Annual Report on Deaths in Custody 2014/15

 

Executive Summary

The reduction and prevention of inmate deaths in custody is a challenge for all correctional jurisdictions, and is directly linked to the Correctional Service of Canada's (CSC) strategic priority of "Safety and security of members of the public, victims, staff and offenders in our institutions and in the community". CSC has strived for many years to address this important issue in a proactive and effective manner.

Over the five fiscal years from 2010/2011 to 2014/2015, an average of 55 deaths in custody occurred per year. Natural deaths accounted for 65% of all deaths, while suicides were the most common type of non-natural death.

The current report, which is the second Annual Report on Deaths in Custody, compiled information gathered by the Policy Sector's Research Branch to examine deaths in custody that occurred in the 2014/2015 fiscal year. The overall rate of deaths in custody in 2014/2015 was found to be 4.52 per 1000 offenders. Characteristics of offenders who died in custody varied considerably but offenders were likely to be male, White, and 55 years of age or older regardless of the reason for death. 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.

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. In addition, in response to the findings of the third Independent Review Committee report on Deaths in Custody, CSC is conducting in-depth research into deaths in custody.

Introduction

The reduction and prevention of inmate deaths in custody is a challenge for all correctional jurisdictions, and is directly linked to the Correctional Service of Canada's (CSC) strategic priority of "Safety and security of members of the public, victims, staff and offenders in our institutions and in the community". The organization has strived for many years to address this important issue in a proactive and effective manner. For example, CSC has had a policy in place regarding the management of suicidal behaviour for over 20 years and has provided training on suicide prevention since the 1980's.

Further, CSC has policies in place concerning the review and investigation of deaths in custody that ensure responsibility, accountability, and transparency, as well as the enhanced ability to prevent or better respond to similar incidents in the future. As per Commissioner's Directive (CD) 041, Incident Investigations (CSC, 2010), 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 no further investigation. The Research Branch (Policy Sector) combines information from these investigations and reviews, as well as other contextual information, to produce this report. In addition, the findings influence organizational policy and practices, thereby contributing to the safety and well-being of the public, staff, and offenders.

CSC recognizes that deaths in custody remains a complex and difficult issue and that it is imperative to continuously work to enhance its related prevention and intervention strategies. Ultimately, all efforts around deaths in custody are designed with the goal of attaining the objective of zero non-natural offender deaths in custody (Government of Canada, 2015), as well as the best possible physical health outcomes for inmates. This second Annual Report on Deaths in Custody provides information in order to enhance accountability and transparency, and to inform prevention and intervention strategies. Additionally, given that this issue remains a challenging one which all correctional jurisdictions face, this report creates an important opportunity for information sharing, which facilitates the ability for correctional jurisdictions to learn from each other regarding the most effective methods to reduce and prevent deaths in custody.

Data Source

All offender level demographic data were obtained from CSC's automated offender data system, the Offender Management System (OMS), and validated by the Research Branch (Policy Sector) using records from the Incident Investigation Branch and Health Services Sector. Additional information surrounding the details of the death was obtained directly from Incident Investigation Branch and Health Services' records and Board's of Investigation and Mortality Review reports. Data were accurate as of March 11, 2016; revisions may occur in subsequent categorizations of death in order to reflect newly-completed investigations or mortality reviews, or additional information received from sources such as Coroner's reports or toxicology results.

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 65% of all deaths. Suicides were the second most common type of death, followed by accidents (including overdoses). Homicides and other causes of death were relatively uncommon.

Table 1
Number of Deaths in Custody by Cause of Death over a 5-year Period
Cause of Death FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014 FY 2014/2015
Natural
Natural Cause 35 35 32 33 43
Under Investigation 0 0 0 0 1
Non-natural
Suicide 4 8 14 9 12
Homicide 5 3 1 2 1
Accident a 4 6 3 3 8
Staff intervention 1 0 0 0 0
Undetermined 1 1 6 1 0
Under Investigation 0 0 0 0 2
All causes 50 53 56 48 67

Note. Results are accurate as known on March 11, 2016. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.
a Accidents include both overdoses and accidents and other hard to classify incidents. There was one non-overdose accident in 2011/2012 one in 2012/2013, one in 2013/14 that involved a poisoning where the source of the poison could not be determined and two in 2014/2015.

In 2014/2015, there was considerable variability across the regions in the number of deaths occurring in custody. The highest number occurred in the Quebec region, while the lowest occurred in the Atlantic region and Pacific regions.

Table 2
Regional Breakdown of Number of Deaths in Custody by Cause of Death, Fiscal Year 2014/2015
Cause of Death Atlantic Quebec Ontario Prairies Pacific
Natural
Natural Cause 5 14 10 9 5
Under Investigation 0 1 0 0 0
Non-natural
Suicide 0 6 1 2 3
Accident a 1 2 5 0 0
Homicide 0 0 0 1 0
Under Investigation 1 0 1 0 0
All causes 7 23 17 12 8

Note. Results are accurate as known on March 11, 2016. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.
a Accidents include both overdoses, accidents and hard to classify incidents.

Profiles of Offenders Who Died in Custody

The overall rate of deaths in custody in 2014/2015 was 4.52 per 1000 offenders. Offenders who died in custody varied considerably, but were generally more likely to be male, White, and 55 years of age or older. They were often serving indeterminate sentences.

Deaths from Natural Causes

Certain characteristics differed by type of death. Not surprisingly, 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. Finally, they were more likely to be White. There was a noticeable increase in the number of deaths from natural causes in 2014/2015.

Table 3
Characteristics of Offenders who Died in Custody by Cause of Death, Fiscal Year 2014/2015
Characteristic Natural Causes Non-Natural Causes Rate per 1000 CSC
Pop.
Suicide Accident Homicide Under Investigation
Gender
Male 41 12 8 1 2 4.52 14163
Female 3 0 0 0 0 4.44 676
Ethnicity
White 34 10 7 1 1 6.27 8448
Aboriginal 7 1 1 0 1 2.74 3650
Black 3 0 0 0 0 2.18 1373
Other 0 1 0 0 0 0.73 1368
Age
18-24 0 0 0 0 1 0.61 1641
25-34 0 4 3 0 0 1.51 4649
35-44 1 3 1 0 1 1.72 3487
45-54 8 2 0 1 0 3.73 2951
55-64 14 3 3 0 0 13.52 1479
65-74 16 0 0 0 0 30.30 528
75 or older 5 0 1 0 0 57.69 104
Offender security levela
Minimum 15 4 0 0 0 6.39 2974
Medium 25 5 7 1 0 4.34 8763
Maximum 2 3 1 0 2 3.76 2127
Undetermined/Unknown 2 0 0 0 0 2.05 975
Sentence length
Less than 4 years 7 0 0 0 1 1.44 5563
4 – 6 years 3 1 2 0 0 2.27 2638
6 – 10 years 6 1 0 0 0 3.48 2013
More than 10 years 2 2 1 0 0 4.62 1083
Indeterminate 26 8 5 1 1 11.58 3542
Time served
Less than 3 months 3 1 0 0 0 2.88 1389
3 months – 1 year 3 2 0 0 1 1.84 3264
1 year – 5 years 10 3 2 0 1 2.23 7184
More than 5 years 28 6 6 1 0 13.66 3002
Index offence
Homicide or related 20 10 5 1 1 9.48 3904
Sexual 10 0 0 0 0 4.62 2164
Assault 0 0 0 0 0 0.00 1701
Robbery 4 1 3 0 1 4.24 2124
Other violent 3 1 0 0 0 5.27 759
Property 4 0 0 0 0 3.54 1131
Drug 3 0 0 0 0 1.46 2061
Other non-violent 0 0 0 0 0 0.00 896
Total 44 12 8 1 2 4.52 14839

Note. Results are accurate as known on March 11, 2016. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded. CSC population numbers reflect the 2014/2015 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.

Deaths by Suicide

Offenders who died by suicide in 2014/2015 tended to be between 25 and 44 years old. They were likely to have an offender security level rating of minimum or medium. The most common sentence length was an indeterminate sentence. In 2014/2015 all suicides involved male offenders. Only one suicide involved an offender with Aboriginal ancestry.

Deaths by Accident including Overdoses

Offenders who died by accident (including overdoses) in 2014/2015 were all male and tended to be White. They were likely to be serving an indeterminate sentence, to have served more than 5 years in custody and to have an offender security level rating of medium.

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

In 2014/2015 the most common cause of a natural death was either related to the cardiovascular system (35%) or from cancer (30%). Respiratory-related deaths accounted for 19% of all deaths from natural causes.

Table 4
Number of Deaths by Natural Causes by Illness or Bodily System over a 5-year Period
Cause of Natural Death FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014 FY 2014/2015
Cancer 9 15 14 12 13
Infection 3 0 2 3 4
Cardiovascular-related 11 8 8 6 15
Respiratory-related 2 4 3 3 8
Liver-related 6 4 3 3 2
Other 4 4 2 6 1
All natural deaths 35 35 32 33 43

Note. Results are accurate as known on March 11, 2016. 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. Natural deaths under investigation are not included.

Deaths by Suicide

In 2014/2015 the most common method of death by suicide was via hanging, ligature, and/or asphyxiation (83%). Other methods of suicide such as cutting were much less common.

Table 5
Method of Suicide over a 5-year Period
Method of Suicide FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014 FY 2014/2015
Hanging / ligature / asphyxiation 4 8 12 8 10
Other 0 0 2 1 2
All deaths by suicide 4 8 14 9 12

Note. Results are accurate as known March 11, 2016. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Deaths by Overdose

In 2014/2015 there were 6 fatal overdoses. Illegally-obtained drugs were the most common source of substances used in overdoses, rather than prescribed drugs.

Table 6
Method of Overdose over a 5-year Period
Method of Overdose FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014 FY 2014/2015
Prescription drugs
Drugs prescribed to offender 0 0 0 0 1
Other 1 1 0 0 1
Illegal substances 3 4 2 2 4
All deaths by overdose 4 5 2 2 6

Note. Results are accurate as known on March 11, 2016. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Deaths by Homicide

In 2014/2015 there was a single homicide incident that involved asphyxiation. In prior years, Table 7 shows that homicides occurring from cutting instruments (e.g. homemade weapons) were more common.

Table 7
Method of Homicide over a 5-year Period
Method of Homicide FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014 FY 2014/2015
Cutting instrument 4 3 1 1 0
Blunt force trauma 0 0 0 1 0
Asphyxiation or strangulation 1 0 0 0 1
All causes 5 3 1 2 1

Note. Results are accurate as known on March 11, 2016. Subsequent investigations or reviews may lead to revisions in where a particular death is recorded.

Conclusion

CSC strives to prevent non-natural deaths in custody and prioritizes learning from any deaths that occur. This report, 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.