Guidelines for mortality review

A "death by natural causes" is one that happens because of a naturally-occurring disease or process. In accordance with Section 19 of the Corrections and Conditional Release Act, CSC is required to investigate and report when an inmate dies. Once the death of an inmate is classified as a "death by natural causes", whether it is expected or unexpected, the Commissioner convenes a Mortality Review.

During a mortality review, a health care professional, with continuous support from CSC's National Medical Advisor, reviews the clinical care provided to that inmate in a CSC facility, as well as the circumstances leading up to the death by natural causes. That health care professional completes a Mortality Review Report, giving an overview of the health care provided to the inmate while in custody. The review may lead to recommendations about practises and procedures, as well as ongoing quality improvement. The review process may reaffirm existing practises and procedures.

The Mortality Review Committee is debriefed on the preliminary findings and recommendations of the review. This ensures that the events, overall care, quality of life issues and clinical care preceding an inmate's death by natural causes have been appropriately reviewed.

In 2016-2017, CSC spent approximately $214M to provide health services (physical health and mental health) for incarcerated inmates. This includes screening, diagnosis and treatment for infectious diseases, other chronic and potentially fatal diseases (such as cancer and heart disease) and mental health illnesses.

Source - Commissioner's Directive 041 – Incident Investigations

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