Review of Practices in Place to Prevent/Respond to Death in Custody

Internal Audit Report

378-1-271

February 13, 2012

Table of Contents

EXECUTIVE SUMMARY

The Review of Practices in Place to Prevent/Respond to Death in Custody is being conducted as part of Correctional Service Canada’s (CSC) 2011-2014 Risk-Based Audit Plan. One of CSC’s strategic priorities is the safety and security of staff and offenders within institutions. This priority is also reflected in CSC’s Transformation Agenda.

In recent years, a significant amount of attention has been focused on the prevention of death of offenders while in CSC custody. A total of 109 separate actions/commitments have been made by CSC to better respond to/prevent deaths in custody. Since 2009, on a semi-annual basis, CSC completes a progress report on the implementation status of these commitments.

Our review examined 24 commitments that we have deemed to be most important to address risks. It provides a moderate level of assurance on the extent to which those commitments have been met and where applicable, the extent to which they have been implemented.

Overall, in our analysis of the commitments, we found that 22 of the 24 commitments had been fully completed. In addition, of the nine commitments where we assessed the implementation, we found that only three of them had been fully implemented.

We suggest that the organization maintains its efforts in implementing its action plan to fully address and fully implement the commitments made.

STATEMENT OF ASSURANCE

This engagement was conducted with a moderate level of assurance.

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria. The opinion is applicable only to the area examined. The evidence was gathered in compliance with Treasury Board policy, directives and standards on internal audit and the procedures used meet the professional standards of the Institute of Internal Auditors. The evidence gathered was sufficient to provide senior management with proof of the opinion derived from the internal audit.

Date: __________________

__________________________________
Sylvie Soucy, CIA
Chief Audit Executive

1.0 INTRODUCTION

Background

The Review of Practices in Place to Prevent/Respond to Death in Custody is being conducted as part of Correctional Service Canada’s (CSC) 2011-2014 Risk-Based Audit Plan. One of CSC’s strategic priorities is the safety and security of staff and offenders within institutions. This priority is also reflected in CSC’s Transformation Agenda.

A core element of ensuring security of offenders within institutions is to have an adequate and effective control framework to help prevent death or serious harm that results from violence. This violence can be initiated by other offenders or be self-inflicted. Death or serious harm can also be caused by negligence and/or inadequate responsiveness to emergencies. In addition, given the increased pressure to manage the growing offender population along with the implementation of the Truth in Sentencing Act, which will apply further pressures on the capacity of the institutions, offender injury, both through self-injuring and violence between offenders, is of significant concern to CSC.

In recent years, a significant amount of attention has been focused on the prevention of death of offenders while in CSC custody. In 2007, the Office of the Correctional Investigator (OCI) released its Deaths in Custody Study. This study, which examined the deaths of 82 inmates while in federal custody between 2001 and 2005, found that some deaths could have been averted through improved risk assessments, more vigorous preventive measures, and more competent and timely responses by institutional staff1. In 2008 the OCI released a report entitled “A Preventable Death”. This report, which identifies the broader issues that contributed to the death of an offender while in the care and custody of CSC, included a total of 16 recommendations2.

Working in collaboration with various partners and stakeholders, including the OCI, CSC has introduced a number of initiatives aimed at preventing and reducing violence, and the possible resulting death, in the institutions. Some of these initiatives were developed to address any mental health issues of offenders before they may lead to self-injuring, suicide or violence towards others. A total of 109 separate actions/commitments have been made by CSC to better prevent / respond to deaths in custody. Since 2009, on a semi-annual basis, CSC completes a progress report on the implementation status of these commitments. The Correctional Service of Canada “is fully committed to finding and implementing appropriate and effective measures that will assist in responding to and preventing, where possible, death in custody.”3

Our review will provide a moderate level of assurance that CSC’s previously made commitments to better prevent and appropriately respond to Death in Custody have been implemented by examining the extent to which those commitments that we have assessed as being most significant to address risks, have been met or completed.

2.0 REVIEW OBJECTIVES AND SCOPE

2.1 Review Objectives

The objective of this review was to provide moderate assurance that the most significant commitments made by CSC to address risks of death in custody have been implemented.

The specific criteria related to the objective for this review are included in Annex A.

2.2 Review Scope

Given the number of commitments that CSC has made with respect to offender death in custody, the focus of this engagement was to follow-up on the implementation of those commitments aimed at mitigating areas that represented the highest risk for CSC. In 2008, CSC made a total of 109 commitments in response to the OCI’s Death in Custody Study, the OCI’s report “A Preventable Death” and CSC’s National Investigation into the Death of an Offender at Grand Valley Institution for Women. The review team assessed all of these commitments, and 24 of those which were deemed to be most important in mitigating risks to CSC were reviewed to assess the status of their implementation.

In addition, where applicable, the implementation of the actions from the commitments was tested. The list of commitments reviewed can be found in Annex C. For the purposes of this report, these commitments have been grouped into seven main themes.

This review was national in scope and included site visits to 20 federal institutions covering all five regions (see Annex B). To determine the institutions to be visited, the review team selected sites at a higher risk for deaths in custody along with a few other sites which were not.

3.0 REVIEW APPROACH AND METHODOLOGY

The approach included site visits with evidence gathered through a combination of interviews, file reviews and observations. Annex D lists and describes the techniques used to gather evidence to complete this Review.

4.0 OBSERVATIONS AND FINDINGS ON STATUS OF COMMITMENTS

4.1 Administrative Segregation

4.1.1
Commitment

“Amend the CD 709, Administrative Segregation, to provide guidelines for Segregation Placement/Admission, Segregation Review Board Report Content and Mental Health Assessment for Administrative Segregation4.”

Discussion

An analysis of CD 709 was completed to determine if the guidelines for Segregation Placements, Segregation Review Boards and Mental Health Assessments for Segregation had been incorporated into the policy. We found that CD 709, was last updated in 2007 and five new annexes to the CD were created to address the commitments made in 2008. These annexes include guidelines on segregation admission, how to run a Segregation Review Board (SRB) and the requirement to provide psychological opinions for administrative segregation cases. As per the March 2011 progress report on this commitment, CD 709 is in the process of being further revised and was expected to be promulgated in June 2011. As of September 2011 the update has not yet been promulgated.

One area which was strengthened in the 2007 version of the CD was regarding the Segregation Placement and Admission Guidelines. These guidelines state that all reasonable alternatives to administrative segregation must be considered prior to making the decision to segregate an offender5. The guidelines also state that the reason why each alternative is not viable must be clearly described6. A total of 159 individual segregation placements were reviewed to determine whether or not alternatives to segregation were always considered in the placement decision. We found that while alternatives were listed in the segregation placement decision in 98% (156/157) of the cases, 30% (47/157) of these did not state why the identified alternatives were not viable.

Another change in the 2007 version of CD 709 was the inclusion of the guidelines on how to run a Segregation Review Board. A SRB must be put in place to conduct review hearings of cases where inmates are in administrative segregation. The board makes recommendations to the Institutional Head as to whether or not an inmate should be released from administrative segregation at that time. The guidelines state that a SRB will be chaired by an individual at a level no less than Manager of Assessment and Intervention. For offenders who have been segregated for longer than 60 consecutive days, an individual at a level no less than Assistant Warden must chair the board. A review of the SRBs conducted for 55 offenders was completed to ensure that the chair of the committee was at the appropriate level for the case being reviewed. Our analysis showed a compliance rate of 100% for both the five and 30 day reviews (53/53 and 33/33 respectively). The compliance rate for the 60 day review was 96% (23/24).

The third aspect of CD 709 which was strengthened in the 2007 release was the requirement to complete mental health assessments for offenders in administrative segregation. These guidelines state that a psychologist is required to assess and report on the mental status of segregated offenders at least once within the first 25 consecutive days in administrative segregation and once every subsequent 60 consecutive days. In our analysis of psychological assessments for segregated offenders, we found that in 97.8% (91/93) of the cases the psychological assessments were completed during the first 25 days and 100% (43/43) of the first 60 day psychological review were completed. For offenders who were in segregation long enough to reach a second 60 day psychological review, we found that 92.9% (13/14) of these required assessments were completed.

Progress on Commitment

Overall, CD 709 was updated in 2007 and satisfies the commitment made. A further update to the CD which was planned for June 2011 had yet to be completed and promulgated as of September 2011; however this update to the CD was not part of the original commitment. As a result, we have assessed this commitment as fully completed.

Progress on Implementation

Our file review demonstrated that institutions were complying with the requirement that SRBs be chaired by a staff member who is at the appropriate level and also demonstrated that psychological assessments were completed as required by the CD. That said, compliance issues were noted with the Segregation Decisions as the file review demonstrated that sites did not fully describe why some alternatives to segregation were not viable options. As such, we have assessed this commitment as partially implemented.

4.1.2
Commitment

Issue a follow-up reminder to reinforce the importance of performing and documenting physical and mental health assessments during the daily visits (in Segregation)7.

Discussion

In July 2009, the Assistant Commissioner, Health Services provided a memo to remind all nursing staff of their responsibilities as stated in the Administrative Segregation section of CD 800, Health Services. CD 800 states that “each inmate in administrative segregation shall be visited daily, including weekends, by a registered Nurse.” It is also stated that during this visit, the nurse must view the inmate in person and verbally interact with the inmate to determine if the offender has any health care needs. The nurse must initial the relevant section of each offender’s Segregation Log and must also record any significant interaction with the offender during the visit in the health care file.

While on site, the review team reviewed both the Segregation Visitors Sign-In Logs and the offender’s Segregation Logs (CSC 218) to determine whether nurses were in the Segregation Units to visit each offender on a daily basis. We found, at each of the sites visited that nurses did meet with each offender on a daily basis and this was documented by their initials on the offender’s individual Segregation Log. It should be noted that neither the quality of the nurse visit nor any notes written in the health care file regarding the visit with the offender were assessed as part of our analysis.

Progress on Commitment

As a follow-up reminder has been promulgated, we have assessed this commitment as being fully completed.

Progress on Implementation

Through our file review tests conducted on site, we have assessed this commitment as being fully implemented.

4.1.3
Commitments

Revise CD 081 Offender Complaints and Grievances8.

Revise Grievances procedures and policies9.

Discussion

During our policy review, we found that both the CD and the manual related to the Complaints and Grievance Process was last updated in 2008 (after the OCI recommendation was issued). In this version of the CD, the policy states that “the Institutional Head must ensure that complaints and grievances are collected and reviewed daily10.”

In May 2009, the Internal Audit Branch recommended in its audit report on the Offender Complaint and Grievance Process that clarification be provided to staff with respect to the collection and review of complaints/grievances on weekends and holidays from inmates on segregation/cell-confinement status. Communication from the Policy Sector was sent to the five regional deputy commissioners in June 2009 to clarify this requirement. Furthermore, an updated version of the CD was released for consultation in July 2011. Among the changes proposed, the CD explicitly includes as part of the institutional heads role that complaints and grievances submitted by segregated offenders must be collected and assessed daily including weekends and holidays. We question whether this statement would be more appropriate if also included in the CD as part of the paragraphs where the process for grievances made by segregated offenders is discussed.

Furthermore, while at each site, the review team determined, through interviews with wardens, grievance coordinators and correctional managers and through observations, the process for collecting and reviewing complaints and grievances on a daily basis for offenders in Administrative Segregation. Of the 20 institutions visited, 15 had a formal Administrative Segregation Unit. Of these, only seven had a process in place to collect and review complaints and grievances on weekends and holidays and to ensure that high-priority complaints and grievances were dealt with immediately. Of the remaining eight sites, one of the sites ensured grievances were collected daily from segregation but had no process in place to ensure that they were reviewed, while the remaining seven sites neither collected nor reviewed complaints and grievances from administrative segregation on weekends or holidays.

Progress on Commitments

An updated CD and Manual were promulgated in 2008 and as such, we have assessed this commitment as completed.

Progress on Implementation

Our review showed that not all sites had a process in place to collect and review the complaints and grievances submitted by offenders in administrative segregation on weekends and holidays. As these compliance issues were found at 60% of the institutions visited which had an Administrative Segregation Unit, we have concluded that this commitment has not been fully implemented.

4.2 Institutional Transfers

4.2.1
Commitment

Revise CD 710-2 Transfer of Offenders11.

Discussion

CD 710-2 was last updated in February 2010 and includes necessary cross references with CD 843, Prevention, Management and Response to Suicide and Self Injuries. Among other changes to the CD, a paragraph was added stating that offenders who are at an elevated risk for suicide or self-injury will not be transferred to an institution other than a treatment centre unless the psychologist or psychiatrist deems that the transfer would reduce the offender’s risk for suicide or self-injury. For the period under review, we were unable to locate cases where an offender who was at high-risk for suicide or self-injury had been transferred to an institution other than a treatment centre. During interviews with wardens, parole officers and managers of assessment and intervention, we asked whether there were any issues or concerns with the policy. Ninety-four percent (47/50) of those interviewed stated that the policy changes related to CD 710-2 were clear and easy to understand. One area where a few individuals raised concerns on the clarity of the policy related to who is responsible for initiating communication between sending and receiving institutions.

Progress on Commitment

Overall, as the CD has been updated and promulgated. As such, we have assessed this commitment as completed.

4.3 Security Practices and Use of Force Interventions

4.3.1
Commitments

Revise CD 567-1, Use of Force12.

Implement new procedures to strengthen accountability in security practices and use of force interventions13.

Discussion

CD 567-1, Use of Force, was promulgated in April 2009 along with a policy bulletin documenting the changes made to the CD. One of the changes made to the CD was the inclusion of the definition of what constitutes a use of force. Use of force is defined as any action by staff, on or off institutional property that is intended to obtain the cooperation and gain control of an inmate. A use of force occurs when one of the following measures is used: non-routine use of restrain equipment, physical handling, use of inflammatory or chemical agents, use of batons or other similar weapons, use of firearms and the deployment of the Emergency Response Team in conjunction with at least one of the measures identified above. Another key change made to the CD included the ability of correctional managers, crisis managers and or institutional heads to develop intervention plans using line staff to manage a situation.

Additional changes include incorporating content from previously issued policy bulletins into the new CD. These include the use of force on pregnant offenders, expedited reviews and updating the definition of this type of review. In addition to the changes to CD 567-1 introduced in 2009, a policy bulletin was issued in May 2010 to provide interim direction while CD 843 was being finalized. In this policy bulletin it was stated that a use of force would occur any time an offender is in the pinel restraint system unless the individual involved in self-injurious behaviour either requests or complies with the request to be placed into pinel. This incident would then be classified as a non-reportable use of force.

During interviews with wardens, correctional officers and correctional managers, we were told that there were no issues with the policy and that there were no significant areas where the policy was unclear.

Progress on Commitments

Overall, the CD was updated and promulgated in April 2009 and no interviewees raised any concerns with the CD. In our comparison of the current CD with the previous one, we found that new procedures had been provided and additional accountabilities, for positions such as the wardens, nurses and correctional managers were listed. As such, this commitment has been assessed as fully completed.

4.3.2
Commitment

Revise CD 560, Dynamic Security, to provide more direction with regard to responsibilities of both management and staff14.

Discussion

Dynamic security is an approach whose aim is to optimize a safe environment for employees, offenders and the public through meaningful interactions between employees and offenders. All staff who interact with offenders are responsible to enhance their knowledge of the offender’s activities and behaviours. To report and record information and observations regarding inmate behaviours, staff are instructed to complete observation reports. These reports are to be shared with security, case management employees and any other individuals as deemed necessary in relation to the nature of the information.

As part of the review, an analysis of the current CD 560, Dynamic Security, was completed. The updated CD, which as per the most recent progress report on the commitments, was to be released for consultation in spring 2011, had yet to be promulgated as of September 2011.

Site visits, observations and interviews with wardens, correctional managers and correctional officers were conducted to determine whether the sites had strong dynamic security. In our opinion, 13 of the 20 sites visited appeared to have fairly strong dynamic security. Our views on the sites dynamic security was validated during debriefs with the institutional heads. Correctional officers at these sites expressed the importance of getting to know offenders as it provides a greater level of security for the institution. Wardens and correctional managers at the sites with strong dynamic security attributed its existence to the culture of their institution and to their ability to ensure officers routinely work the same units to allow them to get to know the offenders. Wardens at some sites also stated that having parole officers, psychologists and nurses who are unit based provides additional dynamic security. Some wardens reiterated the fact that dynamic security is not only the responsibility of correctional officers but should be part of the duties of all staff working in an institution. At the seven sites where dynamic security was less than strong, wardens stated that it is extremely difficult to change the culture of an institution. At many of these sites, we were often told that correctional officers do not believe that their job is to interact with offenders, as they believe that their main responsibility is to provide static security.

Progress on Commitment

As CD 560 has yet to be promulgated, we have assessed this commitment as not completed.

4.3.3
Commitment

Introduce an additional stand-to inmate count at all maximum, medium, minimum and multi-level institutions between the hours of 6:00 pm and 12:00 am15.

Discussion

A stand-to count is a formal count of inmates in a standing position, facing the counting staff member to ensure facial identification is made. In June 2009, a Security Bulletin was issued regarding stand-to counts. The security bulletin states that there will be at least two daily stand-to counts at all maximum, medium and multi-level institutions. Furthermore, one of these stand-to counts must be completed between the hours of 18:00 and 24:00.

The current CD 566-4, Inmate Counts and Security Patrols, states that a minimum of four formal counts, at least one of which must be a stand-to count, must be conducted in each 24 hour period. This CD was last updated in February 2009 and does not yet reflect the new requirement as per the June 2009 Security Bulletin.

We analyzed the post orders and standing orders for the 20 institutions visited to determine the times of the formal counts. We found that each site was conducting a minimum of four formal counts each day, at least two of them being stand-to counts, with at least one stand-to count occurring between 18:00 and 24:00.

Progress on Commitment

With the promulgation of a security bulletin in June 2009, and the subsequent implementation of the additional stand-to counts at the institutions visited, we have assessed this commitment as fully completed. That said, the policy should be updated to include the content of this security bulletin.

Progress on Implementation

We found that all sites visited were compliant with the requirement to conduct the appropriate number of stand-to counts following the issuance of a security bulletin in June 2009. As such, this commitment has been assessed as fully implemented.

4.3.4
Commitment

Increase additional security patrols at all maximum, medium and multi-level institutions (excluding women’s institutions)16.

Discussion

CD 566-4, Inmate Counts and Security Patrols, was last updated in February 2009. It states that a security patrol is an observation by a Correctional Officer, a Primary Worker or a Supervisor of a designated area of the institution to ensure the security of the institution and the well-being of inmates. It further states that during security patrols in accommodation areas, the presence of a live breathing body must be ensured.

In our analysis of this commitment, we reviewed the CD 566-4 - Inmate Counts and Security Patrols along with the site specific post orders and standing orders to ascertain how frequently patrols were required. We also conducted interviews with correctional officers and correctional managers to understand how and when security patrols were being conducted.

In our review of the CD, we found that security patrols in inmate accommodation areas must be as frequent as possible but must be once every 60 minutes from the beginning of the last patrol. A security bulletin was issued in May 2010 and provided clarification to previously issued bulletins on rounds and counts which were issued in December 2007 and June 2008. The 2010 bulletin states that “an additional security patrol will be conducted between the hours of 23:00 and 07:00 at all maximum, medium and male multilevel security institutions.”

A review of individual site specific post orders and standing orders was also completed for each institution visited, to determine if they were aware of the requirement to conduct additional rounds, and if they were formalizing this requirement. Our analysis showed that for the 18 male sites we visited where the extra round was required, only seven of them included this in either their post or standing orders.

Additionally, we analyzed the security patrol electronic logs from the rounds at each site to determine the frequency of the patrols and to further determine whether sites were compliant with the requirement of conducting the extra security patrol. To do this, we selected two fixed points within the institution, one in administrative segregation and one within a regular living unit, to determine the frequency of the rounds made by correctional officers. This analysis was done over four different days and included two weekdays and two weekend days.

Overall, we found full compliance with the rounds taking place in administrative segregation and noted that, at most sites, rounds were done much more frequently than once an hour. That said, issues were noted at some sites with the electronic registers for the regular living units not clearly showing that the additional rounds were taking place. In our analysis of the four days of data, we found that ten of the 18 male sites visited were compliant with this requirement. For those non-compliant sites, three sites never completed an additional round, one site completed it on one of the four days, one site completed it on two of the four days and two sites completed it on three of the four days. In addition, we were unable to complete this analysis for one site as they did not have electronic data registers in working order and have not been using any other electronic system to track the frequency of their rounds.

Progress on Commitment

While we found that a security bulletin was issued in 2010 requiring additional security patrols, we noted that it has not yet been incorporated into the CD. As a result, and noting the compliance issues found, we have assessed this commitment as only being partially completed.

Progress on Implementation

Overall, while most sites were aware of the requirement of completing additional rounds, only 10 of the 18 male institutions visited were fully compliant in our analysis. As such, we have assessed this commitment as not fully implemented.

4.3.5
Commitment

Implement corrective measures immediately following incidents at the local level while the investigative process gets underway17.

Discussion

Through discussions with the regional deputy commissioners, we confirmed that the regions are aware of the requirement of immediately implementing any required corrective action. The process was consistent in all regions. For example, following any incident, a situation report is written by staff at the institution and shared with the regional headquarters. Those situation reports which relate to an incident that is deemed to be serious are reviewed at the daily operational meeting held at the regional headquarters and areas requiring immediate corrective measures will be identified. In all regions, we were told that it is ultimately the responsibility of the institutional head to ensure that corrective measures are implemented immediately following the incident. None of the regions had a formalized documented process which they could provide to substantiate their method.

Progress on Commitments

Overall we confirmed that regional headquarters are made aware of serious incidents which occur in their institutions and expect that sites will implement corrective measures immediately. Based solely on information provided by the regional deputy commissioners, we have assessed this commitment as completed.

Progress on Implementation

Due to the lack of formal documented processes in place in any of the regions to ensure that corrective measures are implemented in a timely manner, we have assessed this commitment as being partially implemented.

4.4 Service and Support for Women Offenders with Significant Mental Health and/or Behavioural Needs

4.4.1
Commitments

Develop short and long term strategies on service, support and accommodation needs for women offenders identified in this group18.

Review capacity to address the needs of women offenders with mental health and behavioural needs19.

Discussion

In February 2009, the Women Offender Sector presented a Short and Long-Term Accommodation Strategy for Women Offenders to the Commissioner Management Team (CMT). The purpose of this Strategy was to address current challenges and the future forecast of the female offender population. In addition, the Strategy was also to provide a plan to more effectively address security, programming and treatment needs of women offenders in maximum security and those struggling with mental health challenges.

We were told that during 2008 and 2009, 45 beds were added to three of the women institutions. In addition, when looking at the current CSC Build Plan, we found that accommodations for a total of 144 new beds have been approved and are either in the final stages of planning or are under construction. Twenty of these new beds will be in Structured Living Environment (SLE) houses. The SLE provides a treatment option for minimum and medium security women with significant cognitive limitations or mental health concerns ensuring that their needs can be met within the women’s institutions. SLE houses are staffed 24-hours a day by primary workers and behavioural counsellors are available 16 hours a day to assist offenders. In addition to increasing the number of SLE beds within the institutions, a plan has been approved which will see the women’s unit at the Regional Psychiatric Centre increase from 12 beds to 18 beds. Women offenders admitted to the Regional Psychiatric Centre are those offenders who require in-patient psychiatric treatment services20.

In addition to increasing the number of beds, the Women Offender Sector informed us that they are also exploring opportunities to gain access to additional mental health beds. In partnership with the Mental Health Services Branch, they are examining options to develop an intervention plan to address the needs of lower functioning women.

Additionally, to deal with capacity, the women institutions have begun hiring additional staff, including occupational therapists, social workers and recreation therapists to work with and assist the women with various mental health needs. In addition, Regional Suicide and Self-Injury Prevention Management Committees have been established. These committees aim to provide a mechanism to assist and support institutions in providing an effective continuum of care to offenders encountering severe mental health and or behavioural difficulties during their period of incarceration. While the introduction of these committees was not specifically targeted for only women offenders, as women offenders are more often repeat serious injurious offenders, these committees assist in addressing the needs of this population.

We were also told by the Health Services Sector that a National Strategy to address the needs of offenders who engage in self-injury has been promulgated. We were told that many plans have been undertaken and completed in relation to this Strategy which relates to the care of Women Offenders with mental health needs, including, for example, the promulgation of CD 843.

Finally, the Health Services Sector also told us that a review of the Dialectical Behavioural Therapy training was started in 2010. This project, which includes reviewing the training for staff and the material and modules for inmates, is currently underway to ensure that they can accommodate low functioning women in this treatment program.

Progress on Commitment

We found that the Women Offender Sector is in the process of increasing capacity, specifically in the secure units, the SLE houses and the Regional Psychiatric Centre. In addition, they have developed strategies to support, accommodate and provide services to women dealing with mental health and behavioural needs. Overall, based on what we found and what we were told by the Health Services Sector, we have assessed both of the above commitments as complete.

4.4.2
Commitment

Create secure interview rooms in the Secure Units of women’s facilities to allow for a separate space for staff and stakeholders to interact with offenders within a safe setting21.

Discussion

During the site visits to Nova Institution and Edmonton Institution for Women, we confirmed the existence of secure interview rooms within the Secure Unit. A secure interview room is a room where the offender is on one side of a glass divider and the interviewee would be on the other.

Progress on Commitment

Following our observations of the secured interview rooms at both women sites visited, and based on the CSC Issued Progress Report on these commitments, we know that all five women sites have had the secured interview rooms in place since 2009. As such, this commitment has been assessed as fully completed.

4.4.3
Commitment

Complete a project to install high resolution digital cameras in the cell range areas of all women’s institutions22.

Discussion

Following communication with the Women Offender Sector, we were informed that in 2010 consultation occurred with the wardens of the women institution and the assistant deputy commissioners of institutional operations to identify the location of the cameras. It was decided that cameras would be installed in the secure unit to improve coverage of the maximum security ranges, in the segregation ranges and in those segregation cells which were being used for suicide observation. The Women Offender Sector also told us that there was no intention of installing cameras in the minimum and medium security houses in the institution.

We have received confirmation from the Women Offender Sector that the installation of the high resolution digital cameras is complete for two of the sites with an additional institution scheduled to have cameras installed in October 2011. The remaining two institutions will have the installation of the cameras completed by the end of March 2012.

Progress on Commitment

In our review of this commitment we found that a plan was in place to install high resolution digital cameras in the cell ranges of each of the five women institutions. We also found that three of the sites had fully installed the cameras while two of them were still in the process of having the cameras installed. As such, this commitment has been assessed as being partially completed as not all five sites have installed all of the cameras.

4.5 Training

4.5.1
Commitment

Mental health training will be provided to correctional officers23.

Discussion

A training course on the Fundamentals of Mental Health was created in April 2009. This course provides correctional officers with knowledge of various mental health issues as they pertain to the mandate of CSC. Additionally, the training includes information on the role correctional officers play in interacting and assisting offenders with mental disorders. This course is required to be taken by all correctional officers working at medium and maximum security institutions, along with women institutions and treatment centres. By March 2010, it was expected that all primary workers (correctional officers) working at women’s institutions would have completed this training. It was also required that correctional officers at both treatment centres and maximum security institutions had completed the course by March 2011. It is required that by March 2013 correctional officers at medium security institutions will have been provided with this training.

In analyzing compliance, data was used from both the Human Resource Management System and the tracking spreadsheets maintained by the individual sites. Our analysis of compliance with the training requirement showed that a total of 76% of the correctional officers at the treatment centres, women institutions and maximum security institutions visited had completed the training. This represented 99% of the correctional officers at the women’s institutions visited, 74% of the correctional officers at the maximum security institutions visited and 72% of the correctional officers at the treatment centres. For the sites where completion rate was not 100%, we were told during interviews with training coordinators and wardens that it was difficult to offer the training as nurses were not readily available to facilitate the course as required.

Progress on Commitment

Overall, we found that the training course has been created and has been offered to correctional officers. As such, we have assessed this commitment as being fully completed.

Progress on Implementation

Our analysis demonstrated that while the women’s institutions visited were compliant with ensuring all correctional officers had been trained, we found that the correctional officers at the treatment centres and maximum security institutions were not fully compliant with this training requirement. As such, we have assessed this commitment as partially implemented.

4.5.2
Commitment

Additional training for CSC psychologists in suicide risk assessment24.

Discussion

Training in Suicide Risk Assessments and Interventions with offenders was provided to CSC psychologists between January and March 2009. This training, which was offered in three different sessions, included a two-day session and a one day workshop. The two day session was led by an expert in the field, while the one day workshop allowed participants to discuss issues related to the assessment of suicide risk assessments and the prevention of suicide within CSC. All psychologists were invited to attend this training, and the majority, we were told, did complete it.

Since 2009, supplementary resources have been provided for each psychologist to support professional development. As part of this, regions were to conduct workshops on risk assessments. Through discussions with the regions, we found that only one conducted formal training on suicide risk assessments.

Progress on Commitment

Overall, we found that training was developed and provided to CSC psychologists back in 2009. As such, we have assessed this commitment as completed.

Progress on Implementation

While our review found that training had been provided in 2009, we were unable to find evidence that, with the exception of one region, any training on suicide risk assessments for psychologists had been provided since. As such, we have assessed this commitment as being partially implemented.

4.6 Values, Ethics and Disclosure

4.6.1
Commitment

Enhance staff awareness of the Office of Internal Disclosure (OID) underscoring its availability to all CSC employees25.

Discussion

Within CSC, the OID reviews allegations of wrongdoing in accordance with the Public Servants Disclosure Protection Act and conducts an investigation when a situation warrants. In 2009, communication was sent out to all CSC employees informing all that an intranet site for OID had been created. This intranet site contains relevant policies and contact information for the office. In order to ensure staff awareness to the OID, the Office will be visiting a number of institutions in the Pacific, Prairie, Ontario and Quebec Regions to further explain the role of the OID. These visits will take place during fiscal year 2011-12, with a visit to one region already complete. Through interviews with Wardens at each of the institutions visited, we confirmed that all wardens were aware of the existence of the OID.

In 2010, the Internal Audit Branch conducted an audit of Values and Ethics. A component of this project examined staff awareness of the Office of Internal Disclosure. The audit asked CSC executives and managers if they felt that their employees were aware of the process surrounding internal disclosure. Of those interviewed, 64% believed that employees were aware of the policy surrounding internal disclosure but would not be aware of the process to follow. 32% of those interviewed believed that employees would know where to find additional information if needed.

Progress on Commitment

Overall, an intranet page exists and communication from the OID has been shared with all employees. There is also a plan in place to visit many of the regions and sites during fiscal year 2011-12. As such, this commitment has been assessed as fully completed.

4.7 Mental Health, Suicide and Self-Injuring Behaviour

4.7.1
Commitments

Implement and enhance mental health screening tool at 13 of the 16 intake assessment sites in FY 2008-200926.

Implement the mental health screening tool at the remaining sites (3 of the 16 intake assessment sites) by the end of FY 2009-201027.

Discussion

CoMHISS is a component of CSC’s mental health strategy and is offered to offenders admitted to CSC under new Warrants of Committal. CoMHISS is a number of computerized tests intended to provide a standardized approach to identifying offenders that require a more in-depth mental health assessment and/or intervention28. Early identification of mental health issues enables timely intervention, prevents further deterioration of an offender’s mental health and contributes to an appropriate penitentiary placement for offenders with mental health needs29.

To ensure that each of the 16 intake assessment sites has fully implemented CoMHISS, the file of an offender who was admitted to each of the 16 sites was selected. Through an analysis of their electronic files in the Offender Management System, we found that CoMHISS was being used at the each of the assessment centres.

Progress on Commitment

The CoMHISS is implemented and is being used at each of the 16 intake assessment sites. As such, we have assessed this commitment as fully completed.

4.7.2
Commitment

Develop a more effective approach to offender case management by focusing on psychological and specialized assessment resources on the highest risk/needs30.

Discussion

In October 2010, a Case Management Bulletin was issued regarding psychological assessments. It clarifies when psychological assessments are required. Psychologists are to conduct comprehensive supplementary assessments for those high-risk, high-need offenders who demonstrate situational adjustment difficulties, suicide risk indicators and self-injurious indicators. At intake, when required, these psychological risk assessments will be completed within 50 days following admission and prior to the completion of the Correctional Plan and penitentiary placement. By more specifically stating when psychological assessments are required, the intent is for psychologists to spend more of their time dealing with mental health issues.

Progress on Commitment

With the issuance of a Case Management Bulletin on Psychological Assessments, which has since been incorporated into the relevant Case Management CDs, we found that CSC had developed a new approach to offender case management by completing psychological assessments when most appropriate. As such, we have assessed this commitment as being fully completed.

4.7.3
Commitments

Amend CD 843 Prevention, Management and Response to Suicide and Self-injuries, to include information about the use of psychological and psychiatric services in the assessment and intervention of offenders at risk for suicide and self-injury31.

Enhance CD 843 to include improved communication to front line staff of offenders risk levels and observation status and best practices in the assessment of suicide and self-injury risk32.

Discussion

In July 2011 CD 843 was promulgated following a lengthy review process with the institutions. The CD was revised extensively and now includes policy direction on the management of inmate self-injurious and suicidal behaviour by taking what was in place and by incorporating an interdisciplinary approach33.

A change to CD 843 was the introduction of varying levels of suicide watch for offenders at risk for suicide or self-injury. Under the new CD, there are three levels of suicide watch, namely high suicide watch, modified suicide watch and mental health monitoring. Annex E of this report further defines these three suicide watch levels. The CD also states that if there is a reason to believe that an inmate may be at an imminent risk to attempt suicide, a mental health professional must assess the inmate in person. If no mental health professional is available, the Correctional Manager will immediately place the offender on a high suicide watch until the inmate has been assessed.

The updated CD 843 also discusses the importance of improving communication to front line staff regarding the risk level and observation status of offenders who are at risk of suicide or self-injury. The new policy states that the institutional head will ensure that a communication process is in place so that staff is informed regarding a change in observation status concerning any offender who they regularly supervise.

Another new area included in CD 843 pertains to the process for assessing offenders who are at risk for suicide and self-injury. The CD states that all inmates will be screened for suicide risk by using the Immediate Needs Checklist – Suicide Risk. The CD further states that this checklist is to be completed within 24 hours of arrival to an institution and upon admission to administrative segregation. If, following completion of the checklist, the offender is deemed to be at an imminent risk for suicide, the Correctional Manager is required to immediately contact a mental health professional for further assessment.

An analysis was completed on the timely completion of the immediate needs checklists for both offenders being transferred into the institution and those being admitted into administrative segregation. We sampled 146 offenders being transferred into the institutions we visited, and we found that in 103 of the transfers (71%), the immediate needs checklist was completed. For offenders being admitted into administrative segregation, we found that of the 159 admissions we sampled, the immediate needs checklist was completed in 113 (71%) of the cases.

Progress on Commitment

With the release of the updated CD 843 in July 2011, we have assessed this commitment as being fully completed.

4.7.4
Commitment

Develop and finalize standardized tools and guidelines for use in creating plans to address self-harming behaviours for use by operational staff34.

Discussion

As an annex to the CD 843, Management of Inmate Self-Injurious and Suicidal Behaviours, there is now a process for self-injury intervention. The objective of this new annex is to outline a two-pronged method for intervening with inmates who self-injure. For the short-term response, there is a Critical Response and Incident Management Plan, which concentrates on the immediate needs for intervention for an inmate following a self-injurious incident. For the long-term response, there is now a tool for an Interdisciplinary Management Plan, which is a comprehensive approach for intervening with inmates who repetitively self-injure and whose ongoing behaviour is posing a significant challenge to the institution. As an additional annex to CD 843, a flow chart now exists depicting the key steps for self-injury intervention in institutions.

Progress on Commitment

With the promulgation of the updated CD 843, standardized tools and guidelines for use in creating plans to address self-injuring behaviours for use by operational staff had been implemented. As such, we have assessed this commitment as being fully completed.

5.0 OVERALL CONCLUSION

The analysis completed for this review included an examination of the status of the commitment, and where applicable, also included an opinion on the status of the implementation.

Overall, in our analysis of the commitments, we found that 22 of the 24 commitments had been fully completed. The commitment regarding the update to CD 560, Dynamic Security, and the commitment regarding the installation of cameras in the cell areas of all women’s institutions were assessed as not completed.

Of the nine commitments where we assessed the implementation, we found that only three of them had been fully implemented. The six commitments which have yet to be fully implemented are:

  • Amend the CD 709, Administrative Segregation, to provide guidelines for Segregation Placement/Admission, Segregation Review Board Report Content and Mental Health Assessment for Administrative Segregation;
  • Revise CD 081 Offender Complaints and Grievances;
  • Revise Grievances procedures and policies;
  • Implement corrective measures immediately following incidents at the local level while the investigative process gets underway;
  • Mental health training will be provided to correctional officers; and
  • Additional training for CSC psychologists in suicide risk assessment.

We suggest that the organization maintains its efforts in implementing its action plan to fully address and fully implement the commitments made.

ANNEX A

Review Objectives and Criteria
Review Objectives Review Criteria
To provide moderate assurance that key high risk commitments undertaken by CSC regarding death in custody have been implemented. CSC key high risk commitments regarding those various areas have been implemented:
  • Administrative segregation
  • Institutional transfers
  • Security practices and Use of Force interventions
  • Service and support for women offenders with significant mental health and/or behavioural needs
  • Training
  • Values, ethics and disclosure
  • Mental health, suicide and self-harming behavior

ANNEX B

Location of Site Examinations
Region Sites
Atlantic
  • Dorchester Institution
  • Nova institution for Women
  • Shepody Healing Centre
Québec
  • Établissement Archambault
  • Établissement Cowansville
  • Établissement Leclerc
  • Centre régional en santé mentale
Ontario
  • Joyceville Institution
  • Kingston Penitentiary
  • Millhaven Institution
  • Regional Treatment Centre
  • Warkworth Institution
Prairies
  • Drumheller Institution
  • Edmonton Institution for Women
  • Regional Psychiatric Centre
  • Stony Mountain Institution
Pacific
  • Kent Institution
  • Matsqui Institution
  • Mountain Institution
  • Regional Treatment Centre

ANNEX C

Commitments Review
Recommendation Commitment
Recommendation 1:
The Office of the Correctional Investigator recommended that CSC implement and apply as widely as possible (including within men’s facilities) all recommendations emanating from the CSC National Board of Investigation into the Death of an Offender at Grand Valley Institution and the Independent Psychological Report produced by Dr. Margo Rivera as part of that investigation.
Review capacity to address the needs of women offenders with mental health and behavioral needs.
Develop short and long-term strategies on service, support and accommodation needs for women offenders identified in this group.
Create secure interview rooms in the Secure Units of women’s facilities to allow for a separate space for staff and stakeholders to interact with offenders within a safe setting.
Revise Commissioner’s Directive 710-2, Transfer of Offenders
Implement new procedures to strengthen accountability in security practices and use of force interventions.
Revise the Commissioner’s Directive 567-1, Use of Force.
Mental health training will be provided to Correctional Officers.
Additional training for CSC Psychologists in suicide risk assessment.
Enhance staff awareness of the Office of Internal Disclosure underscoring its availability to all CSC employees.
Recommendation 2:
The Office of the Correctional Investigator recommended that the Correctional Service provide a full public accounting of its response to the OCI Deaths in Custody Study. This should include a detailed action plan with clearly identified outcomes and timeframes.
Revise the Commissioner’s Directive 560, Dynamic Security, to provide more direction with regard to responsibilities of both management and staff
Introduce an additional stand-to inmate count at all maximum, medium, minimum, and multi-level institutions between the hours of 6:00 p.m. and 12:00 a.m.
Increase additional security patrols at all maximum, medium and multi-level institutions (excluding women’s institutions).
Completea project to install high-resolution digital cameras in the cell range areas of all women’s institutions.
Implement an enhanced mental health screening tool at 13 of the 16 intake assessment sites in fiscal year 2008-2009.
Implement the mental health screening tool remaining 3 of 16 intake assessment sites by end of 2009-2010.
Train CSC Psychologists in suicide risk assessment. (see also Recommendation 1)
Develop a more effective approach to offender case management by focusing psychological and specialized assessment resources on the highest risk/needs offenders.
Amend Commissioner’s Directive 843, Prevention, Management and Response to Suicide and Self-Injuries, to include information about the use of psychological and psychiatric services in the assessment and intervention of offenders at risk for suicide or self-injury.
Implement corrective measures immediately following incidents at the local level while the investigative process gets underway.
Recommendation 4:
The Office of the Correctional Investigator recommended that CSC issue immediate direction to all staff regarding the legislated requirement to take into consideration each offender’s state of health and health care needs (including mental health) in all decisions affecting offenders, including decisions relating to institutional placements, transfers, administrative segregation and disciplinary matters. CSC decision-related documentation must provide evidence that the decision-maker considered the offender's physical and mental health care needs.
Amend the Commissioner’s Directive 709, Administrative Segregation to provide guidelines for Segregation Placement/Admission, Segregation Review Board Report Content, and Mental Health Assessment for Administrative Segregation.
Recommendation 6:
The Office of the Correctional Investigator recommended that CSC seek independent expertise – with a strong women-centred component – to review its policies on managing self-injuring inmates, and inmates displaying challenging behavioural issues. This review should focus on the appropriateness of placing those inmates on administrative segregation status.
Review CSC capacity to address the needs of women offenders with mental health and/or behavioural needs. (see also Recommendation 1)
Develop short and long-term strategies on service, support and accommodation needs for women offenders identified in this group. (see also Recommendation 1)
Enhance policy (CD 843, Prevention, Management and Response to Suicide and Self-Injuries) to include improved communication to front-line staff of offenders’ risk levels and observation status and best practices in the assessment of suicide and self-injury risk.
Develop and finalize standardized tools and guidelines for use in creating plans to address self‑harming behaviours for use by operational staff.
Recommendation 9:
The Office of the Correctional Investigator recommended that CSC amend its segregation policy to require that a psychological review of the inmate’s current mental health status, with a special emphasis on the evaluation of the risk for self-harm, be completed within 24 hours of the inmate’s placement in segregation.
Issue a follow-up reminder to reinforce the importance of performing and documenting physical and mental health assessments during these daily visits.
Recommendation 12:
The Office of the Correctional Investigator recommended that the Senior Deputy Commissioner review all of the complaints and the Service’s response to those complaints that were submitted by Ms. Smith during her period of federal incarceration, inclusive of the complaint submitted by Ms. Smith in September 2007 at Grand Valley Institution. A written response to these complaints should be issued and appropriate corrective action and policy clarification should be undertaken.
Revise the Commissioner’s Directive 081, Offender Complaints and Grievances.
Recommendation 13:
The Office of the Correctional Investigator recommended that all grievances related to the conditions of confinement or treatment in segregation be referred as a priority to the institutional head and be immediately addressed.
Revise grievance procedures and policies.

ANNEX D

Review Methodology

The methodology employed both qualitative and quantitative measures. Information used to facilitate our assessment of the implementation of these commitments was collected through:

  • Site Visits: Site visits were conducted at 20 federal institutions representing a mix of maximum and medium security levels from all five regions as well as treatment centers and women’s institutions.

  • Interviews: 220 interviews were conducted with institutional heads, correctional managers, correctional officers, managers of assessment and intervention, parole officers, psychologists and nurses. Discussions were also held with security intelligence officers, as well as staff responsible for the training coordination and the grievance process. Furthermore, staff from the Women Offender Sector, the Health Services Sector and the Office of Internal Disclosure were contacted to provide additional information.

  • Review of Documentation: Relevant documentation, including 98 Individual Discipline and Dissociation files35, 146 Case Management files36 and the electronic tracking systems used for Correctional Officer Patrols. Commissioner’s Directives, process documentation and/or procedure manuals were also reviewed and analyzed. In addition, three of the commitments were examined as part of a review of mental health at intake which was being conducted concurrently with this review.

  • Observation: Walk-arounds were conducted in segregation units to determine the process for offenders to submit complaints and grievances as well as a review of the suicide observation cells, blind spots and cameras. In addition to the observations in the segregation units, at some sites units with double bunks were visited to observe blind spots, suspension points and other infrastructure concerns.

ANNEX E

As part of the updated CD 843, Management of Inmate Self-Injurious and Suicidal Behaviour, three varying levels of suicide watch for offenders at risk for suicide or self-injury were introduced.

High suicide watch is an observation status for inmates who are imminent risks for suicidal or self-injurious behaviour, during which the inmate is under continuous direct observation. When an offender is placed on this level of observation, a correctional officer must be continually monitoring the offender by direct eye sight as observation via camera is not permitted. During interviews with wardens and correctional managers, we routinely heard of concerns with the logistics of conducting direct observation. Many sites stated that their infrastructure made it difficult to directly observe an offender as the windows in the suicide observation cells did not always provide a clear view of the offender’s actions.

Modified suicide watch is an observation status for offenders who are at an elevated risk for suicide or self-injury. This watch is similar to a high suicide watch, although in this case, offenders can be continuously supervised via closed circuit cameras and do not require direct observation.

Mental health monitoring is the lowest level of observation status and this typically occurs once the offender has been removed from either a high or modified suicide watch. Inmates placed on this level of monitoring will remain under the care of a mental health professional who will determine the frequency and intensity of mental health monitoring.

ANNEX F

Review of Practices in Place to Prevent/Respond to Death in Custody

Management Action Plan (MAP)

Commitment: Commitment No. 1
Amend the CD 709, Administrative Segregation, to provide guidelines for Segregation Placement/Admission, Segregation Review Board Report Content and Mental Health Assessment for Administrative Segregation.
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
CD 709 has been updated and promulgated. As per the March 2011 progress report on this commitment, Commissioner’s Directive - 709 “Administrative Segregation” was further reviewed and promulgation date was anticipated for June 2011. However, in light of additional legislation changes, a further review of the CD was required. The legislative changes are currently being incorporated in CD 709.

In addition, a Case Management Bulletin was issued on December 20, 2011 to remind decision makers of the requirement, as per section 87 of the Corrections and Conditional Release Act (CCRA), to take into consideration an offender’s state of health and health care needs prior to the transfer and administrative segregation of inmates.

These considerations are to be documented in all decisions, and a plan must be developed to address the issues, if any. This requirement will also be included in the newly revised version of Commissioner’s Directive 709 “Administrative Segregation”. The promulgation date is anticipated for June 2012.
Promulgation of CD 709   ACCOP June 2012
  A review of 10% of new segregation placements to ascertain that consideration of alternatives has been documented. This review will ascertain if there has been an improvement in the documentation of alternatives to segregation. RDCs March 2012
  A review of 10% of 60-day segregation reviews will be conducted to ascertain that consideration of alternatives have been documented. This review will verify that alternatives to segregation are being documented during regional reviews of segregation placements ACCOP June 2012

 

Commitment: Commitment No. 2
To revise the Commissioner’s Directive 081, Offender Complaints and Grievances
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
The Offender Complaint and Grievance Procedures Manual has been replaced with Guidelines 081-1, Offender Complaint and Grievance Process;

CD 081 and Guidelines 081-1 now include components of offender accountability and methods of Alternative Dispute Resolution as a means of resolving issues between staff and offenders;

CD 081 was shortened considerably and now more accurately reflects the process as outlined in the Corrections and Conditional Release Act and Regulations;

The CD is less process-oriented, and the Guidelines contain the more detailed aspects of the process;

Guidelines 081-1 are readily available on CSC’s policy site, which was not the case for the Manual.
Promulgation of revised CD 081 The new CD provides more guidance on release responsibilities. ACP COMPLETED
CD 081 was signed by the Commissioner on Nov. 28, 2011
The Commissioner addressed this area of non compliance at the CMT on November 2, 2011 and instructed regions to ensure that they developed strategies to ensure compliance Review of compliance In order to ensure that compliance rates have improved with respect to weekends, a review of 15 sites will be conducted. ACP & ACCOP January 2012
Commitment: Commitment No. 3
To revise grievance procedures and policies.
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
The Offender Complaint and Grievance Procedures Manual has been replaced with Guidelines 081-1, Offender Complaint and Grievance Process;

CD 081 and Guidelines 081-1 now include components of offender accountability and methods of Alternative Dispute Resolution as a means of resolving issues between staff and offenders;

CD 081 was shortened considerably and now more accurately reflects the process as outlined in the Corrections and Conditional Release Act and Regulations;

The CD is less process-oriented, and the Guidelines contain the more detailed aspects of the process;

Guidelines 081-1 are readily available on CSC’s policy site, which was not the case for the Manual.
Issuance of revised Offender Complaint and Grievance Procedures Manual. The new CD provides more guidance on release responsibilities. ACP COMPLETED
The Offender Complaint and Grievance Procedures Manual updates were approved by the Commissioner on Nov. 28, 2011
Following promulgation of the CD, a discussion will be held with CMT to ensure that the appropriate accountabilities and monitoring are in place to ensure compliance. Review of compliance In order to ensure that compliance rates have improved with respect to weekends, a review of 15 sites will be conducted. ACP & ACCOP January 2012

 

Commitment: Commitment No. 4
To revise the Commissioner’s Directive 560, Dynamic Security, to provide more direction with regard to responsibilities of both management and staff.
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
CD 560 has been reviewed to provide more direction with regard to responsibilities of both management and staff. The CD has been sent out for final consultation.

In addition to the changes to CD 560, forthcoming changes to Case Management CDs also reinforce roles and responsibilities for dynamic security. Also, an applied dynamic security training is currently being delivered to all CX in every region.
Promulgation of the CD 560 on Dynamic Security. The new CD provides more direction with regard to responsibilities of both management and staff. ACCOP February 2012
The Commissioner addressed this issue at the November 2, 2012 CMT to reinforce the requirement to provide leadership for dynamic security Site specific management action plans to be developed to address those sites where local management identified gaps in the level of dynamic security Given that the audit identified site specific issues relative to institutional culture, ongoing local and regional leadership will be required to ensure that the dynamic security requirements are addressed RDCs January 2012

 

Commitment: Commitment No. 5
Increase additional security patrols at all maximum, medium and multi-level institutions (excluding women’s institutions).
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
A Security Bulletin was issued June 2009 to provide direction on stand-to-counts. This direction as well as the requirement for an additional patrol has been included in CD 566-4, Inmate Counts and Security Patrols which has been sent out for final consultation.

The number of the patrols has already been increased with the implementation of the new direction on stand-to-counts in 2009. The Guard Tour system (security patrols) is being upgraded to help ensure compliance with policy.

Regional oversight programs have been put into place, including reviews of any late or missed patrols, the presence of an additional patrol, the timeliness of OSORs and spot audits.
Promulgation of CD 566-4 on Inmate Counts and Security Patrols The new CD will include the requirement to conduct a minimum of four formal counts each day, at least two of them being stand-to-counts, with at least one stand-to-count occurring between 18:00 and 24:00 ACCOP February 2012
This information is then discussed at CM, AWO, DW forums as well as monthly Regional Management Committees. Achievement of results in this area will serve as a baseline for the next phase of the program. Review of compliance In order to ensure that compliance rates have improved with respect to weekends, a review of January results for a minimum of 10 sites will be conducted. ACCOP February 2012

 

Commitment: Commitment No. 6
Complete a project to install high-resolution digital cameras in the cell range areas of all women’s institutions;
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
Three of five sites completed.   Cameras for the remaining two sites (EIFW and Joliette) are scheduled to be installed by the end of the current fiscal year (31 March 2012). These cameras are being installed as part of a larger national initiative to install high resolution digital evidentiary range cameras in all Medium and Multi level institutions. ACCS March 31, 2012

 

Commitment: Commitment No. 7
Implement corrective measures immediately following incidents at the local level while the investigative process gets underway.
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
  Inclusion of informal actions in Situation Reports and Investigation Action Follow When corrective measures are noted as required prior to investigation or during an investigation, these measures are reported in the Situation Reports and are subsequently referenced in investigation follow-up. RDC Ongoing

 

Commitment: Commitment No. 8
To provide mental health training to Correctional Officers
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
As noted in the report, training has been provided to a large majority of correctional officers and primary workers at the sites identified in the original recommendation and action plan. Health Services is currently cross referencing the SDS with HRMS to determine which employees at all TC, Women’s Institutions and Maximum Security Institutions have not received this training.

An additional Train-the-Trainer session was completed in November 2011 to increase regional capacity to deliver this training. An additional session will be delivered in March 2012 in French, if required by the Regions.
(a) AC HS will identify CX and Primary Workers currently working in TC, Women’s Institutions, and Maximum Security Institutions who have not received the training and provide this information to the regions. Identification of those staff who have not received the training will facilitate the development of regional training plans ACHS January 31, 2012
Health Services Sector will continue to monitor compliance and provide biannual reports to the Regions. (b) RDCs, in collaboration with RD HS, will develop regional training plans to address non-compliance identified in 1 (a).   RDC
RD HS
February 28, 2012
  (c) Training identified in regional training plans will be completed. Compliance in all targeted institutions will reach and be maintained at 90% or better. RDC
RD HS
November 2012

 

Commitment: Commitment No. 9
To provide additional training for CSC Psychologists in suicide risk assessment
Management Response / Position: checked-box Accepted Accepted in part Rejected
Commitment(s) Deliverable(s) Approach Accountability Timeline for Implementation
What action(s) has / will be taken to address this recommendation? Expected deliverable(s) / indicator(s) to demonstrate the completion of the action(s) How does this approach address the recommendation? Who is responsible for implementing this action(s)? When will action(s) be completed to fully address the recommendation?
A consultant to conduct the needs analysis has been engaged and key information interviews are underway. (a) Health Services is conducting a training needs analysis for front-line health professionals, including mental health professionals Identifying the learning needs of front-line health professionals is key to ensuring the Service can prioritize and deliver the necessary training to its health professionals ACHS May 2012
  (b) Identify priority professional development and training initiatives and develop workplans. Priority training areas for health professionals, including psychologists, will be identified. ACHS Work plans for identified priority training will be finalized by October 2012

1 OCI Backgrounder – A Preventable Death
2 A Preventable Death – Preface
3 CSC Commissioner’s letter to the OCI, Mr. Howard Sapers dated February 10, 2009.
4 Recommendation 4
5 CD 709, Annex B, 2
6 ibid
7 Recommendation 9
8 Recommendation 12
9 Recommendation 13
10 CD 081, 43
11 Recommendation 1
12 Recommendation 1
13 Recommendation 1
14 Recommendation 2
15 Recommendation 2
16 Recommendation 2
17 Recommendation 2
18 Recommendation 4
19 Recommendation 4
20 Short and Long Term Accommodation Strategy for Women Offenders (CMT Feb 209)
21 Recommendation 1
22 Recommendation 2
23 Recommendation 1
24 Recommendation 1
25 Recommendation 1
26 Recommendation 2
27 Recommendation 2
28 2010-2011 HSPMP p. 25
29 COMHISS: An Update – Slide Deck by Mental Health, Health Services, March 2011
30 Recommendation 2
31 Recommendation 2
32 Recommendation 8
33 Policy Bulletin 333, CD 843
34 Recommendation 8
35 Discipline and Dissociation is one of the 13 file banks that CSC maintains on each offender. This bank is used to document disciplinary measures taken against an offender.
36 Case Management is one of the 13 file banks that CSC maintains on each offender. This file bank provides documentation to assist in the case management process for the offender.