Independent Review Committee on Deaths in Custody 2011/2012 to 2013/2014 Corrective Measures and Management Action Plan (CMMAP)

The recommendations outlined below have been extracted from the Independent Review Committee (IRC) on Deaths in Custody Report 2011/2012 to 2013/2014.
Recommendation 1: It is recommended that the comprehensive suicide/self-injury assessment tool be reviewed to reflect the latest best practice in the literature and be quantified to enhance reliability across time and users.  The tool should include both acute and chronic stressors within and external to the prison environment.
Action In order to ensure that suicide/self-injury risk assessments within CSC reflect best practices, a literature review on validated suicide and self-injury risk assessment tools will be conducted.  Such a review is necessary in order to determine the potential benefits of existing tools for CSC. This would include a review of tool validation for correctional populations, Indigenous offenders, and both male and women offenders.  The review would determine next steps for developing or implementing the tool.
Approach A literature review on existing empirically validated suicide and self-injury risk assessment tools will be managed by CSC’s Research Branch.
Accountability Lead: Assistant Commissioner, Policy
Collaborator: Assistant Commissioner, Health Services
Initial Timeline for Implementation Completion by September 2016
Update: December 2016 This report has been completed and is currently in the review process for Research Branch Publications.
Update: March 2017 The report is in the review process and is expected to be published by August 2017.
Recommendation 2: All relevant internal representatives (e.g., mental health, security, research etc…) within CSC should develop a short and long term program of research.  Retrospective studies using Offender Management System data, psychological data, and if possible, all existing Boards of Investigation findings should be prioritized in the short term to evaluate the predictive validity and the utility of the existing screening and comprehensive tools.  CSC should also explore the feasibility of developing an empirically-based structured suicide risk assessment tool that does not rely on self-reported suicide ideation.  There are studies in the literature that could serve as models (see Niculescu et al., 2015).
Action Carry out the following studies : 

Study A: Evaluation of the “Immediate Need Checklist – Suicide Risk” and the “Comprehensive Suicide/Self-Injury Assessment (CSSIA)”.

Study B:  Evaluation of a potential new structured suicide risk assessment tool identified after the completion of action on Recommendation 1.

Study C: Trend analysis at the offender level of Deaths in Custody (DIC) including a thematic analysis of Board of Investigation (BOI) findings, available psychological data and offender information from the Offender Management System (OMS).

Study D: Trend analysis at the meso-level (rates of DIC) including a thematic analysis of Board of Investigation (BOI) findings and exploration of social/policy and environmental changes impact.
Approach 1. Develop Terms of Reference for all studies in co-ordination with all associated stakeholders
2. Develop a revised framework for the “Annual Report of Deaths in Custody” (ARODIC) that incorporates elements of Studies C and D, thereby ensuring an ongoing long-term research  approach
3. Develop a database going back to FY 1999/2000 that contains sufficient information to carry out the proposed studies including coding from all BOIs and Mortality Reviews
4. Undertake and report on studies
Accountability Lead: Assistant Commissioner, Policy
Collaborator: Assistant Commissioner, Health Services
Collaborator: Assistant Commissioner, Correctional Operations and Programs
Initial Timeline for Implementation
  • Preliminary Terms of Reference complete by March 2016
  • Revised Framework for ARODIC for FY 2015/16 complete by May 2016
  • Database developed and completed by October 2016
  • Study A complete by January 2017
  • Study B – completion date dependent on timelines in recommendation 1
  • Study C complete by April 2017
  • Study D complete by September 2017
  • Database maintained and analyses repeated and reported in all future ARODICs
Update: April 2016 The preliminary Terms of Reference were submitted to the Senior Deputy Commissioner on March 31, 2016 and were briefly discussed at the ExCom Meeting of April 12, 2016.  The project is proceeding as scheduled.
Update: June 2016 The revised framework is conceptualized and includes regional and more detailed analyses. It should be considered preliminary at this point as further data gathering (i.e. coding of the files) continues until the end of October 2016 and will further inform the format and content of future Annual Reports of Deaths in Custody.
Update: December 2016 The review of Boards of Investigation and Mortality Reviews is complete for the years 2009/2010 to 2015/2016 for all completed investigations. As additional studies become available the database will be updated. The work on studies A through D is ongoing. Investigations prior to 2009/2010 have been more difficult to obtain (especially Mortality Reviews) and coding of these investigations will proceed as they are available. This should not affect the quality of Studies A through D. Development of the database took somewhat longer than anticipated and this will slightly delay the completion of Study A until the end of February.
Update: March 2017
  • Preliminary Terms of Reference complete by March 2016 – action completed
  • Revised Framework for ARODIC for FY 2015/16 complete by May 2016 – action completed
  • Database developed and completed by October 2016 – action completed
  • Study A complete by November 2017 – The information from Studies A, C, and D will be presented jointly in the Annual Report on Deaths in Custody FY 2015/2016 (review ready July 2017 - tentative publication November 2017).  This allows time for completion of investigations of the FY 2015/2016 deaths.   
  • Study B – Completion date dependent on timelines in recommendation 1 – Report under review within the Research Branch and will be sent to the ACP for review in the first quarter of FY 2017/2018.  Publication will follow by August 2017.
Recommendation 3: CSC should establish a national advisory committee comprised of external experts as well as internal CSC representatives with expertise along with other relevant stakeholders with the expressed mandate to: (1) review existing screening, comprehensive assessment methods, mental health monitoring practices, training materials, suicide intervention practices and (2) advise on the development of a pilot intervention that does not involve the use of isolation.
Action To address recommendation #3, CSC will arrange a roundtable event to specifically examine CSC’s existing suicide prevention initiatives.  A selection of external experts and CSC representatives will be invited to this event, and discussions will include the use of isolation.  A summary document will be produced which will help to inform CSC’s direction on this file.
Approach CSC remains committed to ongoing partnership development to better meet the needs of offenders, including continuing to engage with external independent experts to conduct specialized mental health assessments on offenders with complex needs.  In addition to these external assessments, CSC also continues to engage with community organizations including the Centre for Addiction and Mental Health in Toronto, Royal Ottawa Hospital in Ottawa, and Institut Philippe-Pinel in Montreal.  These partnerships assist CSC in developing policies, interventions, and training initiatives.
Accountability Lead: Assistant Commissioner, Health Services
Collaborator: Assistant Commissioner, Policy
Collaborator: Assistant Commissioner, Correctional Operations and Programs
Initial Timeline for Implementation Roundtable to be arranged during Fiscal Year 2016-17
Summary report to be finalized by April 2017
Update: March 2017 A Roundtable event on suicide prevention, comprised of external experts and CSC representatives, occurred March 7 and 8, 2017, in Moncton, New Brunswick.
Update: May 2017 The Summary Report from the Roundtable event on suicide prevention has been finalized.  Given completion of the above actions, the ACHS considers this recommendation to be addressed.
Recommendation 4: Mandate and automate information sharing amongst all stakeholders.
Action Security Branch understands the need for clear information sharing amongst stakeholders.  This recommendation will need to be addressed with the assistance of all the major stakeholders implicated in dealing with inmates contemplating suicidal ideation in order to effectively prevent the number of deaths in custody as demonstrated in the report.
Approach Most institutions currently have a means and tools in place to facilitate the sharing of information to ensure appropriate measures are taken at the appropriate time to ensure the wellbeing of inmates.  This includes a daily briefing document of incidents and observations that are posted on a common electronic folder available to all staff.  Some units have also created an electronic email distribution list so that information pertinent to unit operations is recorded and shared.  These tools are supplemental to unit log books and observation reports.  Some units also have daily briefing with multi-disciplinary staff using the aforementioned information to facilitate enhanced briefings.

The Security Branch will issue direction that minimally will require institutions to have in place an automated means of sharing pertinent information to support the wellbeing of inmates.
Accountability Lead: Assistant Commissioner, Correctional Operations and Programs
Collaborator: Assistant Commissioner, Policy
Collaborator: Assistant Commissioner, Health Services
Initial Timeline for Implementation May 31, 2016
Update: June 2016 A memo was distributed from the Director General, Security Branch to the Assistant Deputy Commissioners, Correctional Operations (ADCCOs) on July 13, 2016. The ADCCOs were asked to ensure that the institutions have an automated information sharing model, or to enhance the current models to meet a similar standard, by September 1, 2016. It was suggested that an example of an automated information sharing system between stakeholders within an institution could be a daily spreadsheet promptly updated with new pertinent information regarding inmates (ex: threats, possession of contraband, deteriorating behaviour, etc.), which would be saved on a shared drive to be accessed by stakeholders (i.e. operational, case management and health care staff).
Update: December 2016 Action item completed as of September 1, 2016.
Update: June 2017 Security Branch has confirmed that all regions have implemented an automated information sharing system throughout all of their institutions.  Approaches include, for example, the implementation of daily briefings posted on a common drive/Infonet site/SharePoint site accessible to all staff, the use of generic email distribution lists to disseminate operational information/Operations Meeting Minutes to all staff on a daily basis, and the posting of Security Intelligence Officer shift briefings in the Correctional Manager’s office.  

Given completion of the above action, the ACCOP considers this recommendation to be addressed.

Recommendation 5: CSC should ensure that all staff (including employees on contract) are indeed being trained in suicide risk prevention including staff who interact with inmates but not necessarily in a clinical or security capacity (e.g., librarians, chaplains, teachers).

Action

CSC will provide access to individuals hired under contract with CSC who interact with inmates, but not necessarily in a clinical or security capacity, to the online Suicide and Self-Injury Training module.

All CSC staff receive initial suicide and self-injury intervention training through the Correctional Training Program (CTP), the Parole Officer Induction Training (POIT) or the New Employee Orientation Program (NEOP).

Further, all staff (including casuals) having regular interaction with offenders must complete annual refresher training including those who:

• supervise offenders in living areas;
• supervise the work of offenders;
• provide case management, health care, programs, schooling, psychological services, or spiritual support to the offender; and,
• supervise the leisure activities of offenders.

Approach

In partnership with Health Services and Contracting and Materiel Services, Learning and Development will review and update, the Information Guide For Contractors. 

With the assistance of CSC Communications, the online Suicide and Self-Injury Intervention Module that is currently only available on the InfoNet will be made available on the Internet to individuals hired under contract with CSC who interact with offenders.

Contracting and Materiel Services will include a paragraph in all contracts issued by CSC referring contractors to the Guide for Contractors as well as requiring them to complete the applicable online modules, including those related to suicide and self injury, prior to the commencement of any work. 

Contractors will be required to certify that their resources have completed the applicable online modules prior to the commencement of any work, and to retain the signed checklist(s).

Accountability

Lead: Assistant Commissioner, Human Resource Management
Collaborator: Assistant Commissioner, Health Services
Collaborator: Assistant Commissioner, Corporate Services
Collaborator: Assistant Commissioner, Correctional Operations and Programs

Initial Timeline for Implementation

ACHRM: The Information Guide for Contractors will be reviewed, updated, and posted on the Internet by April 2016.

ACCS: Clauses will be added to new contracts referring Contractors to the Information Guide.  New contracts beginning April 1, 2016 will include a clause requiring Contractors to certify that their resources have completed the applicable online modules prior to the commencement of any work, and to retain the signed checklist(s).

Update: April 2016

After discussion at the ExCom Meeting of April 12, 2016, ACHRM provided the following updates:

Approach:

In partnership with Health Services and Contracting and Materiel Services, Learning and Development will review and update the content of the Information Guide For Contractors to include the updated and relevant content from the Suicide self-injury training module.  The guide has three modules (M1: all contractors who are contracted to perform work for CSC; M2: all contractors working in a non-institutional environment: M3: all contractors working in an institutional environment (this module will now include Suicide Self-Injury Training).

With the assistance of CSC Communications, the three modules of the Information Guide for Contractors will be made available on the Internet.    In the short-term, communications will provide access to the Information Guide through Google Dropbox.  In the long-term, Communications will develop a stakeholder portal to share information with outside sources.  Communications has indicated that they expect that the portal will be ready in 2017-18.

Contracting and Materiel Services will include a paragraph in all contracts issued by CSC referring contractors to the Guide for Contractors as well as requiring them to complete the applicable online modules, including those related to suicide and self injury, prior to the commencement of any work. 

Contractors will be required to certify that their resources have completed the applicable online modules prior to the commencement of any work, and to retain the signed checklist(s).

Timeline for Implementation:

ACCE: In the short-term, communications has provided access to the Information Guide through Google Dropbox.  In the long-term, Communications will develop a stakeholder portal to share information with outside sources.  The stakeholder portal will be ready in 2017-18.

Update: March 2017

HRM Update:

The review and updates to the content of the Information Guide for Contractors in order to include content from the Suicide self-injury training module were completed. The updated guides are posted on the L&D online learning portal.

The revised modules of the Information Guide for Contractors are available to contractors through Google Dropbox. 

As of June 30, 2016, a paragraph was added in all contracts issued by CSC referring contractors to Dropbox and requiring them to complete the applicable online modules, including the suicide and self-injury, prior to the commencement of any work. Contractors are required to certify that their resources have done so, and to retain the signed checklist(s).

No further action required from HRM.

Communications Update:

It is anticipated that the stakeholder engagement portal will be operational in the 4th quarter of Fiscal Year 2017/18.

Recommendation 6: CSC should collect data on non-natural deaths in custody as far back as possible to examine trends over time.  This examination should focus on whether noticeable changes in deaths in custody rate might be due to changes in policy, operations, socio/cultural/political factors both internal and external to CSC.
Action Carry out the following studies specified in Recommendation 2: 

Study C: Trend analysis at the offender level of Deaths in Custody (DIC) including a thematic analysis of Board of Investigation (BOI) findings, available psychological data and offender information from the Offender Management System (OMS).

Study D: Trend analysis at the meso-level (rates of DIC) including a thematic analysis of Board of Investigation (BOI) findings and exploration
of social/policy and environmental changes impact.
Approach 1. Develop Terms of Reference for all studies in co-ordination with all associated stakeholders
2. Develop a database going back to FY 1999/2000 that contains sufficient information to carry out the proposed studies including coding from all BOIs and Mortality Reviews
3. Undertake and report on studies
Accountability Lead: Assistant Commissioner, Policy
Initial Timeline for Implementation
  • Preliminary Terms of Reference complete by March 2016
  • Database developed and completed by October 2016
  • Study C complete by April 2017
  • Study D complete by September 2017
Update: April 2016 The preliminary Terms of Reference were submitted to the Senior Deputy Commissioner on March 31, 2016 and were briefly discussed at the ExCom Meeting of April 12, 2016.  The project is proceeding as scheduled.
Update: December 2016 The review of Boards of Investigation and Mortality Reviews is complete for the years 2009/2010 to 2015/2016 for all completed investigations. As additional studies become available the database will be updated. The work on studies C and D is ongoing. Investigations prior to 2009/2010 have been more difficult to obtain (especially Mortality Reviews) and coding of these investigations will proceed as they are available. This should not affect the quality of Studies C and D.
Update: March 2017
  • Preliminary Terms of Reference complete by March 2016 – action complete
  • Database developed and completed by October 2016 – action complete
  • Study C complete by November 2017 – The information from Studies A, C, and D will be presented jointly in the Annual Report on Deaths in Custody FY 2015/2016 (review ready July 2017 - tentative publication November 2017).  This allows time for completion of investigations of the FY 2015/2016 deaths.   
  • Study D complete by November 2017 – see comment for Study C.
Recommendation 7: Account for regional disparities when non-natural deaths vary noticeably across regions.
Action Conduct Regional Analyses and include these within all future Annual Reports of Deaths in Custody (ARODICs)
Approach 1. Develop a database going back to FY 1999/2000 that contains sufficient information to carry out the proposed studies including coding from all BOIs and Mortality Reviews that allows for Regional Analysis
2. Develop a revised framework for the ARODIC that incorporates analysis of regional disparities
3. Undertake regional analyses and report on these in all future ARODICs
Accountability Lead: Assistant Commissioner, Policy
Initial Timeline for Implementation Revised Framework for ARODIC for FY 2015/16 complete by May 2016
Database developed and completed by October 2016
Database maintained and regional analyses repeated and reported on all future ARODICs
Update: June 2016 The revised framework is conceptualized and includes regional and more detailed analyses.  It should be considered preliminary at this point as further data gathering (i.e. coding of the files) continues until the end of October 2016 and will further inform the format and content of future Annual Reports of Deaths in Custody
Update: December 2016 Regional analysis of the database is underway. All analyses reported in the Annual Report on Deaths in Custody will include regional analysis where possible. Small numbers of certain types of cases (i.e. overdose or suicides) may limit complete regional analysis.
Update: March 2017

Revised Framework for ARODIC for FY 2015/16 complete by May 2016 – action completed
Database developed and completed by October 2016 – action completed
Database maintained and regional analyses repeated and reported on all future ARODICs – ongoing – Regional results will be part of the Annual Report on Deaths in Custody FY 2015/2016 (review ready July 2017 - tentative publication November 2017).  This allows time for completion of investigations of the FY 2015/2016 deaths.   

Recommendation 8: That the Incident Investigations Branch reframe the Terms of Reference within Convening Orders for suicides to ensure that the questions get to the root causes of non-natural deaths in custody including dynamic security, case management practices, information sharing, quality of communications, suicide prevention, intervention, and post-intervention etc.
Action The Checklists for incidents of Attempted Suicide and Suicide will be modified to include questions that would get to the root causes of these incidents.  The revised versions of the Checklists will contain questions/areas to be looked at by the Boards of Investigation relating to: a) details of the incident; b) post-incident information; c) history and management of mental health concerns; and, d) medications. 

The Checklist for Terms of Reference for institutional incidents will also be amended to ensure they are more pointed with respect to root causes.
Approach Boards of Investigation into suicides include a mandate “to identify and analyse any issues of compliance to the law, policies and procedures having a direct impact on the incident”. Boards of Investigation have further Terms of Reference to support the analysis of the incident. In the case of suicides, the Terms of Reference typically include the mandate “to analyse any pre-indicators, precipitating factors, and contributing risk factors to the incident and if so, were they known to staff and was any attention provided or action taken by them”. This portion of the Terms of Reference offers a framework for the reporting of what was known prior to the incident, any further discoveries (e.g. such as a suicide note) and an analysis of the dynamics of the situation, including the quality of communication. This is in keeping with the organizational practise of asking investigators to focus first and foremost on the facts and the analysis of the facts as they relate to the incident.

A Working Group has been assembled to review and update the Checklists used by Boards of Investigation into incidents of Suicide and Attempted Suicide to assist in report writing. The Checklist for Terms of Reference is also being amended by this Working Group. The revised documents will be sent to all IIB staff for consultation. Final versions of these Checklists will be saved to the IIB shared templates folder on the y-drive and will be shared with all BOIs into incidents of Suicide and Attempted Suicide as a reference tool for conducting investigations and writing their reports.
Accountability Lead: Senior Deputy Commissioner
Initial Timeline for Implementation
March 31, 2016
Update: April 2016 The Checklists were submitted to the Senior Deputy Commissioner on March 31, 2016 and were briefly discussed at the ExCom Meeting of April 12, 2016.  The Checklists are now saved to IIB’s y-drive and are being shared with Boards of Investigation.  The Checklists have also been sent to policy holders for their review/comments (including Health Services for their review with the national advisory committee as per Recommendation 3), following which amendments will be made accordingly by June 3, 2016.
Update: June 2016 Comments and suggestions from policy holders at National Headquarters were received by IIB during the month of May 2016.  Upon receipt and review of the comments, the checklists were amended as necessary and have now been saved to IIB’s y-drive.  These checklists were also shared with the Office of the Correctional Investigator on June 28, 2016 for review and comment.

Given completion of the above action, IIB considers this recommendation to be addressed.
Recommendation 9: The IRC recommends that future independent reviews be carried out every two years rather than three as there are sufficient incidents and recommendations to warrant an external review.  The two year timeframe for a review should be formalised and put forth in policy.
Action The next IRC will be convened in 2017/2018 which will review deaths in custody from 2014/2015, 2015/2016, and 2016/2017.  The following IRC will be convened in 2019/2020 and will review deaths in custody from 2017/2018 and 2018/2019.
Approach The next IRC will be convened in 2017/2018 which will review Deaths in Custody from 2014/2015, 2015/2016, and 2016/2017.  This timeframe will allow implementation of the action plans to respond to the recommendations made by the current IRC.  Given there have been three IRCs reviewing differing timeframes, it is being proposed that the next IRC (2017/2018) be completed and reviewed by the Service prior to any timeframes being outlined in policy.   
Accountability Lead: Senior Deputy Commissioner
Collaborator: Assistant Commissioner, Policy
Initial Timeline for Implementation
The next IRC will be convened in 2017/2018.
Update: March 2017 A Supply Arrangement is underway through which members of future IRCs and other committees will be selected. The 4th IRC is on track to be convened in FY 2017/2018.