Custody and Caring
International Conference 2007

Howard Sapers
Correctional Investigator

September 26-28, 2007
Saskatoon, Canada

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Overview

• Role and function of the Office of the Correctional Investigator (OCI)
• Framework Regulating Health of Federal Offenders
• Four key challenges:
  1. Mental Health Issues
  2. Infectious Diseases
  3. Accreditation
  4. Investigations of Deaths and Serious Injuries
     • (a) Case Study
     • (b) Deaths in Custody Study

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Mission of the Office of the Correctional Investigator

Responsibilities of the OCI

Key Functions

• Individual inmate complaints
• Systemic Issues and Policy Review related to areas of complaint

Special Portfolios

• Women's Issues
• Aboriginal Issues
• Use of Force, Deaths, Serious Injuries (s.19)
• Mental Health

Office of the Correctional Investigator

OCI Operations 2005-2006

• 7591 inmate inquiries or complaints
• 4655 investigations
• 2426 offender interviews
• 370 days of visits to institutions
• 104 incidents of serious injury or death
• 1016 incidents involving Use of Force

Ten Key Issues

Corrections and Human Rights

The Three Pillars of Effective Corrections

• The absolute necessity of fostering a strong culture of human rights within the Correctional Service of Canada.
• The need for correctional staff and senior managers to be accountable in their administration of law and policy.
• The requirement to assist offenders to ensure their timely safe reintegration into the community.

Health Legislative Framework

• Federal offenders are excluded from the Canada Health Act and are not covered by Health Canada or provincial health systems
• The Correctional Service of Canada (CSC) therefore provides health care services directly to federal offenders, including those residing in Community Correctional Centres
• The CSC is legislatively mandated to provide health care to offenders through the Corrections and Conditional Release Act (CCRA)

Section 86 of the CCRA states that:

(1) The Service shall provide every inmate with

(a) essential health care (which includes mental health care), and
(b) reasonable access to non-essential mental health care that will contribute to the inmate's rehabilitation and successful reintegration into the community.

(2) The provision of health care under subsection (1) shall conform to professionally accepted standards.

Section 87 of the CCRA further states that:

The Service shall take into consideration an offender's state of health and health care needs

(a) in all decisions affecting the offender, including decisions relating to placement, transfer, administrative segregation and disciplinary matters; and,
(b) in the preparation of the offender for release and the supervision of the offender.

1. Mental Health Services

• Proportion of federal offenders with significant, identified mental health needs has more than doubled over the past decade

The percentage of federal offenders with mental health diagnoses at admission has significantly increased over the last decade

• The actual number of offenders with significant MH issues is likely underestimated as CSC's mental health screening and assessment on admission is inadequate.
• Improving outcomes in this area is critical as offenders with mental illnesses continue to be segregated in response to displaying symptoms of their illnesses, and released later in their sentence.
• The Correctional Service acknowledges that it needs to continue to build capacity to addressthe gaps in its MH care services continuum.

• The EXCOM approved a comprehensive MH Strategy (July 2004) which calls for significant investments in four major areas:
  • Comprehensive clinical intake assessment
  • Specific requirements for enhancing the Service's current Treatment Centres
  • Intermediate mental health care units within existing institutions to provide on-going treatment and assessment during the period of incarceration
  • Community mental health to support offenders on conditional release

2. Infectious Diseases

• Inmates are 7 to 10 times more likely than the general Canadian population to be living with HIV, and 30 times more likely to have hepatitis C.
• The spread of blood-borne disease within penitentiaries is linked to intravenous drug use and prison tattooing.
• Drug interdiction alone can only go so far in reducing the rate of infection among the offender population.
• CSC must move beyond existing harm reduction initiatives of education, methadone treatment, condoms and bleach (initiatives that were introduced more than a decade ago).
• In 1994, the Expert Committee on Aids in Prison, established by CSC, recommended making clean needles available to inmates for exchange to prevent serious communicable diseases spreading among the offender population and ultimately to society at large.
• The Kirby Report (May, 2006) recommended "that the Correctional Service of Canada immediately implement expanded harm reduction measures in all federal correctional institutions."
• CSC signed a MOU with the Public Health Agency of Canada (PHAC) to receive scientific and technical advice concerning potential risks and benefits of prison needle exchange programs.
• In its report, PHAC (April, 2006) concluded that prison-based needle exchange programs in other jurisdictions have significantly reduced the transmission of infectious diseases, and that there was no evidence that these programs had jeopardized staff and offender safety.
• In August 2005, the Correctional Service began implementing the Safer Tattooing Practices Pilot Initiative.
• CSC's own evaluation (December, 2006) concluded that "the initiative has demonstrated potential to reduce harm, reduce exposure to health risk, and enhance the health and safety of staff members, inmates and the general public."
• On December 5, 2006, the Government of Canada cancelled the Safer Tattooing Practices Pilot Initiative and closed the six CSC tattoo rooms.

3. Accreditation

• Health care issues are the primary reason for offender complaints to OCI and CSC's internal grievance process.
• By law, CSC must provide essential health care services to every inmate in accordance with professionally accepted standards.
• CSC committed to having all of its health care units, regional hospitals and regional treatment centres accredited.
• Accreditation by the Canadian Council on Health Services Accreditation (CCHSA) began in the mid-1990s.
• To date, CCHSA fully accredited only 3 of the 29 health care facilities (10%) it visited for that purpose.

4. Investigation of Deaths and Serious Bodily Injuries

4(a). Case Study

• First time federal inmate
• Sentenced for armed robbery, was admitted with a long history of drug addiction and mental illness, including schizophrenia, anxiety, depression and previous suicide attempts.
• Hanged himself five weeks later

4(b). Deaths in Custody Study

• The Deaths in Custody Study examined 82 reported suicides, homicides and accidental deaths in custody from 2001 to 2005, inclusive.
• Study reviewed CSC board of investigation reports and action plans, coroners' reports, correspondence between CSC and both OCI and coroners' offices, and other documents pertaining to each fatality.
• Finding #1: Investigative boards and coroners repeatedly raise several common concerns in a significant number of deaths in custody cases.
• Finding #2: There is no evidence that the Correctional Service has improved its overall capacity to prevent or respond to deaths in custody during the five-year study period.
• Finding #3: The Correctional Service tends to act on the findings and recommendations of boards of investigation, but often disagrees with, or takes no action on, coroners' recommendations.
• Finding #4: Typically, a significant period of time elapses between an institutional fatality and the Correctional Service's adoption 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.

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

Training

• 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

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

Conclusion

• CSC is addressing some of the Deaths in Custody Study's findings, including the responsiveness of its investigative process and its capacity to provide timely mental health interventions.
• The Minister announced that defibrilators will be available in all 53 CSC penitentiaries by the end of the year.
• The MH Commission has identified correctional populations as having particular needs.
  Minister appointed a Review Panel to assess CSC's capacity to meet its operational requirements. CSC Panel considers heath care a priority.