Independent Review Committee on Deaths in Custody 2010-2011
Corrective Measures and Management Action Plan (CMMAP)

The recommendations outlined below have been extracted from the Independent Review Committee on Deaths in Custody Report 2010-2011.

Recommendation 1: A more in-depth exploration of organizational gaps in the service is required by exploring why compliance issues occur, and systems and environmental factors that lead to human errors, when they occur.

Action

The Incident Investigations Branch (IIB) will be researching and analyzing tools to assess the efficiency of organizational corrective measures and action plans in order to continue to improve its ability to address areas of opportunity, such as identified compliance issues or deficiencies. Among other tools, the Branch will determine if the Hierarchy of Effectiveness (HOE) can be applied to the correctional field in order to support its objective of addressing areas of opportunity.

Approach

Since 2011, IIB has been developing its capacity to analyze identified issues and determine whether these are:

  • local, regional or national;
  • related to specific areas of responsibility (security, mental health, intervention etc.);
  • policy or operationally based;
  • recurring issues or isolated incidents.

In doing so, IIB will complete an in-depth analysis of the systems and factors that lead to human errors when they occur. As such, the Boards of Investigation (BOI) are encouraged to develop recommendations that promote discussion while striving to enhance CSC's organizational efficiency. In order to reduce deficiencies and gaps, the organization has begun to explore and assess the effectiveness of its action plans and corrective measures. The review, classification and analysis of the corrective measures are necessary in order to identify which steps the organization is taking to create and sustain change, and assess whether the actions taken are effective.

In an effort to determine the effectiveness of corrective measures taken following deaths in custody, a Deaths in Custody - Three-Year Overview by IIB seeks to analyze and address issues raised by BOIs into incidents that were investigated (1). In addition, a summary of the corrective measures taken in response to completed investigations is highlighted within the documentation presented at National Investigations Meetings (NIM). This exercise increases IIB's ability to assess the effectiveness of action plans and corrective measures taken by the organization, and promotes continuous discussion and awareness of the findings (2). IIB will also be conducting a year-end review that will include an analysis of each incident type by region (3). Furthermore, IIB will explore the HOE to determine if it can be applied in its current format to CSC's correctional setting (4). Finally, IIB will continue to monitor recurring compliance issues, and evaluate the effectiveness of the corrective measures taken (5).

Initial timeline for implementation

(1) Completion September 2014
(2) Ongoing since May 2013
(3) Fall 2014, and yearly thereafter
(4) December 2014
(5) Ongoing

Update - June 2015
(Incident Investigations Branch)

(1) The 3rd (and current) IRC was provided with the last version of the Deaths in Custody - Three-Year Overview report. The document was presented to NIM in November 2013 following which a decision was made that the Policy Sector would take over the production of the Deaths in Custody reports, which are now produced annually.

(2) Summaries of the corrective measures taken to address recommendations and findings made by BOIs are outlined in the Discussion Guides prepared for NIM. As well, they are outlined for each investigation within the newly created Case Overview document which provides a snapshot of the incident, the subsequent investigation, and actions taken.

(3) For the past seven months, IIB has been streamlining and increasing the efficiency of the investigations process in its entirety. While doing so, it was decided that a database would be created to track all issues raised in BOIs. Information entered into the database includes the operational site as well as the region where the incident occurred, which will facilitate the analysis of the information available for each incident type. Classifying and presenting the information by site and by region makes the information more meaningful and identifiable. The first report (i.e., year-end roll-up) will be completed in the Fall 2015 and yearly thereafter.

(4) A presentation was made to the Commissioner's Management Team on March 4th, 2015 to share information on how the HOE will be used within the context of CSC investigations. It was decided at that time that a 6-month pilot project would be done to introduce the concept of the HOE within the organization. Three institutions (Springhill, Archambault / Centre régional de santé mentale and Stony Mountain) were identified as part of this project to pilot the new Consultation Grid format in order to ensure that the approach meets the expectations of the organization. The introduction of the new Consultation Grid format will require the responder to consider the effectiveness of their corrective measure(s) and therefore, enhance the positive impact on the organization. The responder is asked to state briefly but with sufficient concrete detail how the action plan effectively addresses the issue and how it sustains positive change.

(5) With the implementation of the new Consultation Grid format as well as the discussions at NIM concerning the types of corrective measures taken and their effectiveness, IIB will continue to meet this commitment.

Update - March 2017

Incident Investigations Branch Update:

(1) Commencing in 2014-15, the Research Branch (Policy Sector) has begun producing an annual report on deaths in custody which includes a high-level overview of the death-related trends over five years as well as a more detailed review of deaths occurring in the preceding year.

(2) A summary of the corrective measures taken in response to completed investigations is included in each individual Case Overview presented to NIM (since April 2015). In addition, IIB creates Discussion Guides or high level snap shot documents (depending on the cases presented at every NIM) wherein corrective measures are summarized. IIB also creates Lessons Learned Bulletins (described in more detail below in response to Recommendation 3) which include real case studies and highlight best practices and lessons learned. Finally, corrective measures are summarized and analyzed within the Annual Investigations Report presented to Executive Committee (EXCOM).

(3) IIB created a database using Microsoft Excel in which BOI information was populated and then manipulated to inform the "year-end reports" noted above. Reports analyzing incident-specific information were created and presented to EXCOM in November 2015, June 2016 and November 2016. IIB recently revised its data management strategy by incorporating a new tool (SNAP Survey) into the branch. SNAP Survey allows IIB to streamline the information captured previously, while offering higher rates of validity within the data. Year-end reports using SNAP are in process for June and November 2017.

(4) At the EXCOM of November 2016, the expansion of the pilot project to all IIB grids was approved. The OPIs are finding the HOE helpful and appear to be implementing more effective corrective measures, or often, multiple corrective measures of different levels of effectiveness. IIB has revised the BOI grid template to include HOE and this change will be rolled out in the coming months.

(5) In addition to the HOE grid format, Discussion Guides, Case Overviews, Lessons Learned Bulletins, and Annual Investigation Reports all support analysis and discussion around corrective measures taken and their effectiveness.

Given the above well-established actions, IIB considers this recommendation to be addressed.

Recommendation 2: Implement a new mandatory section in all BOI reports, outlining what went well in the management of the offender and the response to the incident.

Action

All investigation reports include and identify, in its Findings' section, the quality of management of the offender, the response to the incident, and compliance with policy. IIB will also be conducting a year-end review that will include an analysis of each incident type by region, and identified best practices, when applicable.

Approach

The current investigative process addresses the recommendation. However, in addition to this, the year-end review will provide positive feedback to staff on successful and well managed interventions, and identify where further improvements are needed.

Initial timeline for implementation

September 2014, and yearly thereafter.

Update - June 2015
(Incident Investigations Branch)

IIB has introduced a new BOI Report format which highlights best practices, if any, found by BOIs. These best practices as well as any findings/areas highlighting positive staff response / management of the offender are also included in Discussion Guides (which are depersonalized and shared with front line staff).

Update - March 2017

Incident Investigations Branch Update:

In February 2016, IIB's National Debriefing Checklist was revised to include lessons learned and best practices.

Moreover, IIB also prepares Case Overviews of the incidents being presented to NIM in which best practices are noted. This facilitates a strategic discussion at NIM regarding "what went well", the way forward and how to effect change as an organization.

Additionally, IIB presents all National Tier I and Tier II BOIs at NIM in order to ensure an organizational review and analysis of significant findings and recommendations with national implications which may affect CSC's ability to respond to, and prevent, similar incidents from occurring in the future. In an effort to share critical information stemming from the organizational review and analysis done at NIM, Staff Information Bulletins (or Lessons Learned Bulletins) are created and shared with staff across the country to encourage organizational learning through increasing awareness of incidents being discussed at the National level. The objective is to engage staff in discussions and to reflect on and review their own institutional/regional practices and policies and identify any similarities or linkages to the information being provided. The Staff Information Bulletins are distributed quarterly to encourage continued communication of themes, areas of risk, best practices and lessons learned stemming from national investigations. The Bulletins include real case studies and highlight incidents with both negative and positive outcomes.

Furthermore, as noted above, IIB prepares an Annual Investigations Report (i.e., year-end report as per above) that is presented to EXCOM annually. The report to be presented to EXCOM in November 2017 will provide EXCOM with an overview of all relevant information contained within the BOIs, including incident type and offender information, as well as the findings, recommendations, best practices and themes. Information in this report will provide CSC with the ability for in-depth analysis of the organizational response to Tier I and Tier II investigations, and will inform senior level management of identified themes and results (Best Practices / Areas for Improvement) of nationally investigated incidents for decision-making purposes.

Given the above actions, IIB considers this recommendation to be addressed.

Recommendation 3: An examination of access to means to commit suicide should be explored in every investigation related to death by suicide within medium and maximum security facilities.

Action

All BOIs into incidents of suicide or attempted suicide are specifically requested to indicate the means used in order for the organization to remove hazards, wherever/whenever possible, to prevent future similar incidents. Access to the means used is also discussed with senior management during briefings within the investigation. Checklists provided to the investigators require them to ensure that all relevant questions have been addressed according to the Terms of Reference outlined in the Convening Order. The checklists associated with incidents of suicide or attempted suicide have been amended to specifically address access to the means used.

Additionally, the Facilities and Technical Services Branch has and will continue to try to reduce access to the means to commit an act that leads to death by suicide in the construction of cell accommodation. Our designers of cell units are aware of this circumstance, and are constantly looking for better ways to construct cell items that will mitigate an occurrence. For example, the Technical Services Branch and the Correctional Operations and Programs Sector will assess the installation of the Life Sign Monitoring System (LSMS) technology.

However, Facilities cannot construct regular cells that will completely prevent access to means to commit suicide. As always, sites need to take operational precautions, assess risk, and move offenders, where the risk of suicide becomes known, to a cell designed for observation purposes. We also note that dynamic security remains the most effective means in preventing deaths in custody. As such, continued focus on training in dynamic security is included in our National Training Strategy for Correctional Officers.

Approach

This approach addresses the recommendation. The investigators have to address this issue when they are conducting an investigation into the attempted suicide or the death of an inmate by suicide, and all appropriate checklists have been amended to reinforce this practice.

Initial timeline for implementation

Ongoing

Update - June 2015

Assistant Commissioner, Correctional Operations and Programs: The Correctional Operations and Programs Sector is in agreement with the action and approach identified above.

Assistant Commissioner, Corporate Services: No update from Corporate Services, Technical Services and Facilities.

Update - March 2017

Incident Investigations Branch Update:

While BOIs are asked to report on access to means to commit suicide as well as suspension points for all suicides and attempted suicides, as noted above in response to Recommendations 1 and 2, IIB has created a database wherein this and numerous other incident and offender-related variables are recorded for every investigation. This data forms the basis of IIB's Annual Investigations Report (i.e., year-end report), the purpose of which is to prevent future incidents from occurring. The information provided in the Annual Investigation Report is used to inform decision-making across the Service.

Given the above actions, IIB considers this recommendation to be addressed.

Recommendation 4: The Reception Awareness Program should reflect best or promising practice related to treating and monitoring depression in custody within an institution, rather than community standards.

Action

The current focus of the Reception Awareness Program (RAP) is education on the prevention and treatment of infectious diseases. Participation in RAP is voluntary and therefore participation in the program is not contingent on participation in any other aspect of health services (such as treatment regime, medication compliance, attending health care clinics etc.). Moreover, the RAP actively encourages inmates to contact Health Services should they need any assistance with health concerns.

CSC has a legislative mandate to provide inmates with essential mental health care and reasonable access to non-essential mental health care. Fundamentals of mental health training is provided to front-line staff in order for them to gain knowledge of mental health disorders and their related symptoms/behaviours, as well as to more effectively work with offenders who have mental disorders. Included in the training is a module on motivational interviewing, which is a counseling style for eliciting behavioural change by helping clients to explore and resolve ambivalence. The strategy seeks to help clients think differently about their behaviour and ultimately consider what might be gained through change. CSC has also strengthened its Information Sharing Guidelines to ensure that if an offender is at risk, the information is shared with operations staff so that they can adopt appropriate monitoring. As well, all Treatment Centres are conducting interdisciplinary training sessions for operations and health management to ensure needs of offenders (including those who are depressed and disengaged) are collaboratively addressed.

Approach

The response clarifies what may have been a misunderstanding of the Reception Awareness Program.

Initial timeline for implementation

Interdisciplinary Training Workshops have been facilitated in all Regional Treatment Centres for operational and health care staff as of March 2014.

Update - June 2015
(Assistant Commissioner Health Services)

Complete - Interdisciplinary Training was provided in every region in Fiscal Year 2013/2014. Given the above actions, ACHS considers this recommendation to be addressed.

Recommendation 5: The Correctional Service of Canada should explore automated methods of assuring life, such as detection of body heat, as is being examined in other jurisdictions.

Action

CSC is evaluating a range of technologies that may provide the ability to monitor the life sign of an offender in a non-intrusive manner. They are currently evaluating a system that is designed to detect the movement of a living individual in an enclosed area, e.g. a cell, and to provide an automated alert in the event of lack of movement. In this case, "movement" constitutes any level, down to chest motion caused by breathing. The system is intended to:

  • Provide early warning of the cessation of movement/breathing of offenders
  • Allow additional monitoring of vulnerable offenders
  • Provide an additional management tool
  • Checking that visits have been carried out
  • Provide an audit trail of response to alarms
  • Require minimal maintenance

Approach

The system is also intended to reduce the time required to become aware of a problem and subsequent actions; thus increasing the potential of saving lives. By providing an early warning, medical assistance can be provided promptly, rather than risking the time delay between security rounds. The technology is intended to supplement, not replace, the security round requirements associated with dynamic security. This technology could be positioned as a supplemental technology for the monitoring and observation of offenders in observation cells or treatment units and is not being considered for wider deployment in the general population.

Delco Automation was awarded a contract and installed Life Sign Monitoring System technology (August 2013), in two observation cells at Joyceville Institution. An evaluation has begun and the results will be evaluated to determine the operational, technical and cost benefits of deploying this type of technology in selected CSC locations.

Initial timeline for implementation

Once the assessment of the pilot project is complete, the level of implementation will be determined based on recommendations from the report.

Update - June 2015

Assistant Commissioner, Correctional Operations and Programs: The pilot project has recently ended and the technology itself was deemed effective. However for every installation of the device the cell would have to be retrofitted to ascertain optimal results. The roll-out of the project, if any, is yet to be discussed and in the meantime, our current policies and procedures that address the health and safety of our inmates are to be adhered to.

Assistant Commissioner, Corporate Services: The evaluation of the Life Sign Monitoring System (LSMS) at Joyceville institution was completed in December 2014.

The following is an excerpt from the Executive report:

"The system is accurate, consistent, and reliable. Provided that the state of the facilities matches the requirements of nominal operation, the LSMS will detect the complete and continual cessation of movement of an occupant of one of the Segregation Cells and raise an alarm to the officers on duty."

The next step will be to provide EXCOM, at the earliest available opportunity, a research summary and potential course(s) of action for limited employment of this technology in other institutions. Current cost of this system would preclude a large-scale deployment.

A partnership has been established with the University of Ottawa for further research into this technology. The ultimate goal would be a smaller, affordable system for generalized employment.

Update - April 2017

Assistant Commissioner, Corporate Services / Assistant Commissioner, Correctional Operations and Programs:

CSC has worked in partnership with the University of Ottawa for the development of a Doppler-radar technology that could measure the breathing and heart rates of a person. The results of this study demonstrated that the Doppler-radar technology was accurately measuring these life signs and warn correctional staff of their absence. Still in partnership with University of Ottawa, a second phase was initiated to developed a stand-alone system that could detect life signs in real-time. Due to technological limitations, the research was unsuccessful and the research project was terminated. CSC will be exploring other potential partnerships with research entities in order to assess other technological means of monitoring life signs.

Given the above actions, this recommendation is considered to be addressed.

Recommendation 6: The Correctional Service of Canada should explore means to expand the emergency medical tools available to Correctional Officers, especially those in facilities without 24/7 health care. Medical bags in these facilities should include naloxone and glucagon.

Action

Clinical Services, Legal Services, Security Operations and Labour Relations, and Workplace Wellness and Employee Wellbeing met to discuss this Recommendation. Health Services also attended a presentation by an Associate Professor from the University of British Columbia, School of Population and Public Health on Canada's current community naloxone programs.

Approach

CSC does not support the recommendation to include naloxone and glucagon as emergency medical tools available to Correctional Officers. In the community, lay people can be trained to use these medications for specific family members or close friends who may require them in an emergency situation thus unable to self-administer them. In these cases, the lay person is aware of the family member/friend's personal medical history, has specific training, and the consent of the family member/friend to intervene if required. In CSC, Correctional Officers are not aware of inmates' medical histories. In order to administer medication to a person in an emergency situation, for which the cause could be any number of things (assault/injury, cardiovascular, overdose, diabetic crisis, etc.), the Correctional Officer would need to perform an assessment to determine a diagnosis prior to providing the appropriate medication i.e. the Correctional Officer would need to be able to differentiate an overdose from hyperglycemia from hypoglycemia from a stroke etc. Provision of the wrong medication cannot be assumed to be without potential negative consequences for the inmate; for example, giving glucagon (a hormone that increases blood sugar) to someone who is hyperglycemic (has elevated blood sugar). The level of assessment skills required in choosing the correct medication and the administration of naloxone and glucagon by injection is outside of the current work description, competencies, and training for Correctional Officers.

Current CSC policy is focused on ensuring the inmate has appropriate access to medical personnel in a timely manner, having Correctional Officers apply the knowledge gained through certification in First Aid/Cardiopulmonary Resuscitation with Automated External Defibrillator and immediately contacting community Emergency Services in cases of medical emergency in the response continuum.

Initial timeline for implementation

N/A

Update - April 2017

Assistant Commissioner, Correctional Operations and Programs:

Narcan® is available to nurses and clinicians as part of our emergency medical response to drug overdose or accidental exposure. This said, in September 2016, CSC made Narcan available to correctional staff in all institutions for use in situations when health care staff is not available. Additionally, the organization is currently examining and developing a protocol to also make Narcan available in community parole offices for access by staff in case of emergency situations.

Update - May 2017

Assistant Commissioner, Health Services:

Since September 2016, Narcan® Nasal Spray is available in every institution to non-health care staff in order to respond to suspected opioid overdose medical emergencies involving inmates or staff from an accidental exposure when no nursing staff is available. A Protocol describing signs and symptoms of an overdose, and steps when responding was developed for non-health care staff. A video from the manufacturer on the use of the Nasal Spray and other relevant information is available on the following link: http://infonet/eng/Sectors/HealthServices/ClinicalServices/Pages/Naloxone.aspx.

Given the above actions, this recommendation is considered to be addressed.

Recommendation 7a: The Correctional Service of Canada should consider funding special studies on deaths in custody, specifically in the areas of drug overdose and homicide.

Action

The Evaluation Division is currently conducting an Institutional Security evaluation which will be examining safety and security activities within CSC institutions with specific references to dynamic security. It is also planning an evaluation on Institutional Management and Support, including Population Management Initiatives. While the scope of this evaluation has not been fully developed at this time, the expected results will place CSC in a better position to enhance its capacity to respond to the current and future needs of a changing offender profile and increase its level of confidence that offenders receive appropriate treatment, services and programming at the right time during their sentence.

Also, the Addictions Research Centre has conducted a literature review entitled "Drug-Related Deaths Among Recently Released Offenders" (December 2012). This is Research Review Number 12-1 and is available publicly.

In Fiscal Year 2014/2015, the Research Branch will be conducting a study entitled "Examination of Fatal and Non-Fatal Overdoses among Offenders". Using official incidence reports, this study will examine the prevalence of drug overdose (fatal and non-fatal) among offenders while incarcerated and verify the types of drugs consumed and route of drug administration involved in the overdose, as well as various health and mental health effects, impacts, and consequences.

Approach

Research provides summary based and/or empirically-based information to inform decision-making and better understand the issue at hand. CSC evaluations assess program performance and provide support to decision-makers regarding human and financial resources. Following the Treasury Board Services Policy on Evaluation, they address the core issues of program relevance and performance using a wide range of evaluation approaches and methodologies based on the individual project.

Initial timeline for implementation

Initial findings, recommendations and action plans regarding the Institutional Security evaluation were presented to the Evaluation Committee in June 2014, with an expected completion date for the evaluation of 2016. The Institutional Management and Support evaluation is scheduled to commence in April 2016 and is expected to be completed in March 2018.

As noted, related literature review is already complete, and additional research through external partnerships may be conducted during the 2014/2015 Fiscal Year.

Update - July 2015
(Assistant Commissioner Policy)

During Fiscal Year 2014/2015, the Research Branch completed a study entitled "Drug Overdose Among Federally-Incarcerated Men Offenders". Using official incidence reports, this study examined incidents of drug overdose (fatal and non-fatal) among incarcerated men offenders during the years 2011/2012, 2012/2013, and 2013/2014 to examine the circumstances surrounding the overdose incident, verify the types of drugs consumed and route of drug administration involved in the overdose, as well as to examine other situational and substance abuse history characteristics. A Research In Brief summary of the results is currently at the approval stage.

Commencing in 2014-15, the Research Branch has begun producing an annual report on deaths in custody which includes a high-level overview of the death-related trends over five years as well as a more detailed review of deaths occurring in the preceding year.

The Institutional Security evaluation and management action plan have been completed and approved. The evaluation report is being prepared for publication on the website and is anticipated to be publically available in Fall 2015. The Institutional Management and Support evaluation is scheduled to commence in July 2018 and is expected to be completed in March 2020.

Update - April 2017

The following reports are now available:

The next Annual Report will be forthcoming in late 2017.

Recommendation 7b: The Correctional Service of Canada should assume world leadership in the area of corrections by convening an International Conference on Best Practices to Reduce Deaths in Custody.

Action

Where appropriate, CSC will incorporate the issue of Deaths in Custody and related themes into various aspects of its program of international development:

  • As host country for the 34th Asia Pacific Conference of Correctional Administrators (APCCA) (September 2014)
  • Via CSC's role as the Secretariat for the Group of Friends of Corrections in Peacekeeping (June 2014-2016)
  • During exchanges with various international delegations and visits
  • Seeking joint opportunities at the international level to advance work in this area

Approach

By taking a leadership role within key multilateral fora, such as the APCCA and international visits, CSC will be able to situate the issue of Deaths in Custody and related themes within the broader international dialogue. Highlighting the issue within international fora and making use of CSC subject-matter experts during conferences, etc, will also provide exposure domestically within CSC.

Initial timeline for implementation

In January 2014, Deaths in Custody themes were integrated into the 34th APCCA agenda.

CSC took part in a February 2014 Group of Friends Troika meeting to discuss the strategic agenda going forward. CSC suggested including deaths in custody as a theme for the following United Nations International Corrections Conference.

In January 2014, slides on Deaths in Custody were included within the Overview of CSC's presentation provided to international delegations.

Exploring options in preventing Deaths in Custody and sharing results with other international partners is ongoing.

Update - July 2015
(Intergovernmental Relations)

CSC took part in a February 2014 Group of Friends Troika meeting to discuss the strategic agenda going forward. CSC suggested including Deaths in Custody as a theme for the United Nations International Corrections Conference in July 2014.

As a cross-cutting issue, Death in Custody is inherently touched upon in many of our international exchanges, whether directly or indirectly. For example, on April 23, 2015, the French Minister met with the Minister of Public Safety Canada as well as high-level CSC officials to sign a Cooperation Agreement between Public Safety Canada and the French Ministry of Justice. Mental health was a topic of discussion during the visit and health and mental health services for offenders has been identified as an area for possible collaboration under the agreement.

As a Group of Friends of Corrections in Peacekeeping initiative, CSC also contributed to the development of United Nations Prison Incident Management Training in Jordan in June 2014.

Since 2012, CSC has contributed to four Intergovernmental Expert Group meetings concerning the revision of the 1955 Standard Minimum Rules for Treatment of Prisoners (SMRTPs). CSC worked to ensure the proposed revisions remained consistent with federal as well as provincial/territorial practices in Canada. As the universally acknowledged benchmark for prison administrations, the SMRTPs reflect the extent of issues that are affecting corrections and custodial environments worldwide, many of which can be related to deaths in custody.

Update - May 2017

Internationally, CSC engages with numerous correctional jurisdictions via Memoranda of Understandings, that provide a platform in which to share information, best practices, and explore joint initiatives, including on deaths in custody. In addition to this, CSC participates in various multilateral fora and attends correctional conferences each year. These fora provide an opportunity to engage with experts, practitioners and stakeholders on correctional issues, and deaths in custody is a topic that is regularly raised. Furthermore, when CSC hosted the Asia Pacific Conference of Correctional Administrators in 2014, the theme of Deaths in Custody was incorporated into the agenda.

Additionally, CSC is co-chair to the Heads of Corrections (HoC) committee, which brings together leaders from the federal, provincial, and territorial correctional systems in order to review trends, share lessons learned, and suggest areas of joint collaboration. There are a total of seven subcommittees: Adult Institutions, Community Corrections, CORIS, Females as Correctional Clients, Health and Mental Health, HR Learning and Development, and Legislation and Policy. The majority of the subcommittees touch on Deaths in Custody in some capacity. For instance, the Females as Correctional Clients subcommittee has focused discussions and information sharing on managing self-injury and suicidal inmate behaviour as it relates to female offenders.

In 2015, CSC conducted an international survey with the objectives of gaining a better understanding of the challenges other nations encounter in their correctional organizations and the best practices being used to address them. In 2016, CSC conducted a second international survey focused on the theme of 'Corrections in Transformation'. The survey was organized in four key areas: 1) physical Infrastructure, 2) technology, 3) offender health, and 4) offender rehabilitation. These surveys provide an opportunity to gather information from international correctional jurisdictions with regards to their challenges, best practices, initiatives, etc. and then share the consolidated results with the international corrections community.

Finally, in March 2017 CSC hosted a one and a half day Roundtable expert forum on suicide management and prevention strategies. The Roundtable on Suicide Prevention, Assessment and Management was organized around four key topics in suicide prevention: screening and assessment; management and treatment strategies; communication; and training, with a goal of informing future CSC practices. Thirty-two participants attended the event, including researchers, practitioners and stakeholder groups. There were internal and external participants, including an internally recognized expert in the field of suicide prevention in correctional environments from the United States of America.

Given the above actions, Intergovernmental Relations considers this recommendation to be addressed.

Closing Statement

The IRC proposed three options on how a future IRC could be most helpful to CSC. These included: conducting three-year reviews of deaths in custody; allowing the Committee to conduct follow-up oversight reviews; or separating the deaths in custody reviews by cause of death (suicide, overdose, homicide, etc.).

The Commissioner has agreed to the first option, and an IRC into deaths in custody will be convened every three years. As continuous improvement remains a priority for CSC, this format will provide more data and offer an increased opportunity to improve on trend analysis. As such, the next IRC will be convened in winter 2015 to review fiscal years 2011-12, 2012-13 and 2013-14.

List of Acronyms

APCCA
Asia Pacific Conference of Correctional Administrators
BOI
Board of Investigation
CSC
Correctional Service of Canada
IIB
Incident Investigations Branch
IRC
Independent Review Committee
LSMS
Life Sign Monitoring System
RAP
Reception Awareness Program
NIM
National Investigations Meeting
EXCOM
Executive Committee
HOE
Hierarchy of Effectiveness
CMMAP
Corrective Measures and Management Action Plan