ARCHIVED - Backgrounder: Deaths in Custody Study

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  • In his last Annual report 2005-06, Mr. Sapers stated that his Office was concerned about the number of similar recommendations made year after year by the Correctional Service of Canada's national Board of Investigations, provincial coroners, and medical examiners reviewing inmate deaths.
  • Mr. Sapers undertook to conduct a comprehensive review of reports and recommendations dealing with deaths in custody and other matters. The Office retained the services of a senior academic from the University of Ottawa, to conduct the project on deaths in custody.
  • The Deaths in Custody Study examined 82 reported suicides, homicides, overdoses, and accidental deaths in custody from 2001 to 2005 (inclusive). The study reviewed CSC Board of Investigation reports and Action Plans, Coroner's Reports, correspondence between CSC and both OCI and Coroners' Offices, and other documents pertaining to each fatality. The Objective of the study was to identify areas in which improvements might enhance the Correctional Service's ability to prevent or respond to assaults and self-injury in the future.
  • The study concluded:
    • Finding #1 - Several concerns are raised repeatedly by Investigative Boards and Coroners in a significant number of deaths in custody cases.
    • Finding #2 - There is no evidence that Correctional Services Canada has improved its overall capacity to prevent or respond to deaths in custody during the five-year study period.
    • Finding #3 - Correctional Services Canada tended to act on the findings and recommendations of Boards of Investigation, but often disagreed with, or took no action on, Coroners' recommendations.
    • Finding #4 - Typically, a significant period of time elapses between an institutional fatality and the adoption, by Correctional Services Canada, of formal measures to address issues arising from it.
    • Finding #5 - It is likely that some of the deaths in custody could have been averted through improved risk assessments, more vigorous preventive measures, and more competent and timely responses by institutional staff.
  • The report provides evidence that the Correctional Service has limited capacity to keep a corporate focus on recommendations related to deaths in custody. It fails to consistently incorporate lessons learned and implement corrective action over time and across regions, as such the same errors and recommendations are being made time and again. The study also suggests that the Correctional Service resists or fails to accept a large proportion of Coroners' recommendations, compared to the recommendations of its own Boards of Investigation.
  • The report concludes that "...the Service fell short in implementing its own policies and practices, and in doing everything possible to avert a fatality".
  • The Correctional Service of Canada has indicated a willingness to address many of the Deaths in Custody Study's findings. The Office of the Correctional Investigator is currently in discussion with the Correctional Service related to the responsiveness of its investigative process and its capacity to provide timely mental health interventions.
Issue Raised in Death in Custody Report

Timeliness Issues *
Over 5 months average between incident and Board of Investigation report
10 months average between Board of Investigation report and review of remedies by EXCOM
Delivery of Heath Care
Delay/failure to provide CPR
Outdated health care facilities precluded treatment of inmate in some institutions
Absence of on-site defibrillators
Quality and availability of emergency care and nursing staff (especially on night shift) leading to some gross errors in responding to emergencies
Delivery of Mental Health Care
No comprehensive psychological and psychiatric assessment at intake
Lack of or limited services for those with history of suicide attempts and self-injury (gaps in suicide prevention)
Competence of clinical personnel
Quality of mental health assessments, including degree at risk of suicide
Assumption of, and confusion with, malingering
No multidisciplinary MH team in place at some institutions
Segregation as de facto MH unit with limited or no MH services - MH condition exacerbated by segregation
CPR and First Aid, including prevention of contamination through body fluids
What to do in emergency situation (discovery of body) and how to manage security crisis
Record Keeping
Failure to record relevant medical or mental health information on offender file
Failure to record rounds information (timing and frequencies)
Information Sharing
Poor communications between health care and psychological personnel and front-line staff/managers
Poor communications between front-line staff/managers and health care and psychological personnel
Poor communications between shift changes
Quality of Security Videos
Low quality video surveillance
Inadequate coverage of video surveillance
Physical obstruction preventing monitoring
Security Issues
Poorly controlled inmate movements and monitoring, especially recreational areas
Not prudent institutional placements (i.e., assaults by incompatibles within hours/days of transfers)
Patrol and counts failure to ensure inmates are alive, including in Native centres
Security intelligence capacity lacking (e.g., gangs)
Failure to notify promptly health care staff or emergency responders
Defective Silverguard monitoring system
Limited modifications of infrastructure to make it more difficult for inmate to commit suicide by hanging
Availability of drugs still a major institutional problem leading to overdose and deaths related to drug trade
Diversion of prescription drugs and methadone
Monitoring At-Risk Factors
Involuntary transfers (deaths within 30 days)
Previous suicide attempts and situational factors (e.g., unsuccessful appeals)
Previous institutional infractions, escapes or violation of conditional releases
Officers and/or inmates not offered services (or not offered promptly) to deal with stresses causes by incidents
Younger men more at risk
* The 475 days total following fatalities to formally adopt corrective measures underestimates the true length of time