Annual Report on Deaths in Custody 2013/2014

February 27, 2015

Executive Summary

The Correctional Service of Canada (CSC) recognizes that even one non-natural inmate death is too many and, as an organization, continuously works to enhance its prevention and intervention strategies to respond to the issue of non-natural deaths in custody, with a particular focus on the prevention of inmate suicide, through the integration of best practices, collaborative partnerships, and evidence-based interventions. This report contributes to these efforts by providing information on deaths in custody to enhance accountability and transparency, as well as providing a mechanism for identifying areas that may require increased attention over time or areas in which efforts to decrease deaths in custody are proving effective.

Over the five fiscal years from 2009/2010 to 2013/2014, an average of 51 deaths in custody occurred per year. Natural deaths accounted for half or more of all deaths, while suicides were the most common type of non-natural death. Deaths occurring in the most recent fiscal year were examined more closely, with the overall rate of deaths in custody in 2013/2014 being found to be 3.13 per 1000 offenders. Characteristics of offenders who died in custody varied considerably but offenders were likely to be male, White or Aboriginal, and 55 years of age or older. Most commonly, deaths from natural causes were related to the cardiovascular system or cancer; offenders who died of natural causes tended to be older and to be serving longer sentences. Offenders who died by suicide most frequently did so by hanging, ligature, or asphyxiation, and many were Aboriginal, younger, and placed at a maximum security institution.

CSC is committed to learning from these deaths in custody and to preventing future non-natural deaths. The investigations and mortality reviews conducted following deaths in custody allow for the identification of areas of need, and CSC works proactively to implement recommendations and consider policy and practice in light of findings, thereby contributing to the safety and well-being of offenders as well as staff and the public. Areas of opportunity have been identified and are being addressed relating to segregation, inmate monitoring, physical infrastructure, and communication. In addition, initiatives specific to suicide prevention and intervention have been undertaken in the areas of offender screening; assessment, treatment, and monitoring; training for staff and education for offenders; and, policy and oversight.

Introduction

As per Commissioner's Directive (CD) 041, Incident Investigations, CSC's Incident Investigation Branch investigates all non-natural deaths and CSC's Health Services Sector conducts a Mortality Review for all natural deaths, except in the rare instances where the circumstances warrant further investigation. Investigations of deaths in custody are intended to ensure responsibility, accountability, and transparency, and to enhance the ability of the CSC to prevent or better respond to similar incidents in the future. Where appropriate, investigation and review findings influence organizational policy and practices, thereby contributing to the safety and well-being of the public, staff, and offenders.

CSC recognizes that even one non-natural inmate death is too many. As an organization, CSC continuously works to enhance its prevention and intervention strategies to respond to the issue of non-natural deaths in custody, with a particular focus on the prevention of inmate suicide, through the integration of best practices, collaborative partnerships, and evidence-based interventions. This report contributes to these efforts by providing information on deaths in custody to enhance accountability and transparency, as well as providing a mechanism for identifying areas that may require increased attention over time or areas in which efforts to decrease deaths in custody are proving effective.

Data Source

All high-level data were obtained from CSC's automated offender data system, the Offender Management System, and validated using records from Incident Investigation Branch and Health Services. Additional information was obtained directly from Incident Investigation Branch and Health Services' records. Data were accurate as of January 27, 2015; revisions may occur in subsequent versions in order to reflect newly-completed investigations or mortality reviews.

Deaths in Custody: Causes and Regional Distribution

Natural deaths were the most common type of death in custody across the last five fiscal years, accounting for about 40% of all deaths. Suicides were the second most common type of death, with accidents (including overdoses), homicides, and other causes of death relatively uncommon.

Table 1
Number of Deaths in Custody by Cause of Death over a 5-year Period
Cause of Death FY 2009/ 2010 FY 2010/ 2011 FY 2011/ 2012 FY 2012/ 2013 FY 2013/ 2014
Natural 30 35 35 32 32
Non-natural
Suicide 10 4 8 14 9
Homicide 2 5 3 1 2
AccidentFootnote a 5 3 5 2 2
Staff intervention 0 1 0 0 0
Undetermined Cause 2 2 2 7 3
All causes 49 50 53 56 48

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.
a Accidents include both overdoses and other accidents. There was one non-overdose accident in 2009/2010 and one in 2011/2012.

In 2013/2014, there was variability across the regions in the number of deaths occurring in custody. The highest number occurred in the Prairies region, while the lowest occurred in the Atlantic region, which is consistent with this region's smaller population.

Table 2
Regional Breakdown of Number of Deaths in Custody by Cause of Death, Fiscal Year 2013/2014
Cause of Death Atlantic Quebec Ontario Prairies Pacific
Natural 3 8 6 8 7
Non-natural 2 2 2 5 2
Suicide 2 1 0 4 2
Accident 0 1 1 0 0
Homicide 0 0 1 1 0
Undetermined Cause 0 1 1 1 0
All causes 5 11 9 14 9

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Profiles of Offenders Who Died in Custody

The overall rate of deaths in custody in 2013/2014 was 3.13 per 1000 offenders. Offenders who died in custody varied considerably, but were generally more likely to be male, White or Aboriginal, and 55 years of age or older. They were often serving indeterminate sentences or sentences of four to six years.

Deaths from Natural Causes

Certain characteristics differed by type of death. Not surprisingly, rates of death from natural causes were considerably higher among older offenders, those serving longer sentences, and those who had already served five years or more of their sentence. Those who died of natural causes were also, proportionately, likely to be at minimum or medium security, which may again reflect a longer period of time incarcerated prior to the death. Finally, they were more likely to be White.

Deaths by Suicide

Offenders who died by suicide were more likely to be Aboriginal and tended to be younger, typically 34 or under. They were also more often placed at a maximum security institution. Those in this group were frequently serving either short or indeterminate sentences, with mid-range sentences being less common.

Table 3
Characteristics of Offenders who Died in Custody by Cause of Death, Fiscal Year 2013/2014
Characteristic Natural Causes Non-Natural Causes Undetermined
Cause
Rate per 1000 CSC
Pop.
Suicide Accident Homicide
Gender
Male 31 9 2 2 3 3.20 14,696
Female 1 0 0 0 0 1.58 631
Ethnicity
White 23 2 1 1 3 3.40 8,817
Aboriginal 6 6 1 0 0 3.67 3,542
Black 1 1 0 1 0 2.13 1,406
Other 2 0 0 0 0 1.28 1,562
Age
18-24 1 2 0 1 0 2.25 1,780
25-34 0 6 2 1 1 2.11 4,747
35-44 3 0 0 0 1 1.10 3,631
45-54 7 1 0 0 1 2.95 3,048
55-64 11 0 0 0 0 7.24 1,520
65-74 7 0 0 0 0 13.67 512
75 or older 3 0 0 0 0 33.71 89
Offender security levelFootnote a
Minimum 8 1 0 0 0 2.91 3,089
Medium 20 2 2 1 2 2.93 9,201
Maximum 4 4 0 0 1 4.46 2,017
Unknown/undetermined 0 2 0 1 0 2.93 1,025
Sentence length
2 – 4 years 3 4 1 0 2 1.35 7,418
4 – 6 years 5 1 0 1 0 6.24 1,121
6 – 10 years 3 0 1 0 0 1.94 2,060
More than 10 years 2 1 0 0 1 3.50 1,142
Indeterminate 19 3 0 1 0 6.41 3,586
Time served
Less than 3 months 0 2 0 1 0 2.14 1,399
3 months – 1 year 5 2 0 0 0 2.08 3,369
1 year – 5 years 8 3 2 1 3 2.52 6,736
More than 5 years 19 2 0 0 0 5.49 3,823
Index offence
Homicide or related 19 2 0 1 0 5.94 3,705
Sexual 6 3 0 0 0 4.32 2,083
Assault 1 1 0 0 1 1.73 1,732
Robbery 3 3 1 1 0 3.59 2,226
Other violent 0 0 0 0 0 - 1,061
Property 0 0 1 0 0 0.94 1,063
Drug 0 0 0 0 0 - 2,184
Other non-violent 3 0 0 0 2 4.34 1,153
Total 32 9 2 2 3 3.13 15,327

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded. CSC population numbers reflect the 2013/2014 in-custody snapshot provided by Performance Measurement.
a Offender security level was used instead of facility security level for two reasons. First, the offender's facility at death was not always apparent (e.g., many died while at outside hospital). Second, in many cases, the year-end in-custody snapshot identified offenders' location as multi-level due to their being at a clustered site.

Further Examination of Causes of Death

In order to better understand the deaths by natural causes, suicide, overdose, and homicide, detailed examinations of the causes and methods of these deaths were conducted.

Deaths from Natural Causes

There was considerable year over year variation in the most commonly-represented causes of natural death, but overall, deaths related to cancer and to the cardiovascular system were the most common, together representing 55% of all natural cause deaths. Respiratory-related causes, liver-related causes, infections and other natural causes of death each represented less than fifteen percent of deaths.

Table 4
Number of Deaths by Natural Causes by Illness or Bodily System over a 5-year Period
Cause of Natural Death FY 2009/2010 FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014
Cancer 10 9 15 14 13
Infection 3 3 0 2 3
Cardiovascular- related 8 11 8 8 5
Respiratory-related 6 2 4 3 3
Liver-related 2 6 4 3 3
Other 1 4 4 2 5
All natural deaths 30 35 35 32 32

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded. Cardiovascular-related, respiratory-related, and liver-related deaths do not include cancers involving these body systems.

Deaths by Suicide

By far the most common method of death by suicide, across all five fiscal years, was via hanging, ligature, and/or asphyxiation.

Table 5
Method of Suicide over a 5-year Period
Method of Suicide FY 2009/2010 FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014
Hanging / ligature / asphyxiation 9 4 8 12 8
Other 1 0 0 2 1
All deaths by suicide 10 4 8 14 9

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Deaths by Overdose

Where fatal overdoses occurred, the method of overdose was more frequently illegal substances than prescribed medications.

Table 6
Method of Overdose over a 5-year Period
Method of Overdose FY 2009/2010 FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014
Prescription drugs
Drugs prescribed to offender 0 0 0 1 0
Other 0 1 1 0 0
Illegal substances 4 2 3 1 2
All deaths by overdose 4 3 4 2 2

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Deaths by Homicide

In cases of death by homicide, the most frequent method of homicide was a cutting instrument, often a homemade instrument used for cutting or stabbing. Blunt force trauma, asphyxiation or strangulation, and other methods of homicide each occurred for one or two offenders.

Table 7
Method of Homicide over a 5-year Period
Method of Homicide FY 2009/2010 FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014
Cutting instrument 1 2 3 1 1
Blunt force trauma 1 0 0 0 1
Asphyxiation or strangulation 0 1 0 0 0
Other 0 2 0 0 0
All causes 2 5 3 1 2

Note. Results are accurate as known on January 27, 2015. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Responses

CSC is committed to preventing non-natural deaths in custody. The investigations and mortality reviews conducted following deaths in custody allow for the identification of areas of need, and CSC works proactively to implement recommendations and consider policy and practice in light of findings, thereby contributing to the safety and well-being of offenders as well as staff and the public.

Non-Natural Deaths

As a result of investigations into non-natural deaths, a number of areas of opportunity have been identified, including segregation, inmate monitoring, physical infrastructure, and communication. CSC has implemented, or is in the process of implementing, a range of actions to address these areas. In addition, a comprehensive approach specific to suicide prevention and intervention has also been implemented.

Segregation

CSC is working to address the issue of offenders with mental health concerns residing in administrative segregation. In an effort to alleviate the use of segregation, screening and monitoring tools have been developed and/or updated. In addition, a National Population Management Committee, including a sub-committee (the National Long-Term Segregation Review Committee) has been introduced to provide national monitoring on the use of administrative segregation. All regions are committed to working in collaboration with their Regional Segregation Oversight Manager to ensure proper reviews of cases and to pursue a resolution to long-term segregation cases.

Monitoring of Inmates

CSC is pursuing a greater level of consistency in monitoring inmates. Key actions undertaken to meet this commitment include an additional stand-to inmate count (introduced at all institutions) as well as an additional security patrol at all maximum, medium, and multi-level men's institutions. In all regions, rounds and counts performance results are reported to National Headquarters quarterly. As well, CSC is exploring the use of alternative systems and technologies, including proximity card technology, to identify, track, and record the presence of Correctional Officers conducting security patrols and inmate counts and to increase staff ability to verify offenders' well-being. As an additional tool, CSC continues to install cameras throughout its institutions.

Dynamic security – that is, ensuring security through regular and consistent interaction with offenders, timely analysis of information, and sharing through observations and communication – continues to be a priority for CSC. The organization has enhanced its national training by adding a new module in the Correctional Officer Training Program to place additional emphasis on the importance of dynamic security. Dynamic Security Refresher Training was also developed and delivered to Correctional Managers and Correctional Officers.

Physical Infrastructure

CSC has identified the expansion of accommodation space in existing institutions and modernization of physical infrastructure in order to provide the most effective surveillance and interventions to offenders as a priority. As part of this focus, infrastructure vulnerabilities, and more specifically, potential points of suspension and other cell vulnerabilities, are systematically and consistently identified, inspected, repaired, replaced, repositioned, or removed. In fact, staff complete a National Cell Condition Checklist at a minimum of once per month to identify blind spots and potential points of suspension. The goal is to ensure that frontline staff are aware of any vulnerabilities before placing, in a given cell, an offender who may have a tendency towards self-injurious or suicidal behaviour.

In addition, in order to maintain the security of its institutions and the safety of staff and inmates, CSC has also explored and/or implemented new technologies (e.g., life-sign monitoring, ion scan drug detector units at the principal entrances) or widened the use of existing technologies (e.g., cameras).

Communication

Results of investigations relating to non-natural deaths in custody continue to be communicated and discussed in order to allow for the identification of patterns or further areas of opportunity. The Incident Investigation Branch presents its investigations into deaths in custody, according to classification of death, at National Investigations Meetings and has created bi-monthly incident-specific discussion guides to provide context and analysis to the incidents being examined. These discussion guides are distributed to Assistant Commissioners and Regional Deputy Commissioners to be shared with their management teams in order to disseminate up-to-date analysis on deaths in custody and contribute to ongoing organizational learning.

Deaths by Suicide

Numerous initiatives specific to preventing deaths by suicide have also been undertaken. The comprehensive approach implemented to decrease the number of offender deaths by suicide includes offender screening; assessment, treatment, and monitoring; training for staff and education for offenders; and, policy and oversight mechanisms.

Screening

To identify inmates at elevated risk for suicide, CSC has implemented screening processes at intake and throughout an inmate's sentence. At intake, CSC uses the following four-pronged screening approach: (1) screening within 24 hours of initial reception at a federal institution for suicide risk, usually by a correctional officer; (2) health screening within 24 hours by nursing staff, including screening for suicide risk; (3) comprehensive nursing assessment within the first 14 days following admission, including screening for suicide risk; and (4) comprehensive computerized mental health screening within the first 14 days following admission to identify inmates displaying symptoms typically associated with psychological distress, including those at elevated risk for suicide (Computerized Mental Health Intake Screening System; CoMHISS).

In addition to this initial four-pronged approach to screening, CSC's policy requires formal screening for suicide risk when there are significant changes to an inmate's status, such as on transfer to a new institution, upon admission to segregation, or other occasions when there is reason to believe the inmate is at increased risk for suicide. This ongoing screening is in response to CSC's acknowledgement that, in addition to elevated risk during adjustment to federal incarceration, any situation representing a change from the norm can increase the risk of suicide.

Assessment, Treatment, and Monitoring

Inmates identified as at risk for suicide are referred to a qualified mental health professional for an in-depth assessment of suicide risk. During this assessment, the level of suicide risk and appropriate intensity of intervention, including level of monitoring and follow-up counseling required, is determined. Intervention may be provided within a mainstream institution or can include in-patient treatment at a Regional Treatment Centre (RTC).

To ensure appropriate communication of inmate suicide among staff, CSC has implemented an Alert system in the Offender Management System (OMS; CSC's electronic database of offender files) to allow for communication regarding current and historical risk of suicide. Increasing communication among staff further supports the interdisciplinary approach which is key to the management of inmates exhibiting suicidal behaviours.

Staff Training and Inmate Education

Staff training is designed to increase awareness and specific skill sets to identify and intervene with inmates at risk for suicide and contributes to the reduction and prevention of these behaviours. CSC has provided training on suicide prevention since the 1980s. Suicide/Self-Injury Intervention training (Initial and Refresher Training) has been part of the National Training Standards since April 1, 2005. Initial Suicide/Self-Injury Intervention Training targets all staff through the Correctional Training Program (CTP), the Parole Officer Induction Training (POIT), or the New Employee Orientation Program (NEOP). The CTP and POIT suicide and self-injury training includes online material, in-class knowledge transfer, and application to concrete scenarios. The Suicide/Self-Injury Prevention Refresher training targets all staff that have regular interaction with offenders. This training has recently been revised to include a computer-based training component which is completed every year and an in-class scenario-based session completed every two years to enhance practical skills.

In addition, suicide-related educational opportunities are available to offenders. The Inmate Suicide Awareness Prevention Workshop (ISAPW) is an optional, voluntary program for offenders with the goal of raising awareness about suicide and its prevention.

Policy and Oversight Mechanisms

For over 20 years, CSC has had a policy in place regarding the management of suicidal behaviour. This policy is reviewed and revised based on lessons learned and best practices. Significant revisions were made to Commissioner's Directive 843, Management of Inmate Self-Injurious and Suicidal Behaviour, and were promulgated in July 2011. Based on best practice literature, the current version of Commissioner's Directive 843 has incorporated standardized monitoring and communication protocols for offenders exhibiting suicidal behaviours.

Oversight mechanisms have also been put into place. In April 2010, CSC established Regional Suicide/Self-Injury Prevention Management Committees (RSPMCs) to assist institutions in the management of self-injurious and suicidal behaviour. The RSPMCs functioned as management committees, meeting monthly to review all incidents of self-injury, focusing on repeat self-injurious behaviour, flagging items of concern, and consulting/engaging institutions to offer support and advice in the management and treatment of suicidal and self-injurious offenders, as required. The RSPMCs served to assist and support institutions in meeting the unique needs of offenders exhibiting self-injurious or suicidal behaviour, thus contributing to an effective continuum of care.

In October 2013, CSC expanded the mandate of the RSPMC, which has been renamed the Regional Complex Mental Health Committees (RCMHC), to support the provision of services for all offenders with complex mental health needs, including suicide and self-injury. A National Complex Mental Health Committee (NCMHC) has also been established and national meetings occur between regional and national counterparts. This increased sharing of information on the mental health needs of the most severely mentally ill, including offenders with needs related to suicide, and their treatment approaches and progress facilitates the organization's ability to assist in the planning for offenders with the most acute needs including accessing additional treatment and/or clinical support, as needed.

Lessons learned

Learning from situations, circumstances and actions that resulted in the death of a human being while in custody will help CSC prevent the future occurrence of such tragic situations. This report adds to the existing literature, research and other reports, such as the Independent Review Committee Report into Deaths in Custody (2010-2011), in describing best practices as well as areas that require strengthening in order to fulfill CSC's mission.

CSC's Corporate Risk Profile outlines organizational resources consisting of work force, tools, and infrastructure that reduce to a manageable level the risk that is inherent in correctional work. It also delineates mitigation measures CSC has put in place to deal with residual risks of significance. As in hospitals, airlines, and nuclear industries, where accidents or incidents often have devastating, life-threatening or even deadly outcomes, CSC's objective for non-natural deaths for people in its care and custody is zero. This objective is in accordance with both social and health standards, and the principles that sustain high reliability organizations. In that regard, an opportunity exists for CSC to adopt the concept of Hierarchy of Effectiveness, moving away from lesser effective measures such as verbal or written communications, to effectively proven measures such as standardization, automation, and forced functions and constraints.

This report and recent statistics reveal a relatively stable number of both natural and non-natural deaths in custody, suggesting that CSC has effective methods, procedures and resources in place to manage situations of high mortality risk. It also suggests that opportunities exist to improve policies, procedures, and standards in order to prevent future occurrences. In that regard, promising work has already begun to implement the five pillars for mental health care, consisting of timely assessment, effective management, appropriate intervention, relevant staff training and rigorous oversight. As well, systematic review and analysis conducted as part of Boards of Investigation and the National Investigation Meetings allows for the identification of pre-incident indicators, contributing risk factors, precipitating events, management, and response from which there is much to understand, learn and communicate effectively to front line staff. General and specialized staff training, including on-the-job mentoring, coaching and support are being prioritized to help CSC maintain a proactive, rather than reactive, mode of operations. Finally, fostering, facilitating and maintaining communications between units of various and complementary accountabilities is key. Correctional programs, security, general operations and health services must work with a clear understanding of each others' roles. These actions, activities, and measures will strengthen CSC as a learning organization.

Next Steps

Over the coming months and years, CSC will continue with the implementation of its continuum-of-care model as well as its mental health strategy. It will undertake a comprehensive review of its segregation framework, informed by research, analysis, and consultation. It will strengthen communication lines among various institutional operating units as well as across its management structure. It will use the management tools at its disposal such as investigations, evaluations, audits and compliance reporting to develop a comprehensive approach to monitoring and intervention.

Conclusions

CSC strives to prevent non-natural deaths in custody and prioritizes learning from any deaths that occur. This report, to be produced annually, will contribute to the organization's ability to quickly identify trends, further areas for opportunity, and identify initiatives leading to reducing deaths in custody. This report also aims to provide clear, transparent, and open communication regarding both natural and non-natural deaths, thereby facilitating collaboration with stakeholders and experts who may contribute to the important goal of preventing these deaths.