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Updated Progress Report on the August 14, 2009 Correctional Service of Canada (CSC) Response to the Office of the Correctional Investigator's Deaths in Custody Study, the Correctional Investigator's Report: A Preventable Death and the Correctional Service of Canada's (CSC) National Board of Investigation into the Death of an Offender at Grand Valley Institution for Women - September 8, 2010

The following provides an update to progress made in support of the August 14, 2009 Correctional Service of Canada (CSC) Response to the Office of the Correctional Investigator's Deaths in Custody Study, the Correctional Investigator's Report: A Preventable Death and the CSC National Board of Investigation into the Death of an Offender at Grand Valley Institution for Women.

Maintaining a safe operating environment is essential to effective corrections and ensuring the Correctional Service of Canada's contribution to public safety. By providing for the safety and security of each of its 57 penitentiaries and 16 community correctional centres, CSC offers offenders a safe environment where they can work to address the factors that contributed to their criminal behaviour, and become law-abiding citizens.

CSC promotes healthy living and provides essential health care, including mental health treatment to help offenders cope with incarceration and focus on their program participation and rehabilitation efforts. Despite our many efforts to safeguard offender well-being, when a death in custody does occur it is among the most disturbing of events that can happen in a correctional environment and is surely devastating to the offender’s family, as well as to fellow inmates and CSC staff members.

During the past two years, the organization has strengthened its efforts to prevent deaths in custody.

Working in collaboration with stakeholders and partners, including the Office of the Correctional Investigator (OCI), we have introduced a broad number of initiatives specifically  aimed at preventing violence within our institutions and addressing offenders’ mental health issues before they can lead to self-harm, suicide, or violence towards others.

The majority of these initiatives are now in place and we are firmly committed to the reduction of all deaths in custody due to unnatural causes. The organization also recognizes that offenders with complex mental health needs will continue to enter our institutions, and we will therefore continue to search for new solutions as we improve upon the effectiveness of our current initiatives and treatment methods.

As part of these measures, CSC established an independent review committee to meet each year and assess CSC's actions and responses to any deaths in custody due to unnatural causes. Members of the Independent Review Committee will review all non-natural deaths that occurred in CSC institutions during the 2009-2010 fiscal year and the appropriateness and adequacy of the corrective measures initiated by CSC. We anticipate that the committee will share their findings and recommendations with our executive committee by the end of November 2010 and we intend to share a final report with the OCI by mid-January 2011.

A verification team was also put in place and was mandated to visit a number of institutions across the country to determine whether CSC has fulfilled the commitments made last year as part of its response to the issue of deaths in custody. The team was also asked to independently assess the impact of various operational initiatives. The visits have now been completed and members were reportedly impressed by the quality of work and efforts CSC staff dedicate towards managing offenders who come under our supervision and care.  They provided important insight into some of the challenges CSC is facing as it tries to balance the security requirements of a correctional institution with providing meaningful rehabilitation opportunities and interventions to address offenders’ physical and mental healthcare.

Recently, we received feedback from two independent experts who conducted an external review of CSC's use of administrative segregation in the context of this issue. As part of their review, these experts focussed on offenders presently housed in long-term segregation and offenders accommodated in segregation with mental health concerns. The experts also presented strategies for reducing the number of long-term segregation cases and the placement of offenders with mental health concerns in segregation. We have shared these reports with the OCI and are now reviewing them to determine how we may integrate the recommendations into our practices.

CSC has also commissioned an external review of its operations and policies in the area of inmate grievances in order to ensure fair and expeditious resolution of offenders’ complaints and grievances.  The review is completed and the final report, along with CSC’s response to recommendations, will be discussed at a senior management meeting in winter 2010-2011.

Furthermore, CSC has strengthened its information-sharing practices.  For example, provinces are now also reviewing the circumstances regarding any death in custody and we are working with them to further strengthen our relationship. This will help us to learn from their experience and expertise and to make improvements in our capacity to prevent, anticipate and respond to life-threatening incidents.

In the same vein, an initial meeting was held with the provincial representatives from the Coroner’s offices and a strategy developed to increase our sharing of documents to permit an annual review of our efforts to prevent deaths in custody.   A follow-up meeting took place in August of this year and discussions focussed on ways to improve our performance and learn from each other’s experiences.

These steps not only measure our progress, they allow us to build on and demonstrate the diligence regularly demonstrated by our staff.

Each day our front-line staff work together to ensure important information related to offenders’ physical and mental well-being is gathered, shared, and acted upon. For example, health services staff administer an enhanced mental health screening tool for all incoming offenders to identify any mental health concerns and make referrals for treatment where appropriate.  More than 3,400 offenders were screened using this tool during the 2009-2010 fiscal year alone.

Health care staff also make contact with offenders housed in administrative segregation on a daily basis to ensure that any deterioration in an offender's well-being is addressed.  Psychologists are brought in when needed and a formal assessment is completed after 25 days.

In addition, front-line staff members provide dynamic security by interacting with offenders on a continual basis. They take note of changes to an offender's routine or behaviour and share with colleagues any signs that an offender's physical or mental health may be at risk. When necessary, we take appropriate measures such as increased monitoring and referrals to specialized staff. In cases where an offender's mental health is deteriorating, the offender may be referred to a psychologist. In other cases, they may be transferred to one of CSC’s regional psychiatric or treatment centres.

We recognize the need to focus on monitoring and measuring our progress, and we must evaluate our actions to ensure that our strategies have the desired results and lead to safer, healthier environments for offenders, staff and volunteers. We have developed a performance management framework that includes a series of performance indicators such as the incidence of self-injury, suicide, homicide, and overdoses. To ensure increased accountability on this important issue, we will measure actions such as the timeliness of the mental health screening, the implementation of training initiatives and other important health and safety measures. These performance indicators will form the basis of ongoing quarterly assessments and will help us identify where more actions or focus are needed.

As part of our efforts to reduce deaths in custody, we will continue to review and improve upon our processes. We will continue and expand our work with our partners including mental health experts, community stakeholders and provincial and territorial heads of corrections and Coroner’s offices to share best practices and lessons learned.

We will continue to share quarterly Deaths in Custody – Significant Findings documents with the OCI and our staff members. We will routinely share findings from investigations that are convened whenever an offender dies under our supervision due to unnatural causes, and we will strongly reinforce and communicate the importance of preservation of life across the organization to all levels of staff.

We have identified deaths in custody in our Report on Plans and Priorities and we will report on our progress and results in our annual Departmental Performance Report.  In addition to our formal reports to Parliament, we will periodically report on our progress to the Canadian public through our website.

Canadians expect that CSC will maintain safe and secure institutions that assist offenders in their efforts to make positive life changes for their own betterment and for the sake of improved public safety. Every day, front-line staff including correctional officers, program officers, parole officers, nurses and psychologists work collaboratively to identify mental health concerns that may preclude this positive progress, and take the necessary steps to effectively intervene and preserve life in our institutions. We expect nothing less than our best effort from one another and we are committed in our resolve to strengthen our capacity, expand our expertise, learn from our experiences, and contribute to safer communities as we help the offenders in our care work towards a healthier life as a law-abiding citizen.

 

Recommendation Key Actions/Commitments Update

Recommendation 1: (Supported)

The Office of the Correctional Investigator (OCI) 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.

CSC has categorized the recommendations as follows:

  • 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, staffing and resourcing
  • The Women Offender Sector’s role and mandate
  • Values, ethics and disclosure

*all 15 recommendations are contained in these seven categories.

ADMINISTRATIVE SEGREGATION  
  • review capacity to address the needs of women offenders with mental health and behavioural needs

Between August 2008 and March 2009, 45 beds were added to CSC women’s institutions (three sites) resulting in a significant increase in capacity for women offenders.

In February 2009, a proposed long-term accommodation strategy for women was presented to, and supported by CSC’s Executive Committee (ExCom). CSC’s overall infrastructure will be completed by March 31, 2011. It will integrate elements of the ExCom-approved strategy for women.

  • develop short- and long-term strategies on service, support and accommodation needs for women offenders identified in this group
  • pursue these through regular Treasury Board processes
  • expand the inter-disciplinary team approach to now include more precisely defined roles for Health Care and Psychology in the review process prior to, as well as during, segregation placements

The Commissioner’s Directive (CD) 709 on Administrative Segregation was promulgated on November 09, 2007 and paragraphs 68 to 71, as well as the Annex E were added to address this issue.

  • 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

All five secure interview rooms have been operational since August 2009.

  • undertake an operational examination of long-term segregation using a representative sampling methodology and an external review process

A committee with terms of reference was established in December 2009.  It has met and examined 25 case samples and will continue to convene on a regular basis.

In addition, CSC established in October 2009, an External Review Board composed of two independent external consultants. They have completed their work and it will be presented to ExCom in winter 2010-11 for review and decision on next steps.

  INSTITUTIONAL TRANSFERS  
  • revise CD1 710-2, Transfer of Offenders

The revised policy became official on February 10, 2010.  In particular, it cross references CD 710-2 Transfer of Offenders and CD 843 Prevention, Management and Response to Suicide and Self Injuries.

  • issue a Case Management Bulletin in the interim to remind staff of the paragraphs in the CD on prevention, management and response to suicide and self-injuries

A Case Management Bulletin was issued on May 9, 2008 to remind  staff of the three paragraphs: 1) an inmate considered imminently suicidal or self injurious should not  be transferred other than to a treatment facility; 2) it may be necessary to transfer a minimum-security inmate to a higher security institution for suicide watch or other interventions and 3 the psychologist from the sending institution should advise the psychologist at the receiving institution and provide written notification of inmate’s suicidal state.

  • add 45 beds to CSC women’s institutions to address the increase in federally-sentenced women offenders (Fraser Valley Institution in British Columbia: eight beds; Grand Valley Institution for Women in Ontario: 30 beds; and Nova Institution for Women in Nova Scotia: seven beds).

The 45 beds have been added to three sites as per below:
Fraser Valley Institution, British Columbia, August 2008
Nova Institution, Nova Scotia, February 2009
Grand Valley Institution, Ontario, March 2009

Recommendation 1 (continued) SECURITY PRACTICES AND USE OF FORCE INTERVENTIONS  
  • implement new procedures to strengthen accountability in security practices and use of force interventions

The Policy Bulletin (284) and CD
567-1 were promulgated on April 1, 2009.  A significant portion of the CD was changed and some of the more important changes are related to the definition of what constitutes “Use of Force”, the ability of managers to develop an “intervention plan” using line staff to manage a situation and the incorporation of the content of the Security Bulletin on Use of Force on Pregnant Inmates.

Furthermore, another Policy Bulletin was issued on May 19, 2010 to provide interim direction as CD 843 and 844 are finalized regarding the use of the Pinel Restraint System in response to self-injury.

  • reinforce and communicate the importance of preservation of life across the organization to all levels of staff

In May 2008, a message was sent to all CSC staff reinforcing the continuing need for vigilance in preventing inmate suicide.

FThe Significant Findings from National Investigations on Inmate Suicides Report was distributed to all sites.

  • discuss at the Executive Development Symposium for all senior leaders of the organization, at all regional management committee meetings and major union meetings at all sites across the country

Next Executive Development Symposium is September 2010.
All regions confirm that the issue of preservation of life is discussed regularly at Regional Management Committee meetings and at key union meetings.

  • issue a Security Bulletin to clarify “immediate intervention” in response to suicidal and self-injurious offenders

The following four Security Bulletins were written:

  • 2008.04.23: "REMINDER: CD 843 Prevention, Management and Response to Suicide and Self-Injuries".
  • 2009.08.20: "Self-Harm Cases". 
  •  2009.10.29: "Head Banging"
  •  2010.05.19:  “CD 843 –   Prevention, Management and Response to Suicide and Self-Injuries, CD 844 – Use of Restraint Equipment for Health Purposes, CD 567-1 – "Use of Force” (Policy Bulletin 309).
  • revise the CD 567-1, Use of Force

CD on Use of Force (CD 567-1) was promulgated April 1, 2009.

Recommendation 1 (continued) SERVICE AND SUPPORT FOR WOMEN OFFENDERS WITH SIGNIFICANT MENTAL HEALTH AND/OR BEHAVIOURAL NEEDS

 

  • assess 14 women offenders, identified as having significant mental health and/or behavioural needs, using external clinical expertise to better inform their management
  • For the 14 women still in CSC custody, these assessments have been used to assist the treatment team in the management of these cases.

NOTE: Contracts have been in place since June 2009 in order for institutions to arrange external assessments, as required.  In addition to the original 14 assessments, four external assessments were undertaken (two for men and two for women) and a fifth is currently underway for a female offender.

  • develop an internal Mobile Interdisciplinary Treatment Assessment and Consultation Team (MTAC)
  • The MTAC Team pilot program was extended to March 2010, and expanded to men’s facilities.
  • A management review of MTAC has been completed and a presentation occurred at a Commissioner’s Management Team (CMT) meeting on February 24, 2010, to discuss next steps.
  • CMT decided to implement Regional Suicide/Self-Injury Prevention Management Committees in all five regions. These committees began operating April 1st, 2010.
  • expand the MTAC to include male offenders who exhibit significant mental health and/or behavioural needs
  • precisely define roles for Health Care and Psychology in the review process prior to, as well as during, segregation placements (see also Recommendation 1)

CD 709 – Administrative Segregation - was promulgated on November 09, 2007. The CD has five new annexes, which provide guidelines for memorandum of understanding, segregation/admission, how to run a Segregation Review Board, Segregation Review Board report content and providing psychological opinions for administrative segregation cases.

  • hold quarterly meetings with Assistant Deputy Commissioners, Institutional Operations, Deputy Commissioner for Women and Wardens of women’s institutions to discuss issues pertinent to women’s facilities

Quarterly meetings are ongoing. Assistant Deputy Commissioners, Institutional Operations (ADCIO)/Women’s Wardens face-to-face meeting occurred April 12, 2010.   The next ADCIO/Wardens face-to-face meeting is scheduled for September 27th, 2010.

In addition, ADCIO/Wardens’ conference calls are held on a monthly basis.  These meetings and conference calls ensure consistent communication on pertinent issues related to women’s corrections, including population management, staff training, and program requirements. They also provide an opportunity to share best practices and strategies in the management of challenging cases.

  • distribute results from these meetings to women’s facilities and Regional Headquarters

Meeting minutes are distributed to Assistant Deputy Commissioners, Institutional Operations (ADCIO) at each Regional Headquarters and to Wardens.

  • share best practices as they relate to institutional operations

Best practices are shared during ADCIOs/Wardens face-to-face meetings as well as in regular monthly conference calls.  These best practices include sharing of information on successes/challenges regarding self-harming behaviour.

Recommendation 1 (continued) TRAINING, STAFFING AND RESOURCING  
  • complete a pilot project on integrated mental health awareness and security training for front-line health, security and management staff, the three key groups critical to success in the effective management of the unique needs of women offenders

In 2008-09 and 2009-10 CSC developed and delivered training in Women Offender facilities.

ITo date, approximately 1,200 institutional staff (including 300 nurses) have been provided the two-day mental health awareness training, and this includes approximately 700 staff who were trained in fiscal year 2009-10.  Approximately 2,000 correctional officers are targeted to be provided with the mental health awareness training for fiscal year 2010-11.
Health Services is currently reviewing / updating the Staff Suicide Prevention Training (orientation and refresher) to be completed January 2011.

  • Mental health training will be provided to Correctional Officers
  • develop a strategy to fill vacant positions at Grand Valley Institution

The Ontario Region developed a strategy and all vacant positions were filled.

  • additional training for CSC Psychologists in suicide risk assessment

For fiscal year 2008-09 additional suicide risk/assessment training was offered to approximately 300 CSC psychologists.
 - For National Training Standards 2009-10, resources were provided for each psychologist to support professional development.
 - As part of this, all regions conducted workshops on risk assessment.
 - Health Services Sector is actively monitoring the professional development resources provided in the region.
-  Health Services is currently reviewing / updating the Staff Suicide Prevention Training (orientation and refresher) to be completed January 2011. Based on a needs’ analysis done by Learning and Development, Health Services aims to refine the training to make it more relevant to the needs of our front-line staff.

Recommendation 1 (continued) WOMEN OFFENDER SECTOR’S ROLE AND MANDATE  
  • communicate and reinforce to staff and stakeholders the Sector’s role as the functional authority on women offenders

The Women Offender Sector Governance, Roles and Responsibilities document was approved by ExCom and shared with everyone in CSC and CSC stakeholders in November 2008. It is now operational and reinforced at ADCIO/ Women’s Warden’s meetings.

Recommendation 1 (continued) VALUES, ETHICS AND DISCLOSURE  
  • develop/establish local ethics advisory committees at select operational sites

Local Committees:
Atlantic Region: Nova Institution, Shepody HC;
Quebec Region: Centre Régional de Santé Mentale,  Comité Consultatif Régional Multidisciplinaire;
Ontario Region: Grand Valley Institution;
Prairies Region: Regional Psychiatric Center, and Edmonton Institution for Women
Pacific Region: Fraser Valley Institution, Regional Treatment Center.

The Values and Ethics Branch attended the Women’s Wardens meeting January 19, 2010 and provided advice on the creation of Values and Ethics Committees in institutions.  Grand Valley Institution has implemented a Values and Ethics committee and shared their Terms of Reference with other women’s facilities.

  • provide workshops to staff members throughout CSC at all levels

All 49 scheduled workshops were conducted in 2009-2010.

  • reinforcement by RDCs to Wardens the importance of holding unit and town hall-type meetings to encourage increased staff dialogue and interaction

Ongoing in all five regions – All five Regional Deputy Commissioners confirm that their Wardens are holding unit and town hall type meetings with their staff.

  • examine ways to increase its capacity to deliver additional Values and Ethics workshops across the Service

On Sept. 30, 2009, CMT approved the participation of unions in the National Ethics Advisory Committee (NEAC) and the participation of members of the NEAC in Regional Management Committees.  This assists in integrating discussions and learning about values and ethics within ongoing operations.  In addition, CMT approved the plan to establish executives in each region with specific responsibilities in values and ethics, including the establishment of ethics committees at select operational sites within their region.

  • enhance staff awareness of the Office of Internal Disclosure underscoring its availability to all CSC employees

Communication went out in June 2009 to highlight the Internal Disclosure process.  A new web site was launched on the Infonet and identifies the Office of Internal Disclosure and related policies and contact information.

Recommendation 2: (Supported)
The OCI 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.

Six themes have been identified that relate to the Deaths in Custody Study and CSC has categorized them as follows:

  • Dynamic Security
  • Ongoing Assessments
  • Need to Enhance Provision of Intervention Services
  • Physical Infrastructure Deficiencies
  • Strengthening Managerial Accountabilities
  • Additional Actions
DYNAMIC SECURITY  
  • revise CD 560, Dynamic Security, to provide more direction with regard to responsibilities of both management and staff

Consultation and final draft completed. The National Policy Review Team has taken on this CD. They are revising it, bringing it forward to their consultation group and finalizing it for promulgation in fall 2010.

  • place additional emphasis on dynamic security in new Correctional Officer Training Program (CTP) that was being piloted in the Pacific and Ontario regions
  • Introduce in all other regions

As of April 2010, all regions are delivering CTP which contains a module on Dynamic Security.  The last region (Atlantic) will be delivering their first CTP of the year in September 2010.  The Train the Trainer session for the instructors of the course was completed in July 2010.

  • develop a Dynamic Security refresher course

''Dynamic Security'' was identified as a priority by the Learning and Development (L&D) Board in March 2010.  L&D is costing the initiative and once resources are confirmed will proceed with the development and implementation of the training.

  • distribute letters of expectation to all Correctional Managers to ensure that staff members are supervised consistently and that issues are brought to management’s attention in a timely fashion

Letters of expectations were distributed to all Correctional Managers to ensure consistency in supervision and issues management. The Correctional Managers were assessed amongst other factors, against these standards in their 2009-2010 performance evaluation.

  • issue a Security Bulletin to remind all Correctional Officers of their responsibilities with regard to security patrols and counts and the importance of their observations of offender activities in all areas of the institution

In December 2008, a Security Bulletin was issued and it reminded all Correctional Officers of their responsibilities regarding counts and rounds.
Moreover, quarterly reviews and quality assurance checks for rounds and counts was instituted in August 2010.

  • remind all Correctional Managers of their responsibility to provide constructive feedback to Correctional Officers when necessary

A Security Bulletin was issued in December 2008 and all Correctional Managers were reminded of their responsibility to provide, when necessary, constructive feedback to Correctional Officers.

  • 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.

An additional stand-to inmate count was introduced on July 10, 2009 at all maximum, medium, minimum, and multi-level institutions between the hours of 6:00 p.m. and 12:00 a.m. This direction was included in a Security Bulletin issued in July 2009.

  • increase additional security patrols at all maximum, medium and multi-level institutions (excluding women’s institutions)

An additional security patrol was introduced at all maximum, medium and multi-level institutions (excluding women’s institutions) in July of 2009.

  • confirm that all institutional policies (standing orders and post orders) are in compliance with CD 566-4, Inmate Counts and Security Patrols

In 2008-09, CSC confirmed that all institutional policies (Standing Orders and Post Orders) are in compliance with the CD on Inmate Counts and Security Patrols.

  • randomly analyse, on a regional basis, inmate counts and security patrols on a quarterly basis and report their results to National Headquarters

In all regions, rounds and counts performance are reported upon quarterly.

  • initiate a project to install high-resolution digital cameras in the cell range areas of all women’s institutions

The project has been initiated. Implementation will take place by end of August 2011.

  • complete a project to install high-resolution digital cameras in the cell range areas of all women’s institutions

The Request For Proposal (RFP) for Pacific Region has been published on MERX and it closed at the end of August 2010. The RFPs for the other regions will follow shortly. The projects for the five regions were all approved by the Contract Review Board earlier this summer (2010).

The sites, in consultation with CSC’s National Headquarters’ Technical Services, will determine the optimum location for the installation of cameras to ensure that the dignity and privacy of women offenders is respected while simultaneously ensuring necessary visual coverage of common areas to ensure good security practices.

  • examine the use of alternate systems, including proximity card technology that identifies, tracks, and records the presence of Correctional Officers conducting security patrols and inmate counts

The installation of the system by CSC’s Corporate Services will be completed in December 2010; the operational evaluation will be completed by CSC’s Correctional Operations and Programs by September 2011.

  • explore the use of new technologies (by way of market survey)  to enhance security and increase staff ability to verify offender well-being, especially during the night shift

In 2009, CSC undertook a review of currently available technologies and was not able to identify a system that would operate with a high level of accuracy in CSC’s physical environment with uncooperative inmates. CSC continues to investigate new technologies.

Recommendation 2 (continued) ONGOING ASSESSMENTS  
  • implement an enhanced mental health screening tool at the remaining 3 of 16 intake assessment sites in fiscal year 2008-2009

Mental health screening has been implemented at 16 CSC intake sites and women’s institutions. Computerized Mental Health Intake Screening System (CoMHISS) assists in identifying offenders who are experiencing significant psychological distress at intake. Early identification of mental health issues enables timely intervention, prevents further deterioration of mental health and contributes to an appropriate penitentiary placement for offenders with mental health needs.

CoMHISS version II project is underway to identify and implement further improvements such as a cognitive screening tool.

  • implement the mental health screening tool remaining three of 16 intake assessment sites by end of 2009-2010
  • train CSC Psychologists in suicide risk assessment (see also Recommendation 1)

300 psychologists were trained during 2008-09.

  • develop guidelines on sharing mental health-related information and share with staff to provide important reference points to follow

Consultation has been completed and it will be promulgated in Fall of 2010.

Recommendation 2 (continued) NEED TO ENHANCE PROVISION OF INTERVENTION SERVICES  
  • review the resources available and allocated to the care of women offenders to ensure their efficient use and capacity to achieve correctional results

This exercise was completed in November 2009 and sufficient funding has been allocated to Women Offender Sector.

  • implement new deployment standards for correctional staff

The CD was promulgated on June 8, 2009 and national standards for the deployment of Correctional Officers at all institutions were implemented. This increased standardization is aimed at promoting consistency, equity, efficiency and transparency across institutions, which will in turn enhance the security of the public, staff and offenders.

These standards provide a common blueprint and useful tool for all institutional managers.  They will also enable overtime challenges to be addressed systematically.

  • develop a more effective approach to offender case management by focusing psychological and specialized assessment resources on the highest risk/needs offenders.

On November 12, 2008 CSC revised its policy on intake assessments to emphasize the importance of specialised psychological assessments for offenders who would demonstrate the highest risk/need.

CD 705-5 directs psychologists to conduct comprehensive supplementary assessments for those “at risk” offenders who demonstrate situational adjustment difficulties, suicide risk indicators, and self-mutilation indicators. These assessments are normally conducted within the first 30 days of admission.

  • 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 or self-injury

Final consultation on this CD ended June 2010. Promulgation will occur in the fall of 2010.

  • engage an expert consultant on best practices in the assessment of risk of suicide and self-injury and in intervention techniques for offenders at risk and to provide advice on processes to allow for the sharing of information between staff when an inmate is exhibiting suicidal or self-harming ideations

Health Services Sector has developed a Self-Injury Strategy to facilitate better management and prevention of self-injury by our offenders.  A further update of the strategy will be completed in fall 2010.

  • integrate the elements of the Women’s Violence Prevention Program into a Women’s Modular Intervention (WMI) to allow for delivery to women offenders in the Secure Units and Segregation Units

A new correctional program was developed incorporating not only elements from the Women's Violence Prevention Program but other programs as well (i.e. Women Offender Substance Abuse Program). The newly designed WMI includes integrated skills and targets all problematic behaviours linked to a maximum security classification and crime. Experienced program facilitators completed training in August 2009. Grand Valley Institution started a pilot in October 2009, Edmonton Institution for Women started in January 2010; Joliette Institution started in June 2010 and Fraser Valley Institution in September 2010. Expect to remain in pilot program mode until April 2011.

Recommendation 2 (continued) PHYSICAL INFRASTRUCTURE DEFICIENCIES  
  • compile a review of construction-related deficiencies identified in reports, reviews and investigations to develop appropriate criteria for future construction projects

A comprehensive list of construction related vulnerabilities was compiled and corrective strategies identified.  Regions were subsequently tasked with initiating projects to address the vulnerabilities.

  • develop mitigating strategies for identified deficiencies will be developed

Identified vulnerabilities included the lack of a Secure Interview Room in all Secure Units and the absence of service hatches (i.e. food slots) in all five institutions identified maximum-security cells.

All five sites have now constructed a Secure Interview Room and service hatches in the identified maximum-security cells. These upgrades were completed in the five multi-level Women’s Institutions.

Recommendation 2 (continued) ACCOUNTABILITIES  
  • implement corrective measures immediately following incidents at the local level while the investigative process gets underway

Notwithstanding whether CSC initiates an investigation, Situation Reports on serious incidents include corrective measures. Follow-up and closure on these measures is completed by the Regional Deputy Commissioners and when applicable, their actions are verified through the investigative process.

  • produce quarterly summaries highlighting all pertinent issues and statistical information around deaths in custody (excluding deaths by natural causes) and share with the OCI

To date, three quarterly summaries have been produced and widely distributed to operational staff and managers throughout CSC and the OCI.

  • share these summaries with all regional and institutional management committees as part of their meeting agendas on a quarterly basis
  • establish an independent review group to assess CSC’s actions and responses to deaths in custody on an annual basis

The Independent Review Committee was established in June 2010. The members are: a senior provincial government official as well as a provincial Chief Coroner and a Criminology University Professor.  CSC will benefit from the committee members’ experience and seek out their suggestions and advice on the approaches and techniques that we could introduce that would enhance our capacity to respond more effectively to these types of incidents in our correctional institutions. The Independent Review Committee will also provide feedback on the appropriateness and adequacy of the corrective measures initiated by CSC in response to its prior investigations into deaths in custody. Their final report is expected in December 2010.

  • share significant findings so that CSC can reduce the chances of similar future incidents

Six significant finding documents have been completed and widely distributed to date.  Some of the topics covered are suicides, hostage takings, murders in institutions and major disturbances.

  • review (monthly) by ExCom of the investigation reports and corrective measures for each death in custody

Since March 2010, 33 national investigation reports and their corrective measures have been presented at Executive Committee meetings. In many cases the corrective measures were already implemented at the time of the review.

Recommendation 2 (continued) ADDITIONAL ACTIONS  
  • include the CSC commitment to enhancing our capacity to assess and respond to issues related to preventable deaths in custody in the Report on Plans and Priorities to Parliament for 2009-2010

CSC's Report on Plans and Priorities 2010-11 makes specific reference to organization-wide responsibility of staff for preventing self-injury and unnatural deaths by offenders. It identifies plans that are directly targeted at reducing self-injury and death such as mental-health interventions, gang prevention strategies, and use of technology. A reduction in self-injuries and deaths is one of the outcomes expected from a number of strategies such as reinforcing dynamic security, eliminating drugs in institutions, hiring and training specific groups of staff and addressing other health issues amongst offenders.

Recommendation 3: (Not Supported)
The OCI recommended that CSC group its women facilities under a reporting structure independent of the regions, with the Wardens reporting directly to the Deputy Commissioner for Women.

  • clarify and communicate the role and responsibilities of the Deputy Commissioner for Women and the Women Offender Sector to National Headquarters, the regions and women’s institutions (see also Recommendation 1)

As previously mentioned, the Women Offender Sector‘s Governance, Roles and Responsibilities document was approved by CSC’s Executive Committee and shared with everyone in CSC and with CSC stakeholders in November 2008. It is now operational and functional.

  • discuss, on a regular basis, with the OCI, how issues of concern in women’s facilities can be brought to the national level when some urgency or serious difference of opinion exists relating to the care provided to women offenders

Discussions occur at quarterly meetings.  Meetings between the OCI, Health Services and Women Offender Sector were held on February 12, 2010 and May 20, 2010.

Consultation with the OCI on Management Protocols in place to deal with very high-risk women was held on February 18, 2010.

The consultation report was shared with the OCI in June 2010.

Recommendation 4: (Supported)
The OCI 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 CD 709, Administrative Segregation to provide guidelines for Segregation Placement/Admission, Segregation Review Board Report Content, and Mental Health Assessment for Administrative Segregation

CD 709 was promulgated on November 09, 2007. It clearly identifies roles and responsibilities in administrative segregation at the national, regional, and institutional levels. It contains changes in policy objectives, expanded definitions and the formalization of a number of principles.

A Policy Bulletin was issued on the same date.
The CD has five new annexes, which provide guidelines for memorandum of understanding, segregation/admission, how to run a Segregation Review Board, Segregation Review Board report content and providing psychological opinions for administrative segregation cases.

CD 709 will be completed by the Policy Review Team by October 15, 2010.

The Commissioner ordered a follow up compliance review of these (and several other) segregation related items, essentially to see whether we have followed through on commitments. The Verification Team presented its findings and recommendations to the ExCom meeting in August 2010.

  • conduct a management review to assess the level of compliance with this direction
  • expand definitions and the formalization of a number of principles related to administrative segregation
  • clearer identification of roles and responsibilities in administrative segregation at the national, regional, and institutional levels
  • clearer direction on responsibilities related to administrative segregation
  • provide psychological opinions for administrative segregation cases
  • establish a role for Health Care and Psychology to supplement the existing review mechanisms for long-term segregation placements
  • produce and distribute a segregation handbook for staff to clarify the policy expectation for the timely review of these cases

A segregation handbook for staff was produced in June 2008 and it was widely distributed to clarify the policy expectation for the timely review of these cases and it is also intended to serve as a reference and a guide for all CSC staff involved in any aspect of the administrative segregation process.  It is also available on the Infonet.

Recommendation 5: (Supported)
The OCI recommended that CSC immediately review all cases of long-term segregation where mental health issues were a contributing factor to the segregation placement. Particular attention should be paid to inmates with histories of suicide attempts or self-injurious behaviours. Results of this review should be provided to the institutional heads, Regional Deputy Commissioners and, in the case of women offenders, to the Deputy Commissioner for Women.

  • conduct an operational examination of long-term segregation using representative sampling methodology and an external review process  (see also Recommendation 1)

As previously mentioned, CSC established an External Review Board composed of two independent external consultants. They have now completed their work and it will be presented to CSC’s ExCom for review and decision on next steps.

Since December 2009, a committee meets to examine long-term segregation using representative sampling methodology (25 cases).

This committee meets on a regular basis and has established terms of reference.

Recommendation 6: (Supported)
The OCI 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)

As previously mentioned, the short-term accommodation needs related to women offenders were addressed through increased capacity (45 new beds) at three sites. A long-term strategy for CSC’s overall infrastructure will be completed by March 31, 2011. It will integrate elements of the ExCom-approved strategy for women.

  • develop short- and long-term strategies on service, support and accommodation needs for women offenders identified in this group (see also REC 1)

As previously mentioned, an accommodation strategy was presented and supported by ExCom in Feb 2009.

  • engage an expert consultant to assist CSC efforts at making improvements to its CD 843, Prevention, Management and Response to Suicide and Self-Injuries

As previously mentioned, the report CSC received from the external consultant was used to make proposed revisions to CD 843.  This CD has been distributed to staff for final consultation. Expected promulgation is October 2010.

  • 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

Changes have been incorporated into the revised version of the CD. The CD was sent for final consultation June 2010. Expected promulgation is October 2010.

  • develop and finalize standardized tools and guidelines for use in creating plans to address self-harming behaviours for use by operational staff

These tools are included as an annex to CD 843, contained in the Process for Self-Injury Interventions. The tools have been revised and updated. They were sent out for final consultation with CD 843, expected promulgation is October 2010.
Both the Process for Self-Injury Interventions and CD 843 will assist staff in the management of offenders who engage in self-injury.

Recommendation 7:  (Not Supported)
The OCI recommended that all CSC National Boards of Investigation into incidents of suicide and self-injury be chaired by an independent mental health professional. 

  • utilize and optimize existing process and CSC resources to ensure that each Board of Investigation understands that it can access a wide variety of external experts and specialists as deemed necessary

All CSC investigators are trained and understand that they have access to a wide variety of experts as needed.  During the Board of Investigation the Chair of the said board can also access these external experts and on more complex investigations – specialized expertise is added to the board where feasible.

Recommendation 8: (Supported in part)
The OCI recommended that CSC review and revise its administrative segregation practices to ensure that all long-term segregation placements are reviewed by regional managers, inclusive of health care, after 60 days of segregation. They further recommended in those cases where segregation status is maintained, that the decision and supporting documentation be referred to the Senior Deputy Commissioner and, in the cases of women offenders, to the Deputy Commissioner for Women.

  • ensure that Regional Segregation Review Boards and Regional Segregation Oversight Managers across CSC perform the delegated responsibilities of the regional reviews and ensure that the case of each inmate in segregation is reviewed regionally every 60 days (see also Recommendation 5)

All five regions are committed to working in collaboration with the Regional Segregation Oversight Manager (RSOM) to ensure not only proper reviews of cases but more importantly in pursuing true resolution of long term segregation cases.

CSC has produced an Annual National Trends Report to monitor placement in segregation.

Recommendation 9: (Supported in part)
The OCI 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

A follow-up reminder was issued to staff in July 2009. This message continues to be reinforced verbally with all Health Services staff.

 Recommendation 10:  (Not Supported)
The OCI recommended that CSC immediately implement independent adjudication of segregation placements of inmates with mental health concerns. This review should be completed within 30 days of the placement and the adjudicator’s decision should be forwarded to the Regional Deputy Commissioner. In the case of a woman inmate, the adjudicator’s decision should be forwarded to the Deputy Commissioner for Women.

  • introduce a National Population Management Committee to provide national monitoring of the use of administrative segregation

This committee meets on a regular basis and has established Terms of Reference

  • Women Offender Sector to provide input and support and perform a functional oversight role regarding women offenders placed in segregation through a review of a random sample of segregation cases

A review of a random sample of segregation cases was completed by CSC’s Women Offender Sector in summer 2009. Individual (site level) results were communicated with the Assistant Deputy Commissioners Institutional Operations and Wardens of Women Offender Institutions in July 2009. Where required, corrective measures were identified and implemented.

  • undertake an operational examination of segregation placements of inmates with mental health concerns using a representative sampling methodology and an external review process

As mentioned earlier, CSC established an External Review Board composed of two independent external consultants. They have now completed their work and it will be presented to ExCom for review and decision on next steps.

Recommendation 11: (Supported in part)
The OCI recommended that the Situation Management Model be modified to require staff give consideration to an offender’s history of self-harm and his/her potential for future or cumulative self-harm when determining whether immediate intervention is required.

  • reinforce the paramount responsibility concerning preservation of life across the organization at all levels of staff, both verbally and in writing (Security Bulletin) (see also Recommendation 1)

In May 2008, a message was sent to all CSC staff reinforcing the continuing need for vigilance in preventing inmate suicide.

The Significant Findings from National Investigations on Inmate Suicides Report was distributed to all sites.

  • issue a bulletin clarifying that “past behaviour” includes an offender’s history of self-harm

A Security Bulletin was issued on August 19, 2009 to remind all staff that that the CSC Situation Management Model requires staff to consider the offender’s “past behaviour” during and throughout an incident.

This includes giving consideration to an offender’s history of self-harm and the potential for future of cumulative self-harm when determining whether immediate intervention is required.

Recommendation 12: (Supported)
The OCI 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.

  • complete written responses for all complaints and grievances submitted

Written responses for all complaints and grievances were  completed on August 14 and December 15, 2008

  • share a summary report with the OCI

A summary report was shared with the OCI on August 14 and December 15, 2008

  • review and prepare recommendations concerning the procedures for collecting and receiving segregation grievances at all institutions to ensure confidential, complete access to the process, as well as expeditious receipt of complaints and grievances across the Service

As of October 31, 2008, the policy directs that the Institutional Head must ensure that complaints and grievances are collected and reviewed daily.

  • revise CD 081, Offender Complaints and Grievances

A policy review was completed on October 31, 2008.  The policy and a manual are currently being reviewed based on recommendations of an External Review Committee.

  • review  the access to the grievance process at Grand Valley Institution for Women and make changes to ensure timely, effective and appropriate responses

The process at Grand Valley Institution for Women was reviewed and changes were made to their process in September 2008.

  • deliver training sessions with the institutional staff at Grand Valley Institution for Women on how to process and respond to grievances

Staff from CSC’s National Headquarters visited the institution, reviewed their process, recommended and implemented changes and provided training and assistance to institutional staff.

Recommendation 13: (Supported in part)
The OCI 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

As previously mentioned, the policy review was completed on October 31, 2008. The policy and a manual are currently being reviewed based on recommendations of the External Review Committee.

Recommendation 14: (Supported)
The OCI recommended, once again, that CSC immediately commission an external review of its operations and policies in the area of inmate grievances to ensure fair and expeditious resolution of offenders’ complaints and grievances at all levels of the process.

  • complete internal audit and initial action plans and present to the CSC Audit Committee

The audit was completed in May 2009 and recommendations were accepted.  Implementation of some recommendations was delayed to incorporate recommendations from the external review process.

  • complete Audit Committee action plans

The Audit Committee made recommendations. These were centered on the clarification of definition of complaints - this was completed in July 2009. The other recommendations were in the areas of: multiple griever status, review of the practices related to Outside Review Boards, enhancing training available to staff and reviewing the timeliness of responses.  These recommendations will be completed in 2010.

CSC initiated an external review of the offender complaints and grievance process.  The report has been submitted and will be reviewed by ExCom members in the winter 2010-11 for next steps.

Also, deployment of the updated automated offender management system in fall 2010, will address some of the recommendations contained in the audit plan.

  • develop a process for an external review of the Offender Complaint and Grievance process

An external review was completed. Recommendations are currently being reviewed.

  • development of the process will follow consultations with key stakeholders, including the Correctional Investigator

Final Report was submitted to the Commissioner.  Both the report and CSC’s response to recommendations will be discussed at ExCom meeting in fall 2010.

Recommendation 15:
The OCI recommended that the Minister of Public Safety, together with the Minister of Health, initiate discussions with their provincial/territorial counterparts and non-governmental stakeholders regarding how to best engage the Mental Health Commission of Canada on the development of a national strategy for corrections that would ensure a better co-ordination among federal/provincial/territorial correctional and mental health systems. The development of the national strategy should focus on information sharing between jurisdictions and promote a seamless delivery of mental health services to offenders.

  • develop a cross-jurisdictional approach to mental health services that includes identifying gaps in the continuum of care, building stronger partnerships with stakeholders outside of the federal correctional system, and developing innovative solutions

In November 2008, the Heads of Corrections (HOC) created a new Federal/Provincial/Territorial (FPT) Working Group on Mental Health (WGMH). The WGMH serves as an advisory body to the HOC and was tasked to develop a national corrections mental health strategy in consultation with the Mental Health Commission of Canada.

The HOC FPT WGMH met for the third time on March 30-31, 2010 to continue work to build partnerships within/outside CSC, to improve flow of information / services, including gap analysis, best practices, identification of risks, and opportunities for future collaboration.

The draft framework for a national correctional mental health strategy, which was presented in March 2010, will be further discussed at the October 5-6, 2010 meeting in Halifax, Nova Scotia. The framework includes consideration for self-injurious behaviour and suicide.

  • host a Symposium on Mental Health that brought together international and Canadian experts to examine practical solutions to improving delivery of health services

A symposium was held in May 2008.

Continued implementation of the mental health strategy, ongoing work of the FPT WGMH, and discussion at ExCom will expand on some of the issues raised during this Symposium.

  • hold a Forum to explore the nexus between Canada’s mental health and criminal justice systems

A forum was held June 2009 to identify opportunities for improvement with partners. Ongoing engagement with key stakeholders.

Recommendation 16: (Supported)
The OCI recommended that the CSC undertake a broad consultation with federal/provincial/territorial and non-governmental partners to review the provision of health care to federal offenders and to propose alternative models for the provision of these services. The development of alternative models should include public consultations.

  • review the status of efforts with FPT and non-governmental partnersto address these complex issues

Partnership opportunities discussed at the September 2009 strategic planning session. Both the Health - FPT Working group and the Mental Health - FPT Working Group are working collaboratively to improve the continuum of health care for offenders across all jurisdictions.  Emphasis is placed on opportunities for collaboration and knowledge exchange.  For example, CSC has actively shared and trained other jurisdictions on its two-day mental health awareness training.  As well, other jurisdictions who have explored alternative service delivery models for health delivery provide updates to these groups.

  • develop a framework to assess alternative models for the provision of health care services to federal offenders

Initial work is underway to define the scope and objective of the framework to assess alternative models for the provision of health care services to federal offenders.  To be completed by December 2010.

  • actively participate in the  WGMH

Next meeting will be held in October 2010. Last meeting was in March 2010, it was a productive meeting with active participation from members including representation from all jurisdictions and the Canadian Mental Health Commission.

The first draft of the framework was developed and reviewed at the March 30-31, 2010 FPT WGMH meeting held in Ottawa, Ontario.

Presentation of a final draft framework will be made to the FPT WGMH at the October 5-6, 2010 meeting to be held in Halifax, Nova Scotia. A draft action plan will be developed as part of this meeting. The framework and the action plan will form the National Corrections Mental Health Strategy to be presented to HOC for approval.

  • share best practices for assessment, treatment, training and discharge planning
  • chair the WGMH, which includes membership from the Mental Health Commission of Canada. CSC also works closely with other partners, including provincial coroners’ offices, to discuss opportunities to prevent future deaths in custody
  • hold a meeting with the Coroners and Medical Examiners from across Canada to discuss information sharing and to reinforce our commitment to co-operation

To allow for maximum cooperation within the parameters and legal frameworks of the respective jurisdictions, these meetings help clarify the cooperative process and provide a valuable opportunity to identify recurring and evolving issues related to deaths in custody. The second meeting occurred in Ottawa in August 2010.

Several commitments are referenced more than once in this grid as they contribute to more than one of the Office of the Correctional Investigator’s recommendations. CSC has now completed a verification of these commitments at 11 major operational sites using an expert CSC team.

Key performance indicators have been established to help measure the overall impact of these commitments.

1 Commissioner’s Directives are rules prescribed for the management of the Service as described in Section 97 of the Corrections and Conditional Release Act