Policy Bulletin

Policy Bulletin 558

Why was this policy changed?

This policy was modified in response to feedback from staff and findings of Boards of Investigation. Key changes are summarized below.


  • Addition of consultation with a health care professional in the application and removal of restraints, when possible.


  • Clarification of expected inmate transfers and movements requiring screenings using the Immediate Needs Checklist – Suicide Risk.


  • Removal of requirement for Psychiatrist/ Physician medication review for all inmates on Suicide/Self-Injury Watch. Replaced with nursing review and consultation as required.
  • Addition of new documentation requirements for High Suicide/Self-Injury Watch initiated by operational staff.
  • Addition of requirement for a dedicated staff member to provide constant camera observation.
  • Addition of review periods for inmates placed on High or Modified Suicide/Self-Injury Watch.
  • Clarification of application of Mental Health Monitoring Form. Since this form applies to suicide/self-injury only, it is being renamed “Monitoring for Suicide/Self-Injury Form”.


  • Addition of considerations on the reduction/removal of restraints to all health assessments of inmates while in the Pinel Restraint System.

Offender Management System Alerts

  • New policy requirement added for the Interdisciplinary Mental Health Team to complete monthly reviews of active Suicide/Self-Injury Alerts on the Offender Management System to ensure accuracy.

Annex B – Process for Suicide and Self-Injury Intervention

  • Addition of requirement to complete the Critical Response and Incident Management Plan following incidents of self-injury or attempted suicide.
  • Comprehensive Suicide/Self-Injurious Assessment section removed from the policy and placed as non-mandatory content guidelines on the Mental Health InfoNet page.
  • Alternatives/Avoiding Use of Restraints section removed from the policy and placed as non-mandatory content guidelines in the Mental Health InfoNet page.
  • Clinical Opinion and Behavioural Summary section removed from the policy. Its content is to be included in interim Interdisciplinary Management Plans.
  • Interdisciplinary Management Plan form restructured in a narrative format.
  • Renamed the Comprehensive Psychological/Psychiatric Assessment to Mental Health Assessment for Risk of Suicide/Self-Injury. This assessment can be used as required for inmates who engage in self-injurious or suicidal behaviour but is mandatory for all inmates who require an Interdisciplinary Management Plan.

Other Changes

  • Technical changes were made to the CD, which include replacing mental health professionals with health care professionals throughout the policy to allow greater flexibility for staff completing required tasks.

How was it developed?

This policy was developed by the Health Services Sector in collaboration with Legal Services and the Policy Sector, with internal and external consultation.

Who will be affected by the policy?

All staff and anyone else interacting with inmates could potentially be affected.

For more information

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