clothes, for example). For male offenders, vocational and apprenticeship training – for example, in carpentry, electrical and mechanical work – provides a better foundation for securing employment, earning a living and remaining crime-free in the community after release.

14. I recommend that CSC increase the number of work releases and enhance access to meaningful prison work and vocational skills training opportunities where such needs are identified in a correctional plan in order to better prepare offenders for their safe and successful release to the community.


In October 2012, it was announced that part-time contracts for prison chaplaincy services would not be renewed at the end of FY 2012-13. This move mostly affects religious services provided by non-Christian chaplains on a contractual basis to CSC facilities. All but a few of CSC’s more than 70 full-time chaplains represent Christian beliefs. The part-time chaplains are to be replaced by a mix of volunteers while permanent chaplains are to be made available to provide multi-faith spiritual advice, religious counselling and guidance to the general offender population.

Canada is a multicultural and multi-faith society. The religious identification of the offender population is increasingly diverse. Prisoners do not lose their constitutional right to express their religious and spiritual beliefs by virtue of incarceration. CSC has a positive duty to accommodate different religious faiths and beliefs.

15. I recommend that an external review of inmate access to spiritual services, freedom of religious expression and practice in CSC facilities be conducted
in 2013-14.

VI. Federally Sentenced Women

Population Trends

The federally sentenced women population remains small when compared to males, but it is increasing at a much faster rate. In the 10-year period between March 2003 and March 2013, the female inmate population increased by just over 60%. One in three federally sentenced women offenders is Aboriginal. Since 2003, this group has increased by 83.7%.

In September 2012, an independent review commissioned by the Department of Public Safety entitled Marginalized: The Aboriginal Women’s Experience in Federal Corrections was released.37 The external report examined the reasons behind the over-representation of Aboriginal women in federal penitentiaries, revealing a depressing picture of dislocation, isolation, violence, poverty, victimization and discrimination. It examines several themes that are consistent with the Office’s own findings and recommendations in this area of corrections: over-classification of Aboriginal women inmates; high prison self-injury rates among Aboriginal women; lack of culturally appropriate programming; and limited use of CCRA provisions to share care and custody of Aboriginal offenders with Aboriginal communities.

There are a range of specially adapted services, programs and supports available to Aboriginal women offenders in federal custody. Even so, like their male counterparts, Aboriginal women are over-represented in segregation, maximum security units and use of force interventions. In 2011-12, Aboriginal women accounted for close to 75% of all self-injury incidents among all women offenders. Too often, security-driven responses to these incidents – institutional charges, segregation placements, security reclassifications – limit access to the very services and supports that could prove beneficial to these women.

16. I recommend that CSC respond publicly to the issues and concerns contained in the 2012 external report entitled, Marginalized: The Aboriginal Women’s Experience in Federal Corrections.

A Look Forward in Women’s Corrections

In the coming year, the Office will release an investigation into the treatment and management of women offenders who chronically self-injure in CSC custody.

Reflecting complaints brought forward by federally sentenced women, the Office will continue to monitor population management challenges in the Ontario and Prairie Regions, participation in the mother-child program, access to the outside world and the need for more meaningful prison work and vocational skills training opportunities for women.

Transparency and Accountability in Corrections

The CSC and the OCI believe that openness, good faith, respect, cooperation and effective communication characterize a good working relationship.38

Timely resolution of offender complaints and addressing concerns regarding conditions of confinement are in the interest of all parties, and should almost always be attainable within the context of a cooperative, productive and professional working relationship between the CSC and my Office. As Correctional Investigator, I only have the power to recommend; I cannot compel the Correctional Service to accept or act on any of my recommendations. I accept that some points of disagreement will always exist between a review body and the agency that it oversees. But even in disagreement, the agency is still required to respond. Answerability is in fact a central requirement of a modern and responsive correctional system.

The Office’s Annual and Special Reports are tabled in Parliament by the Minister of Public Safety. As a matter of best practice that goes back several years consistent with observations of the Arbour Commission of Inquiry in 1996 and the Parliamentary sub-Committee’s five year review of the CCRA in May 2000, the CSC’s response to recommendations contained in my Annual Reports has been included as an integral part of the report itself. Although technically not a CCRA requirement, this is standard practice for most review bodies. Auditor General of Canada reports, for example, include responses from the Departments or Agencies subject to its findings and recommendations.

As a result of a decision taken during the reporting period, I was informed by the Commissioner in correspondence dated February 01, 2013, that the Government of Canada would respond only after my reports have been tabled in Parliament. This is not the way that I would prefer to conduct business. My Office, those under sentence and their families, Parliament and all Canadians deserve to know how CSC responds to recommendations aimed at increasing accountability and ensuring fairness, legality and policy compliance. If CSC supports or accepts a recommendation of my Office, there is every reason to expect that it will be acted upon in good faith and in a timely and proactive manner. On the other hand, if a recommendation is not supported or is rejected by the Service, it should publicly explain why, and this position, in turn, will inform the substance of any debate upon tabling in Parliament.

17. In the interest of transparency and accountability, I recommend the best practice of including the Correctional Service of Canada’s response as an integral part of my reports tabled in Parliament be reinstated.

Correctional Investigator’s Outlook for 2013-14

I am mindful that these are challenging times for the Correctional Service of Canada. In the coming year, the cumulative impact of a series of legal and policy reforms will be more fully felt, placing additional strain on the CSC to do more with less. By the end of 2014, the Service’s contribution to the government’s Deficit Reduction Action Plan (DRAP) will mean a reduction in its operating budget of $295M. CSC’s planned spending for 2013-14 is $2.6B, which marks a 14% decrease from the previous year. The closing of three penitentiaries (Leclerc, Kingston and the Ontario Regional Treatment Centre) and relocation of 1,000 inmates in the Ontario and Quebec regions, some with complex mental health needs, involves a huge logistical and operational undertaking. Meantime, the massive $637M construction effort to commission 2,700 new or refurbished cells at more than 30 operational sites by the end of 2014 adds to the Service’s considerable operational and budgetary pressures.

Media and public scrutiny of the ongoing inquest into the death of Ashley Smith is expected to continue through 2013-14, undoubtedly raising more unsettling questions about the appropriateness of managing significant mental illness in a prison setting. My Office will release an investigation into the treatment and management of self-injurious women offenders in the coming year, and I fully expect the Service to make real progress in finding more humane responses and appropriate alternatives to manage complex mental health needs.

As my report this year makes clear, the increase in ethno-cultural diversity presents a significant array of challenges with respect to the delivery and relevancy of correctional programs and the need to increase cultural competency, awareness and sensitivity training within CSC ranks. As recent Census data suggests, these challenges are for the long-haul and they must be met with determined resolve and committed leadership. This year’s report on these matters provides some findings and recommendations that should help direct and guide future reforms.

My Office is receiving more complaints involving staff-inmate interactions, prison conditions and routines, all issues which appear partly attributable to workforce climate factors. The high number of staff refusals to work on alleged violations of Canada Labour Code health and safety standards is but one indicator of conditions of work on the frontlines, as are the troubling results of the CSC’s 2012 Ethical Climate Survey.

One of the products of a compromised workplace environment is compromised decision making. It is difficult to focus on fairness toward others when you feel unfairly treated yourself. Much of what an ombudsman does is to weigh the degree to which an administrative decision is reasonable and fair. In so doing, my Office tries to determine if the decision maker considered all evidence and policy and if there is a clear relationship between the facts and the conclusion. For a decision to be reasonable, all arguments must have been considered and the process used or path taken to move from problem to resolution must establish that while alternative outcomes were possible, all factors taken together lead to only one outcome as the appropriate and fair one. It is not enough for correctional staff to simply confirm that policy has been followed. Reasonable decisions are more than just compliant; they are also demonstrably fair. Discretionary decisions must not only be rationally related to policy, they must also be clear, rooted in consideration of all relevant factors and be free of bias. We will increase our effort in the coming years to help strengthen a culture of fairness across the CSC and help ensure that decisions made are not just legal, but also reasonable and fair.

While my Office has traditionally not commented upon labour relations, at some institutions a negative labour environment is increasingly disrupting prison conditions and inmate routines. In light of these developments, my Office will not hesitate to investigate when these issues negatively impact on the ability of the Service to conduct lawful, safe, fair and appropriate correctional practices.

Looking forward, I would hope to see the Service make progress in the various matters of concern identified in this report. I will, as per my mandate, keep an eye on slippage and gaps in correctional practice and bring corrective action to the attention of the Commissioner, Minister and Parliament as necessary. In the year ahead, I recommit myself and my Office to the principles that have served the Office since its creation in 1973 – independence, impartiality, accessibility and responsiveness.

Issues in Focus


Ed McIsaac Human Rights in Corrections Award

The Ed McIsaac Human Rights in Corrections Award was established in December 2008, in honour of Mr. Ed McIsaac, long-time Executive Director of the Office of the Correctional Investigator and strong promoter and defender of human rights in federal corrections. It commemorates outstanding achievement and commitments to improving corrections in Canada and protecting the human rights of the incarcerated.

The 2012 recipient of the Ed McIsaac Human Rights in Corrections Award was Jean-Claude Bernheim, Criminologist and lecturer at Laval University.

Ed McIsaac Human Rights in Corrections Award

Left to Right: Mr. Howard Sapers, Mr. Jean-Claude Bernheim (centre) and Dr. Ivan Zinger

Text description of image

Annex A: Summary of Recommendations

  1. I recommend that CSC develop a National Diversity Awareness Training Plan that provides practical and operational training in the areas of diversity, sensitivity awareness and cultural competency. This Training Plan should be integrated within the overall training framework.
  2. I recommend that CSC establish an Ethnicity Liaison Officer position at each institution responsible for building and maintaining linkages with culturally diverse community groups and organizations, ensuring the needs of visible minority inmates are met and facilitating culturally appropriate program development and delivery at the site level.
  3. I recommend that CSC appoint independent patient advocates or quality care coordinators to serve each of its five Regional Treatment Centres.
  4. I recommend that the CSC immediately identify the most severely mentally ill male and female inmates for review by external mental health experts and formulate health-focused treatment and placement options.
  5. I recommend that the Minister of Public Safety create an independent national advisory forum drawn from experts, practitioners and stakeholder groups to review trends, share lessons learned and suggest research that will reduce the number and rate of deaths in custody in Canada.
  6. I recommend that CSC’s inmate accommodation policy reinstate the principle that single occupancy is the most desirable and correctionally appropriate method of housing offenders.
  7. I recommend that any use of force incident involving a mentally disordered offender be subject to a mandatory review at the institutional and regional levels. Issues of non-compliance should be submitted to National Headquarters for review and identification of corrective measures.
  8. I recommend that regional authorities review all use of force incidents involving the use of Institutional Emergency Response Teams.</li>
  9. I recommend that Emergency Response Training be updated to include standards and protocols when responding to situations where a mental health concern is identified. Awareness training in mental health issues and self-injurious behaviour, including de-escalation techniques, should be mandatory components of this training.
  10. I recommend that the CSC conduct an internal audit of its practices and procedures to protect personal inmate information.
  11. I recommend that the Correctional Service of Canada publish a public accountability report card summarizing key correctional outcomes, programs and services for Aboriginal people to be tabled annually in Parliament by the Minister of Public Safety.
  12. I recommend that in the coming year, the Correctional Service of Canada publish an update to its response to Spirit Matters in collaboration and consultation with its National Aboriginal Advisory Committee.
  13. I recommend that the Correctional Service of Canada audit the use of Gladue principles in correctional decision making affecting significant life and liberty interests of Aboriginal offenders, to include penitentiary placements, security classification, segregation, use of force, health care and conditional release.
  14. I recommend that CSC increase the number of work releases and enhance access to meaningful prison work and vocational skills training opportunities where such needs are identified in a correctional plan in order to better prepare offenders for their safe and successful release to the community.
  15. I recommend that an external review of inmate access to spiritual services, freedom of religious expression and practice in CSC facilities be conducted
    in 2013-14.

  16. I recommend that CSC respond publicly to the issues and concerns contained in the 2012 external report entitled, Marginalized: The Aboriginal Women’s Experience in Federal Corrections.
  17. In the interest of transparency and accountability, I recommend the best practice of including the Correctional Service of Canada’s response as an integral part of my reports tabled in Parliament be reinstated.


Annex B: Annual Statistics

Table A: Complaints (1) By Category
Complaints - see Glossary (1), Internal Response - see Glossary (2), Investigation - see Glossary (3)
Category I/R (2) INV (3) Total
Administrative Segregation
Conditions 52 64 116
Placement/Review 131 177 308
Total 183 241 424
Case Preparation
Conditional Release 9 35 44
Post Suspension 8 5 13
Temporary Absence 2 4 6
Transfer 4 6 10
Total 23 50 73
Cell Effects 220 179 399
Cell Placement 22 26 48
Decisions 4 2 6
Processing 18 10 28
Total 22 12 34
Community Programs/Supervision 8 8 16
Conditions of Release 7 6 13
Conditions of Confinement 306 203 509
Conviction/Sentence-Current Offence 4 0 4
Correspondence 51 33 84
Death or Serious Injury 13 15 28
Decisions (General) - Implementation 310 62 372
Medical 8 10 18
Religious 5 9 14
Total 13 19 32
ICP Decisions 6 6 12
Minor Court Decisions 7 2 9
Procedures 18 15 33
Total 31 23 54
Discrimination 6 7 13
Double Bunking 9 9 18
Employment 44 36 80
Financial Matters
Access 24 26 50
Pay 26 33 59
Total 50 59 109
Food Services 47 30 77
3rd level review 12 10 22
Decision 15 18 33
Procedure 65 43 108
Total 92 71 163
Harassment 35 29 64
Health and Safety - Inmate Worksites/Programs 2 4 6
Health Care
Access 86 135 221
Decisions 78 85 163
Medication 82 89 171
Total 246 309 555
Health Care - Dental 10 12 22
Hunger Strike 2 7 9
Access/Disclosure 43 31 74
Correction 51 37 88
Total 94 68 162
Inmate Requests 19 12 31
Legal Counsel - Quality 18 14 32
Mental Health
Access/Programs 4 13 17
Quality 8 2 10
Self-Injury 14 33 47
Total 26 48 74
Methadone 7 9 16
Official Languages 2 2 4
Operation/Decisions of the OCI 12 0 12
Outside Court 5 2 7
Parole Decisions
Conditions 22 11 33
Day Parole 16 9 25
Detention 36 12 48
Full Parole 13 5 18
Revocation 43 18 61
Total 130 55 185
Women 0 3 3
Aboriginals 8 3 11
Access 26 25 51
Decisions 15 8 23
Language Access 1 3 4
Other 5 4 9
Total 55 46 101
Provincial Matter 7 1 8
Release Procedures 34 36 70
Religious / Spiritual 10 25 35
Safety / Security
Incompatibles 15 22 37
Worksite 0 1 1
Total 15 23 38
Safety/Security of Offender(s) 17 37 54
Search and Seizure 8 17 25
Security Classification 78 37 115
Sentence Administration 5 8 13
Staff 228 140 368
Telephone 69 66 135
Temporary Absence
Escorted 23 22 45
Unescorted 5 4 9
Total 28 26 54
Temporary Absence Decision 22 20 42
Implementation 22 51 73
Involuntary 99 79 178
Pen Placement 20 15 35
Section 81/84 0 1 1
Voluntary 48 41 89
Total 189 187 376
Urinalysis 4 5 9
Use of Force 12 19 31
Private Family Visits 51 44 95
Regular Visits 63 55 118
Total 114 99 213
Uncategorized(*)     61
Grand Total     5477
(*) Includes: complaint topics which are not represented by the complaint categories outlined above, or complaints that address multiple categories at the same time.



Complaints may be made by an offender or a third party on behalf of an offender by telephone, facsimile, letter or during interviews held by the OCI’s investigative staff at federal correctional facilities. The legislation also allows the OCI to commence an investigation at the request of the Minister or on the OCI’s own initiative.

Internal Response:

A response provided to a complainant that does not require consultation with any sources of information outside the OCI.


A complaint where an inquiry is made with the Correctional Service and/or documentation is reviewed/analyzed by the OCI’s investigative staff before the information or assistance sought by the offender is provided. Investigations vary considerably in terms of their scope, complexity, duration and resources required. While some issues may be addressed relatively quickly, others require a comprehensive review of documentation, numerous interviews and extensive correspondence with the various levels of management at the Correctional Service of Canada prior to being finalized. Systemic investigations examine areas of common concern of offenders and can be aimed at the institutional, regional or national level.

Table B: Complaints by Institution / Region
Region Institution Number of Complaints Number of Interviews  Number of
Days Spent in Institution
  Edmonton Women Facility 63 24 6
  Frasure Valley 40 23 4.5
  FSW-RPC 0 0 0.5
  Grand Valley 144 56 9
  Joliette 47 12 4
  Nova 65 15 3
  Okimaw Ohci Healing Lodge 32 13 2
  Total 391 143 29
  Atlantic 232 74 14
  Dorchester 167 23 4
  Shepody Healing Centre 12 3 0.5
  Springhill 1009 51 11
  Westmorland 15 8 2.5
  Total 535 159 32
  Bath 58 27 9
  Beaver Creek 41 0 3
  Collins Bay 63 27 8
  Fenbrook 144 39 6
  Frontenac 20 12 2
  Joyceville 105 17 6
  Kingston Penitentiary 281 105 19
  Millhaven 126 73 7.5
  Millhaven -Assessment Unit 45 0 7.5
  Pittsburgh 38 20 4
  RTC Ontario 71 15 7
  Warkworth 165 0 0
  Total 1157 335 70
  Ferndale 7 5 2
  Kent 293 40 18
  Kwikwèxwelhp 4 1 0.5
  Matsqui 75 27 5
  Mission 76 13 4
  Mountain 153 32 5
  RTC Pacific 144 45 8
  William Head 11 4 1
  Total 763 167 43.5
  Bowden 189 75 12.5
  Bowden Minimum 1 0 1.5
  Drumheller 53 21 4
  Drumheller Minimum 1 0 1
  Edmonton 188 40 10
  Grande Cache 142 36 6
  Grierson Centre 7 3 1
  Pê Sâskâstêw 14 7 1
  Riverbend 26 7 1
  Rockwood 17 6 2
  RPC-Prairies 92 6 1.5
  Saskatchewan Penitentiary 109 31 3
  Saskatchewan Maximum 124 0 3
  Stan Daniels Centre 7 1 1
  Stony Mountain 137 35 7
  Willow Cree 1 35 1
  Total 1108 303 56.5
  Archambault 82 33 10
  Archambault-CRSM 35 13 5
  Cowansville 65 23 8
  Donnacona 107 52 13
  Drummond 83 48 9.5
  FTC 77 13 6
  La Macaza 224 68 7
  Leclerc 89 15 4
  Montée St-François 26 12 4
  Port-Cartier 224 32 7
  RRC Québec 92 14 9
  SHU-USD 209 67 12
  Ste-Anne-des-Plaines 19 12 2
  Waseskun Healing Lodge 11 4 1
  Total 1343 406 97.5
CCC/CRC/Parolees in Community 172 0 0
Federal Inmates in Provincial Institutions 8 0 0
  Grand Total 5477 1513 337.5
Table C: Complaints and Inmate Population - By Region
Region Total Number
of Complaints
Population (*)
Atlantic 535 1,373
Quebec 1343 3,204
Ontario 1157 3,655
Prairie 1108 3,623
Pacific 763 1,821
Women's Facilities 391 513
CCC/CRC/Community/Provincial Facilities 180 N/A
Grand Total 5477 14,189
* Inmate Population broken down by Region: As of April 14, 2013, according to the Correctional Service of Canada’s Corporate Reporting System.

Table D: Disposition of Complaints by Action
Action Disposition Number of
Internal Response  
  Uncategorized 63
  Advise/Information Given 1803
  Assisted by Institution 222
  Pending 7
  Recommendation 1
  Refer to Grievance Process 193
  Refer to Institutional Staff 190
  Refer to Warden 270
  Rejected as unfounded 173
  Systemic/Multiple 26
  Withdrawn 77
  Total 3025
  Uncategorized 3
  Advise/Information Given 653
  Assisted by Institution 835
  Pending 17
  Recommendation 29
  Refer to Grievance Process 85
  Refer to Institutional Staff 256
  Refer to Warden 131
  Rejected as unfounded 149
  Systemic/Multiple 26
  Withdrawn 23
  Total 2207
  Uncategorized 0
  Advise/Information Given 70
  Assisted by Institution 37
  Pending 3
  Recommendation 24
  Refer to Grievance Process 8
  Refer to Institutional Staff 18
  Refer to Warden 48
  Rejected as unfounded 21
  Systemic/Multiple 14
  Withdrawn 2
  Total 245
  Grand Total 5477

Table E: Areas of Concern Most Frequently Identified by Offenders
Category # %
Total Offender Population
Health Care 555 10.13%
Conditions of Confinement 509 9.29%
Administrative Segregation 424 7.74%
Cell Effects 399 7.29%
Transfer 376 6.87%
Decisions (general) - Implementation 372 6.79%
Staff 368 6.72%
Visits 213 3.89%
Parole Decisions 185 3.38%
Grievances 163 2.98%
Aboriginal Offenders
Staff 70 10.77%
Health Care 61 9.38%
Conditions of Confinement 58 8.92%
Administrative Segregation 51 7.85%
Cell Effects 41 6.31%
Transfers 41 6.31%
Mental Health 27 4.15%
Parole Decisions 27 4.15%
Decisions (general) - Implementation 25 3.85%
Visits 22 3.38%
Women Offenders
Conditions of Confinement 65 15.44%
Health Care 40 9.50%
Mental Health 36 8.55%
Administrative Segregation 29 6.89%
Staff 27 6.41%
Cell Effects 20 4.75%
Decisions (general) - Implementation 17 4.04%
Telephone 16 3.80%
Temporary Absences 14 3.33%
Cell Placement 13 3.09%


Annex C: Other Statistics

A. Mandated Reviews Conducted in 2012-13

As per the Corrections and Conditional Release Act (CCRA), the Office of the Correctional Investigator reviews all CSC investigations involving incidents of inmate serious bodily injury or death.

Mandated Reviews By Type of Incident
Assault 68
Murder 1
Forcible Confinement 0
Suicide 3
Attempted Suicide 15
Self-Harm 21
Injuries (Accident) 31
Overdose Interrupted 17
Death (Natural Cause)* 3
Death (Unnatural Cause) 6
Other** 0
Total 165

* Deaths due to ‘natural causes’ are investigated under a separate Mortality Review process involving a file review conducted at National Headquarters.

** Investigations convened under S. 97 & 98 of the CCRA, including disturbances,
     sexual assault, etc.

B. Use of Force Reviews Conducted by the OCI in 2012-13

Per policy, the Correctional Service is required to provide all pertinent and relevant use of force documentation to the Office. Use of force documentation typically includes:

  • Use of Force Report,
  • Copy of incident-related video recording,
  • Checklist for Health Services Review of Use of Force,
  • Post-incident Checklist ,
  • Officer’s Statement/Observation Report, and
  • Action plan to address deficiencies.
OCI Use of Force Statistics for FY 2012-13
  Atlantic Region Quebec Region Ontario Region Prairie Region Pacific Region Federally Sentenced Women National
REPORTED INCIDENTS REVIEWED BY THE OCI 127 286 291 376 191 187 1458
Emergency Response Team 38 42 29 8 11 8 136
Verbal Intervention 122 242 282 337 179 171 1333
Physical Handling 121 192 233 268 163 175 1152
Restraint Equipment 109 235 219 273 150 148 1134
Display of OC 11 81 125 154 52 33 456
Use of OC 34 142 113 117 96 43 545
Use of CS 1 16 5 5 0 5 32
Distraction Device 0 5 2 2 2 1 12
Shield 6 51 41 11 19 14 142
Baton 3 30 20 6 6 3 68
Display / Charging of firearm 0 5 2 6 1 0 14
Use of firearm - warning shot 0 1 3 4 2 0 10
Use of firearm - aimed shot 0 0 1 0 0 0 1
Aboriginal 28 21 38 179 49 45 360
Women 0 0 0 0 0 196 196
Mental Health Issues Identified (CSC) 31 13 34 33 39 37 187
Injuries to Offender - Non Serious Bodily Injury 7 62 56 33 24 13 192
Injuries to Offender - Serious Bodily Injury 0 2 1 2 3 1 9

C. Toll-Free Contacts in 2012-13

Offenders and members of the public can contact the OCI by calling our toll-free number (1-877-885-8848) anywhere in Canada. All communications between offenders and the OCI are confidential.

Number of toll-free contacts received in the reporting period: 18,259.
Number of minutes recorded on toll-free line: 84,437.

D. National Level Investigations Initiated in 2012-13

  1. Aboriginal Offenders - Spirit Matters: Aboriginal People and the Corrections and Conditional Release Act – Released March 7, 2013.
  2. Black Offenders in Federal Corrections - A Case Study of Diversity in Corrections: The Black Inmate Experience in Federal Penitentiaries – Special Focus on Diversity in Corrections: 2012-13 Annual Report.
  3. Deaths in Custody (Mortality Review) – to be released in FY 2013-2014.
  4. Chronic Self-Injury Among Women Offenders – to be released in FY 2013-2014.
  5. Follow-up to Unauthorized Force: An Investigation into the Dangerous Use of Firearms at Kent Institution between January 8 and January 18, 2010 – ongoing.

[1] Report of the Commission of Inquiry into Certain Disturbances at Kingston Penitentiary during April, 1971. J.W. Swackhamer, Chairman, April 24, 1972.

[2] Members of visible minorities are defined by the Canadian Employment Equity Act as “persons, other than Aboriginal people, who are non-Caucasian in race or non-white in colour.”

[3] “Asian” includes offenders who are Arab, Asiatic, Chinese, East Indian, Filipino, Japanese, Korean, South East Asian, Arab/West Asian and South Asian.

[4] “Hispanic” includes offenders who are Hispanic and Latin American.

[5] Public Safety Canada, Corrections and Conditional Release Statistical Overview 2012.

[6] CSC Data Warehouse, accessed April 30, 2013.

[7] ACPAC is a research coalition whose members bring a unique and distinctive mix of knowledge, skills, expertise and experience related to issues of the over-representation of African Canadians in corrections, mental health and marginalized groups, racial discrimination and cultural competence.

[8] Statistics Canada, Immigration and Ethnocultural Diversity in Canada, 2013.

[9] Eduardo Bonilla-Silva and David Dietrich, “The New Racism: The Racial Regime of Post-Civil Rights America,” in Covert Racism: Theories, Institutions, and Experiences (2011).

[10] Among others see: First Nations Representation on Ontario Juries, Report of the Independent Review Conducted by the Honourable Frank Iacobucci, 2013; Racism Behind Bars: The Treatment of Black and Other Racial Minority Prisoners in Ontario Prisons, Commission on Systemic Racism in the Ontario Justice System, 1994; Report of the Commission of Inquiry into Matters Relating to the Death of Neil Stonechild, 2004.

[11] Scot Wortley, “Hidden Intersections: Research on Race, Crime and Criminal Justice in Canada.” Canadian Ethnic Studies Journal 35 (3): 99-117 (2004).

[12] Scot Wortley and Julian Tanner, “Discrimination or ‘Good’ Policing: The Racial Profiling Debate in Canada,” in Our Diverse Cities, Number 1, Spring 2004.

[13] CSC, Assessment of Affiliation with a Security Threat Group.

[14] CSC Data Warehouse, accessed April 2013.

[15] Corporate Reporting System, accessed April 24, 2013.

[16] Schedule II is comprised of serious drug offences or conspiracy to commit serious drug offences.

[17] Parole Board of Canada, Performance Monitoring Report 2011/12.

[18] CSC, 2012 Ethical Climate Survey: Results and Analysis.

[19] CSC staff work in a difficult and often stressful environment. There is no doubt that CSC personnel are also harassed and threatened by inmates at times. As the survey makes clear, however, the main source of harassment and discrimination, as reported by CSC staff, was co-workers, not offenders.

[20] CSC, Departmental Performance Report 2011-12

[21] CSC, Health Services Sector 2011-2012 Performance Measurement Report, November 2012.

[22] The Structured Living Environments at the regional women’s facilities provide intermediate mental health care. With expansion at each of the regional facilities, CSC will have a total capacity of 60 such beds for the federally sentenced women population.

[23] The intermediate care unit at Kingston Penitentiary is still operational. The resources are planned to be transferred to Millhaven Institution upon Kingston’s closure.

[24] See, for example, the United Kingdom’s Ministerial Council on Deaths in Custody, which consists of three tiers: Ministerial Board, Independent Advisory Panel and Practitioner and Stakeholder Group.

[25] Corporate Reporting System, March 2013.

[26] Double Bunking at Bath Institution (received January 2013), Foreward Statement to Union of Canadian Correctional Officers (UCCO), Syndicat des Agents Correctionnels du Canada (SACC) and Confédération des Syndicats Nationaux (CSN): A Critical Review of the Practice of Double Bunking within Corrections: The Implications on Staff, Inmates,
Correctional Facilities and the Public,
April 2011.

[27] CSC, Audit of Offender Population Management, January 2013.

[28] Frederic Moyer, “Current Theory and Application,” in Prison Architecture: An International Survey of Representative Closed Institutions and Analysis of Current Trends in Prison Design, United Nations, 1975.

[29] CSC Research Report, Review of the Prison Crowding and Double-Bunking Literature, November 2012.

[30] In FY 2012-13, the Office reviewed 1,458 reported uses of force incidents in CSC facilities. Of these, 31% involved the display of pepper spray and another 37% involved its use (or discharge). Combined, the display and/or use of pepper spray were reported in nearly 70% of all use of force interventions last year. CSC recorded 1,495 uses of force in FY 2012-13, which represents an increase of nearly 20% since 2008-09. CSC use of force policy was clarified in May 2011 to the effect that: “removing a chemical or inflammatory agent from its holster and displaying it at an individual(s) is considered a use of force.” Between 2008-09 and 2012-13 the display of pepper spray (out of the holster) became a ‘reportable’ (therefore reviewable) use of force. The display of pepper spray as a ‘reportable’ use of force impacts on the rising number of use of force incidents.

[31] Today, Aboriginal people account for 4.3% of the total Canadian population, up from 3.8% in the 2006 Census. Aboriginal children aged 14 and under make up 28.0% of the total Aboriginal population, compared to 16.5% of the total non-Aboriginal population. Statistics Canada, Aboriginal Peoples in Canada: First Nations People, Métis and Inuit, National Household Survey, May 2013.

[32] In 2010-11, Canada’s overall incarceration rate was 140 per 100,000 adults.

[33] A small number of chronic self-injuring Aboriginal women offenders account for a disproportionate number of total incidents.

[34] Office of the Correctional Investigator, Spirit Matters: Aboriginal People and the Corrections and Conditional Release Act, March 2013, available at

[35] CSC, Outcomes for Offender Employment Programs: The Impact of CORCAN Participation, August 2012.

[36] Public Safety Canada, Corrections and Conditional Release Statistical Overview 2012.

[37] The Wesley Group, Marginalized: The Aboriginal Women’s Experience in Federal Corrections, 2012.

[38] Memorandum of Understanding Between the Office of the Correctional Investigator and the Correctional Service of Canada, 2000.