Commissioner's Directive

Incident Investigations

POLICY OBJECTIVE

  1. Investigations of institutional and community incidents are intended to ensure responsibility, accountability and transparency, and to enhance the ability of the Correctional Service of Canada (CSC) to contribute to the safety of the public, staff and offenders by ensuring that:
    1. CSC takes appropriate action following an incident;
    2. the review and analysis of reports influence organizational policy and practices where appropriate; and
    3. significant findings from investigation reports are shared in order to prevent similar incidents from occurring in the future.

AUTHORITIES

  1. Corrections and Conditional Release Act (CCRA), sections 19, 20, 21, 97, 98 and subsection 152(4)

    Inquiries Act, sections 7-13

    Privacy Act

    Access to Information Act

APPLICATION

  1. This Commissioner's Directive (CD) applies to inmates and/or offenders, and all institutional and community operational units and staff where a CSC incident investigation is taking place.
  2. This directive does not apply to:
    1. disciplinary investigations (see CD 060 ’ Code of Discipline, and Standards of Professional Conduct for Employees);
    2. harassment investigations involving staff and/or offenders (see Treasury Board Policy, “Prevention and Resolution of Harassment in the Workplace”, and CD 081 ’ Offender Complaints and Grievances);
    3. fact finding reviews (administered under general powers of management as authorized in sections 97 and 98 of the CCRA at the national, regional or local levels) except for those that are identified in Annex B of this CD (as tier II and/or local investigations) or in the SDC's records of decision;
    4. investigations into the unacceptable use of network and/or electronic resources (see CD 226 ’ Use of Electronic Networks);
    5. internal security investigations/non-reportable security incidents (see CD 568-1 ’ Recording and Reporting of Security Incidents);
    6. applications for security clearances.
  3. The fact that the police may be conducting a criminal investigation into a particular incident does not in and of itself preclude the need for CSC to conduct its own investigation into that incident.

RESPONSIBILITY TO CONVENE (see Annex B)

  1. Under section 20 of the CCRA, the Commissioner may convene national tier I investigations to investigate and report on any matter relating to the operations of the Service. An investigation may also be convened under both sections 19 and 20 with respect to a death or serious bodily injury of an inmate. Section 21 of the CCRA applies to all investigations convened under section 20 of the CCRA.
  2. Under section 19 of the CCRA, an investigation shall be convened when an inmate dies or suffers serious bodily injury. In the case of the death of an inmate by natural causes, a mortality review will be convened by the Commissioner.
  3. The Director General, Incident Investigations, may convene national tier II investigations under section 19 of the CCRA in the case of the death or serious bodily injury of an inmate; or, into any other incident as authorized under sections 97 and 98 of the CCRA (general powers of management) and in accordance with this CD.
  4. Institutional Heads and District Directors may convene local investigations or file reviews under section 19 of the CCRA in the case of the death or serious bodily injury of an inmate; or, into any other incident as authorized under sections 97 and 98 of the CCRA (general powers of management) and in accordance with this CD.
  5. Under subsection 152(4) of the CCRA, the Chairperson of the National Parole Board may appoint a person or persons to investigate and report on any matter relating to the operations of the Board.
  6. On matters of joint interest, and when appropriate, the Commissioner, under section 20 of the CCRA, and the Chairperson, under subsection 152(4) of the CCRA, may jointly convene a national investigation.

ROLES AND RESPONSIBILITIES

  1. The Executive Committee will:
    1. review significant findings, issues and/or recommendations from national investigations and mortality reviews which could have a national impact on the Service;
    2. approve all corrective measures and action plans resulting from national investigations and mortality reviews; and
    3. close all national investigations and mortality reviews.
  2. The Senior Deputy Commissioner will, following a significant incident:
    1. assess the need for an investigation under section 20 of the CCRA and submit that assessment to the Commissioner for decision under section 20 of the CCRA (in the record of decision);
    2. determine (in the record of decision), where death or serious bodily injury has resulted, who will be responsible for convening an investigation under section 19 of the CCRA, unless it is an investigation convened by the Commissioner under both sections 19 and 20, or it is a mortality review convened by the Commissioner;
    3. determine (in the record of decision) whether an investigation ought to be convened by the Director General, Incident Investigations, or by the Institutional Head or District Director under sections 97 and 98 of the CCRA (general powers of management), or whether a file review or a Situation Report or Addendum is required;
    4. ensure the Executive Committee is kept apprised of ongoing national investigations; and
    5. approve extensions to established timeframes for all national investigations.
  3. The Director General, Incident Investigations, will:
    1. recommend to the Senior Deputy Commissioner whether an investigation should be convened, under what authority (i.e., section 19, section 20, or sections 97 and 98 - general powers of management), and what type of investigative process should be used (i.e., national tier I, national tier II, local, etc.);
    2. oversee the entire investigative process and be accountable to the Senior Deputy Commissioner for that process;
    3. present the results of national investigations to the Executive Committee;
    4. in the case of the non-natural death of an inmate, notify the next-of-kin, or other designated person, that an investigation has been convened and that they may request a copy of the report from the Access to Information and Privacy Division of CSC. In cases where an inmate suffers serious bodily injury, he/she will be notified of the same;
    5. in the case of a mortality review, if notified by the Director General, Clinical Services, that there is reason to believe that an inmate did not die from natural causes, or significant issues are identified that would require further investigation including interviews with staff, prepare a revised convening order and convene a board of investigation;
    6. ensure that significant findings of investigations are shared nationally with all staff, relevant unions, and the chair of the National Executive Committee of the Citizen Advisory Committees; and
    7. approve extensions to established timeframes for local investigations initiated by the record of decision.
  4. The Director General, Clinical Services, will:
    1. advise the next-of-kin, or other designated person, in the case of a death of an inmate by natural causes, that a mortality review will take place and that they may request a copy of the report from the Access to Information and Privacy Division of CSC;
    2. notify the Director General, Incident Investigations immediately if during a mortality review, he/she determines that there is reason to believe that the inmate did not die from natural causes or that significant issues are identified that would require further investigation, including interviews with staff.

TIMELINES

  1. Timelines are outlined in the Investigation Process Chart.
  2. CSC national investigations should be completed and prepared for review by the Executive Committee within six months from the date of the convening order. However, in the case of more complex investigations (e.g., multiple incidents, sensitive, high profile, recurring), the Senior Deputy Commissioner may extend the time to investigate beyond the established timeframe.
  3. CSC local investigations should also be completed and prepared for review by the relevant Regional Deputy Commissioner within six months from the date of the convening order.

REQUIREMENT TO REPORT AND INVESTIGATE INCIDENTS

  1. Following an incident, the Institutional Head or District Director will submit a Situation Report (Warden or District Director) to the relevant Regional Deputy Commissioner and National Headquarters with the facts surrounding the incident as well as any immediate remedial action taken or planned at the operational unit. Follow-up on these remedial actions is the responsibility of the Regional Deputy Commissioner.

    NOTE: The Situation Report is to be submitted within 72 hours, except in the case of incidents occurring on Fridays ’ when reports would be due at National Headquarters the following Tuesday, no later than at 12:00 hours.

DECISION TO INVESTIGATE - CONVENING AUTHORITY

  1. Upon receipt of a Warden's Situation Report, a District Director's Situation Report, an Incident Report or a Sensational Incident Report, the Senior Deputy Commissioner, in consultation with the Director General, Incident Investigations, will determine, as described in paragraphs 13 and 14 of this CD, whether an investigation will be convened, the authority under which the investigation will be convened and the type of investigative process to be applied.
  2. The Director General, Incident Investigations, will issue a record of decision to the appropriate regions and sectors. This will advise them of the convening authority under which the investigation is being convened and the type of investigative process to be applied. Consideration will be given to such factors as:
    1. the level of violence and injuries sustained;
    2. the profile(s) of the inmate(s) and/or offender(s) involved;
    3. the possible impact on the Service's capacity to deliver programs;
    4. public interest;
    5. the frequency with which similar incidents have occurred in the past; and
    6. the recurrence of similar incidents at a particular site.

Serious Bodily Injury

  1. Subsection 19(1) of the CCRA requires that where an inmate dies or suffers serious bodily injury, the Service must investigate the matter.
  2. The determination of serious bodily injury is made by the health care professional at the operational unit (see CD 568-1). This determination may subsequently be reviewed by NHQ Health Services to ensure consistent interpretation of this definition.
  3. Where an inmate suffers an accidental serious bodily injury, submitting a Situation Report and/or a review by the local Joint Occupational Safety and Health Committee is sufficient to satisfy the requirements of subsection 19(1) of the CCRA. Submissions should be consistent with the process for recording and reporting offender injuries.

NOTIFICATION OF A FORTHCOMING INVESTIGATION

  1. For the purpose of transparency and openness, a first notice will be sent to the Institutional Head(s) and/or District Director(s) by the Incident Investigations Branch advising that a national investigation will be convened. They must post the notice at their operational site(s). They must also advise their staff, the respective unions and the local Citizen Advisory Committee Chair of the convening of a board of investigation.
  2. Subsequently, a second notice will be sent to the Institutional Head(s) and/or District Director(s) by the Incident Investigations Branch, accompanied by the signed Convening Order, advising of the board's date of arrival to the site and the board's composition. They must post the notice at their operational site(s). They must also advise their staff, the respective unions, and the local Citizen Advisory Committee Chair of the board's date of arrival and composition.

COMPOSITION OF BOARDS OF INVESTIGATION

  1. CSC staff on boards of investigation must be trained in conducting incident investigations. In exceptional circumstances, the Director General, Incident Investigations, can approve board member participation where training has not been provided.
  2. A CSC staff member may not be a member of the board if he/she was directly involved in the management of any inmate or offender involved in the incident(s), the incident(s), or the response to the incident(s) being investigated.
  3. Investigations convened by the Commissioner must always include at least one community member on the board. Joint boards of investigation convened under section 20 and subsection 152(4) of the CCRA must be chaired by a community member.
  4. Investigations convened by the Director General, Incident Investigations, may include a community member on the board.
  5. Boards of investigation into incidents involving health care issues will normally include a registered health care professional. If this is not practicable, the board must have access to individuals with the required health care expertise, and will be encouraged to consult with those experts.
  6. Boards of investigation into incidents involving Healing Lodge issues (CSC and section 81) will normally include an Aboriginal community member. If this is not practicable, the board must have access to individuals within the Aboriginal Initiatives Directorate.
  7. To the extent possible, each board of investigation should include individuals with appropriate expertise relevant to the incident being investigated.
  8. Any CSC staff member appointed to a national or local board of investigation shall immediately be relieved of his/her regular duties while conducting the investigation and writing the report.

STAFF'S DUTY TO PROVIDE EVIDENCE

  1. All CSC staff members and those under contract with CSC must cooperate with boards of investigation and provide written and/or verbal information as requested (see CD 060 and subsection 10(1) of the Inquiries Act). To ensure the integrity of the process, staff who have provided information to a board, or staff who are made aware of this information, may not discuss or share the information until the investigation report has been presented to the Executive Committee. Certain information may remain protected/confidential even when the investigation has been completed and approved by the Executive Committee, and as such, should not be shared.

PROCEDURAL SAFEGUARDS FOR INDIVIDUALS BEING INTERVIEWED

  1. For boards of investigation convened under section 20 and/or subsection 152(4) of the CCRA:
    1. sections 7 to 13 of the Inquiries Act apply. The board must advise each individual interviewed during the investigative process of his/her protection under section 13 of the Inquiries Act before starting the interview;
    2. a written notice will be issued by the board to an individual under section 13 of the Inquiries Act when, in the board's opinion, there is a serious potential for adverse impact upon his/her reputation as a result of the non-compliance and/or statements made in the report (e.g., non-compliance with a law, policy, or procedure directly related to the incident under investigation);
    3. the board will use its discretion in determining how the matter is brought to the individual's attention in cases where the non-compliance was not of critical importance to, or had no impact on, the incident being investigated. This will be documented on the investigation file.

      NOTE: For investigations convened by the Commissioner under both sections 19 and 20 of the CCRA, the Inquiries Act will apply.
  • The duty to act fairly principles apply to investigations convened under sections 19 and 20 of the CCRA, and all other incident investigations or reviews defined in this directive. The board must advise individuals being interviewed of the duty to act fairly principles before the interview begins.
  • When the board encounters non-compliance with a law, policy, or procedure that is not related to the incident and therefore not included in the investigation report, the board will use the following principles to decide what actions are to be taken:
    1. include all findings that are of critical importance in the local, regional and national debriefings;
    2. advise the individual and his/her supervisor for all findings that are of some importance and when the board is satisfied that appropriate actions will be taken locally; and
    3. advise the individual only for findings that are minor technical breaches and when the board is satisfied that appropriate actions will be taken by the individual.
  • No statement made by a staff member or evidence gathered during the course of investigations or reviews covered by this directive can be used for disciplinary purposes.
  • CONSULTATION WITH RELEVANT POLICY HOLDERS DURING INVESTIGATIONS

    1. To ensure correct interpretation of policies, boards and those conducting reviews of incidents are expected to consult relevant policy experts at National and Regional Headquarters. Regional Directors, Health Services, and other health care experts will be consulted in local investigations involving health care issues as appropriate.

    COLLECTION AND PROTECTION OF INFORMATION DURING THE INVESTIGATIVE PROCESS

    1. To ensure the integrity of the process and to allow the board to determine the relevance and importance of specific information or factors, information collected as part of the investigative process will be managed in accordance with the Privacy Act and safeguarded in accordance with the Government Security Policy.
    2. If, during the course of an investigation, a board discovers a potentially dangerous situation, this information will be reported immediately to the responsible authority.

    DISCLOSURE OF CONFIDENTIAL MEDICAL INFORMATION

    1. When an investigation is convened pursuant to the CCRA and where the Inquiries Act applies, these acts permit the disclosure of relevant medical information to members of the board of investigation and/or those conducting reviews of incidents. Health care professionals (i.e., medical practitioners, psychologists, nurses) on the board, conducting reviews of incidents, or who are consulted by them, will determine the relevance of the medical information. When necessary, disclosure of personal medical information is made in accordance with the Privacy Act as well as the rules of conduct of the respective professional governing body.

    DEBRIEFINGS

    1. Prior to submitting their report to the convening authority, boards of investigation will conduct debriefings at the local, regional and national levels on the findings and recommendations that will be in the investigation report. The participants at the local debriefing will include the Institutional Head(s) and/or District Director(s) and the Chief of Health Services (where applicable). The participants at the regional debriefing will include the Regional Deputy Commissioner(s), relevant regional policy holders and the Regional Director, Health Services (where applicable). The participants at the national debriefing will include the Director General, Incident Investigations, and relevant national policy holders. These debriefings must be documented.
    2. The Institutional Head(s) and/or District Director(s) will verbally debrief, as soon as practicable, the staff involved in the incident(s), those who manage the offender's case, their local Citizen Advisory Committee and relevant members of the criminal justice system of the findings and recommendations that will be in the investigation report.
    3. The Mortality Review Committee will be debriefed on the findings and recommendations subsequent to mortality reviews.

    REVIEW AND ACCEPTANCE OF REPORTS

    1. Staff in the Incident Investigations Branch will review each national investigation report, as well as reports from local investigations convened as per the record of decision, to ensure compliance with the terms of reference outlined in the convening order, after which the report will be formally accepted by CSC.

    CONSULTATIONS

    1. Relevant policy holders at National and Regional Headquarters will then be consulted to assist senior managers to identify emerging or recurring themes or possible policy gaps, and to seek corrective measures and action plans in response to the findings, recommendations and other issues raised by the board.

    APPROVAL AND CLOSURE OF INVESTIGATIONS AND MORTALITY REVIEWS

    1. Once a national investigation or mortality review has been completed, members of the Executive Committee will review the report. In particular, they will review findings, recommendations and/or issues which have a national impact on the organization, as well as the proposed corrective measures and/or action plans.
    2. The Director General, Incident Investigations, will present members of the Executive Committee with information from other investigations or fact findings (e.g., police, coroner, etc.) relevant to the incident under investigation so they are aware of key issues.
    3. The Senior Deputy Commissioner will formally close national investigations and mortality reviews via a closure memo, and will forward a copy to the Office of the Correctional Investigator.
    4. The Regional Deputy Commissioners will formally review, close and document all Situation Reports initiated by their region.
    5. The Regional Deputy Commissioners will review all local investigation reports and file reviews initiated by their region. They will formally close these investigations/reviews. In particular, they will review findings, recommendations and/or issues, as well as the proposed corrective measures and/or action plans.

    RETENTION OF DOCUMENTS

    1. The Director General, Incident Investigations, must ensure that documentation related to national tier I investigations is held at National Headquarters as per government retention schedules. Documentation related to national tier II investigations, local investigations and file reviews initiated under National Headquarters' authority will be retained at Regional Headquarters by the Incident Investigations Branch. The Assistant Commissioner, Health Services, will ensure all documentation related to mortality reviews is similarly retained.

    SHARING OF SIGNIFICANT FINDINGS

    1. The Incident Investigations Branch creates Significant Findings documents. They provide a general overview of the significant findings and recommendations, corrective measures and action plans, and best practices stemming from various investigations. They are distributed to all CSC staff, relevant unions and the chair of the National Executive Committee of the Citizen Advisory Committees, and are posted on the InfoNet.

    INFORMATION SHARING

    1. Requests for investigation reports must be solicited formally under the Access to Information Act or the Privacy Act.
    Commissioner,

    Original signed by:
    Don Head


    Annex A

    DEFINITIONS

    1. Accidental serious bodily injury: a physical injury which cannot be attributed to an altercation or any other type of assaultive behaviour between inmates.
    2. Board of investigation: Board designated by the Commissioner, the Director General, Incident Investigations, or Institutional Head(s) or District Director(s) to conduct an investigation into an incident (see examples of incidents where investigations are convened in Annex B of this CD).
    3. Closure memo: memo issued by the Senior Deputy Commissioner to the Regional Deputy Commissioner(s) and/or sector head(s) advising of the decision made by the Executive Commitee to formally close an investigation as all actions were completed, or contingent upon the implementation of outstanding action(s) within the prescribed deadlines.
    4. Community member: an individual who is not employed nor has ever been employed by CSC or the National Parole Board, who participates as a member of a board of investigation.
    5. Convening authority: the level and position with authority and/or responsibility to convene an investigation (see Annex B).
    6. Convening order: a legal document which outlines the mandate and the authority, as stipulated in law and policy, for the investigation or mortality review, as well as the issues to be investigated, analyzed and reported on, and the report due date.
    7. Duty to act fairly: an obligation to ensure the fundamental right of others to be treated fairly. This usually includes being involved in the process and having an opportunity to respond verbally and/or in writing to assessments that are made related to conduct and performance and that could negatively affect the reputation of an individual.
    8. File review: a review of an offender's CSC file(s) and related documentation. This process is convened by District Directors when there has been an incident involving an offender in the community, or as a result of a request in the record of decision. The goals are to determine if there are any concerns with the release and/or supervision of the offender; to determine is there are any concerns with other activities related to the incident (e.g. sharing of information, incident reporting, etc.); to determine if the actions of staff or contracted individuals providing service to CSC have met all the requirements of the CCRA and CSC's policies and procedures; and, to determine whether or not a national investigation is required.
    9. Local investigations: investigations convened by Institutional Heads or District Directors under section 19 of the CCRA in the case of death or serious bodily injury of an inmate, or with respect to an offender, as authorized under sections 97 and 98 of the CCRA (general powers of management). Local investigations may also be convened as a result of a request in the record of decision.
    10. Mortality review: a file review process which follows relevant aspects of the investigative process (i.e. convening, approval, and closure) outlined in this CD and is convened by the Commissioner under section 19 of the CCRA. The clinical care provided in a CSC facility and the circumstances leading up to deaths by natural causes of inmates are reviewed by a health care professional during this process. The review may lead to recommendations concerning future practices and procedures, as well as ongoing quality improvement. Further, the process may reaffirm existing practices and procedures. The Mortality Review Committee will be debriefed on the preliminary findings and recommendations of the review to ensure that the events, overall care, quality of life issues and clinical care preceding an inmate's death by natural causes have been appropriately reviewed.
    11. National tier I investigations: investigations convened by the Commissioner under section 20 of the CCRA into any matter relating to the operations of the Service (and in cases of death or serious bodily injury of inmates, also under section 19 of the CCRA).
    12. National tier II investigations: investigations convened by the Director General, Incident Investigations, under section 19 of the CCRA in cases of death or serious bodily injury of inmates; or, as authorized under sections 97 and 98 of the CCRA (general powers of management).
    13. Professional governing body: the relevant provincial or territorial licensing, governing and/or certifying body for health care professionals.
    14. Record of decision: a document that lists all incidents where an investigation, a file review, and/or a mortality review is to be convened, or a Situation Report (where not submitted) or Addendum is required. This document also indicates the convening authority and the type of investigative process to be used.
    15. Section 13 of the Inquiries Act: outlines that an individual has a right to respond in person and/or in writing to assessments of their conduct that could negatively affect their reputation.

    Annex B

    RESPONSIBILITY TO CONVENE AN INVESTIGATION

    Responsibility to convene investigations can and will vary according to incident dynamics. Other incident types not listed in this annex may be investigated when deemed necessary.

    NOTE 1: For the purpose of incident investigations, Community Residential Facilities, Community Correctional Centres, and section 81 facilities are considered CSC facilities.

    NOTE 2: Offenders on long-term supervision orders are under CSC jurisdiction.

    *community board member required


    Responsibility to convene investigations can and will vary according to incident dynamics. Other incident types not listed in this annex may be investigated when deemed necessary.

    EXAMPLES OF INCIDENTS
    NATIONAL*
    TIER I
    COMMISSIONER
    NATIONAL
    TIER II
    DGII
    LOCAL
    OPERATIONAL
    UNIT HEAD
    Murder in a CSC facility or in the community where the alleged perpetrator is an offender

    X*    
    Attempted murder in a CSC facility or in the community where the alleged aggressor is an offender

      X*  
    Suicide in a CSC facility

    X*    
    Attempted suicide in a CSC facility

      X X
    Suicide of an offender in the community

      X* X
    Attempted suicide of an offender in the community

        X
    Death of an inmate by overdose

    X* X*  
    Death of an inmate by natural causes in a CSC facility or in a community hospital

    Mortality review process    
    Death of an inmate unknown cause

    X* X*  
    Hostage-taking or forcible confinement in a CSC facility or in the community when involving an offender

    X*    
    Major disturbance in a CSC facility (an incident that seriously disrupts the daily activities of an institution)

    X* X*  
    Assault on an offender or other person in a CSC facility (depending on severity)

    X* X X
    Sexual assault on an offender or other person in a CSC facility

    X* X* X
    Serious bodily injury of an inmate

    X* X X
    Escape from a CSC maximum security institution

    X*    
    Escape from a CSC medium security institution

      X*  
    Escape from a CSC minimum security institution, including Community Correctional Centres, Section 81 Facilities, and Community Residential Facilities where applicable

      X X
    Escape from a CSC escort

      X* X
    Assault causing serious harm or sexual assault perpertrated by an offender in the community

    X* X* File review
    Other serious offences in the community, involving an offender

      X File review

     

    For more information

    To learn about upcoming or ongoing consultations on proposed federal regulations, visit the Canada Gazette and Consulting with Canadians websites.