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The safe, secure, and humane custody of offenders is a fundamental part of the mandate for federal corrections in Canada and the Correctional Service of Canada (CSC) takes its responsibilities for the preservation of life and the safety and security of our institutions very seriously. When a death in custody does occur, CSC mobilizes its resources to take the steps that are necessary to prevent a reoccurrence. The difficult lessons that are learned from such tragedies lead to important changes that help CSC to more effectively manage its operations.
However, CSC continues to face challenges, particularly when offenders choose to end their lives and wait until a time when staff are not present on the ranges. As well, with a segment of the offender population aging within the institutions, the number of deaths by natural causes will continue to be high.
It should be noted that, on a daily basis, the interventions of Parole Officers, Correctional Officers, Psychologists, Nurses, and other staff who interact directly with offenders play a significant role everyday in assisting more than 13,000 offenders cope with their period of incarceration.
The following represents a progress report in relation to the August 14, 2009 public release of CSC’s 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. The recommendations from the Correctional Investigator's report and the CSC investigation are contained in the attached Annexes.
Substantive changes have been made by CSC since the Office of the Correctional Investigator released its Deaths in Custody Study in 2007. By examining the findings and recommendations detailed in the above mentioned reports and the CSC response, several themes emerge that CSC will use to publicly report on results and help promote a better awareness of the progress being made. The key initiatives that CSC is taking will be found in its next Report on Plans and Priorities and the results of those actions will be described in the follow-up Departmental Progress Report.
CSC believes that all of these reporting mechanisms will help to ensure transparency and increase public understanding of our efforts to provide safe, secure and humane custody of offenders.
Many of our actions, particularly those in relation to offenders with mental health and behavioural needs, will require broad change and sustained effort over the long term. Other actions will be completed in the short term and it is our intent to use these progress reports to describe what has been accomplished, initiatives that are underway, and steps that will be taken in the future to achieve the desired impact of reducing the number of deaths in custody.
The fundamental issue connected to our experience with deaths in custody surrounds the challenges we face in dealing with the steady growth of offenders who suffer from mental health disorders, their behaviours, our capacity to properly manage their care, and the resources that we have in place to provide the appropriate treatment. For example, at the time of Ashley Smith’s death in 2007, 21 per cent of women offenders were identified as having a mental health disorder upon admission - a 61 per cent increase over the previous 10 years. For male Aboriginal offenders, the increase was well over 100 per cent from the 13 per cent identified as having a mental health disorder in 1997.
In large part, we have become a last resort for people who have persistently come into contact with the criminal justice system and who experience unresolved mental health problems, often acute, and all too often untreated. Many have slipped through the cracks, been severely stigmatized or shunned, or have never before had to face issues that concern their mental health. Because of the complexities and, in some instances, limited proven treatment methods for the most acute cases, the solutions will evolve over the long-term, as we strengthen our capacity and continue to develop the necessary expertise to manage these challenges effectively.
We are working to build an integrated model - a continuum of care – within a multi-jurisdictional context, while partnering with several provinces and territories, as well as many of the agencies and institutions outside of corrections that are responsible for mental health care in Canada.
We are receiving support for the implementation of our strategic plans. For example, in 2007 we received $21.5 million in funding from the federal government over two years to support key elements of our institutional mental health strategy. In budget 2008, we received permanent funding of $16.6 million annually for institutional mental health services beginning in this fiscal year.
CSC is continually trying to find sufficient people in sufficient numbers with the expertise and motivation to work with mentally disordered offenders who are located at most of our institutions and parole districts across Canada, many in remote communities. We must also ensure that our operations staff – from all occupational groups – are provided with the training and assistance to understand, respond to and support the treatment plans that are developed for offenders with mental health issues.
This will require time and, as stated earlier, many of our strategies will unfold over the longer term as we see the gaps close and CSC become part of a fully integrated mental health care delivery model.
We have, however, made progress and come a long way as a result of the dedication of CSC employees working everyday to make a difference in the lives of our offenders. It has taken the commitment of staff from many disciplines - such as Parole Officers, Correctional Officers, Psychologists, Nurses - working together, engaging offenders, sharing observations with one another, and collaborating to intervene, that have assisted many offenders to better manage their mental health issues.
Much more needs to be done and we are working hard to prevent deaths and improve our capacity to deliver on the commitments we have made to Canadians.
Although deaths in custody will inevitably occur, our resolve will remain high as we continue to move forward in consultation with our stakeholders, including the Office of the Correctional Investigator. We believe that we are on the right path and, together with our partners, we are determined in our efforts to produce the results that will contribute to safer institutions and communities.
The Office of the Correctional Investigator recommended that CSC implement and apply as widely as possible (including within men’s facilities) all recommendations emanating from the CSC National Board of Investigation into the Death of an Offender at Grand Valley Institution and the Independent Psychological Report produced by Dr. Margo Rivera as part of that investigation.
CSC has categorized the recommendations as follows:
The Office of the Correctional Investigator recommended that the Correctional Service provide a full public accounting of its response to the OCI Deaths in Custody Study. This should include a detailed action plan with clearly identified outcomes and timeframes.
Six themes have been identified that relate to the Deaths in Custody Study and CSC has categorized them as follows:
The Office of the Correctional Investigator 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.
The Office of the Correctional Investigator recommended that CSC issue immediate direction to all staff regarding the legislated requirement to take into consideration each offender’s state of health and health care needs (including mental health) in all decisions affecting offenders, including decisions relating to institutional placements, transfers, administrative segregation and disciplinary matters. CSC decision-related documentation must provide evidence that the decision-maker considered the offender's physical and mental health care needs.
The Office of the Correctional Investigator 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 and Regional Deputy Commissioners and, in the case of women offenders, to the Deputy Commissioner for Women.
The Office of the Correctional Investigator recommended that CSC seek independent expertise – with a strong women-centred component – to review its policies on managing self-injuring inmates, and inmates displaying challenging behavioural issues. This review should focus on the appropriateness of placing those inmates on administrative segregation status.
The Office of the Correctional Investigator recommended that all CSC National Boards of Investigation into incidents of suicide and self-injury be chaired by an independent mental health professional.
The Office of the Correctional Investigator 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.
The Office of the Correctional Investigator recommended that CSC amend its segregation policy to require that a psychological review of the inmate’s current mental health status, with a special emphasis on the evaluation of the risk for self-harm, be completed within 24 hours of the inmate’s placement in segregation.
The Office of the Correctional Investigator 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.
The Office of the Correctional Investigator 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.
The Office of the Correctional Investigator recommended that the Senior Deputy
Commissioner review all of the complaints and the Service’s response to those complaints that were submitted by Ms. Smith during her period of federal incarceration, inclusive of the complaint submitted by Ms. Smith in September 2007 at Grand Valley Institution. A written response to these complaints should be issued and appropriate corrective action and policy clarification should be undertaken.
The Office of the Correctional Investigator recommended that all grievances related to the conditions of confinement or treatment in segregation be referred as a priority to the institutional head and be immediately addressed.
The Office of the Correctional Investigator 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.
The Office of the Correctional Investigator 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.
The Office of the Correctional Investigator recommended that 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.
That Correctional Service of Canada immediately begin the process of identifying and putting in place appropriate alternatives to long-term administrative segregation for inmates with severe mental health issues who are not certifiable under provincial mental health legislation and do not consent to treatment. It is imperative in the design/development of such alternatives that there be no contact between high profile/high risk inmates (i.e., Management Protocol offenders) and inmates who have difficulty with behavioural and emotional disregulation and therefore require this specialized type of facility.
That the role of the Women Offender Sector, including authorities, reporting relationships, accountabilities and responsibilities, be reviewed, revised as necessary and communicated to all parts of CSC so they are working collaboratively to effectively manage women offender issues, particularly those impacting challenging inmates such as this one.
That the Women Offender Sector, in collaboration with Mental Health and in conjunction with regional management, establish an inter-disciplinary mental health team approach, involving external experts as required, to assist institutional management effectively deal with each woman inmate with severe mental health needs. The role of the inter-disciplinary team would be to work with each site to identify the necessary resources, develop the management and reintegration plan, ensure appropriate staff are available and trained to implement the plan and provide direction and support to the institution to ensure the quality and effectiveness of implementation. The inter-disciplinary team should have final decision making authority on all aspects of managing the case.
That the Correctional Service of Canada policy be introduced and/or revised to clarify that any authorized item that is used, or altered to be used, by an inmate for self-injury be considered unauthorized and be required to be removed immediately regardless of the level of assessed risk.
That the role of health care at women’s institutions be strengthened to ensure they are an integral part of the Secure Unit team and that the Chief Health Care is involved in all decisions relating to the management and care of inmates with severe mental health needs.
That a more efficient use of force review process be developed for cases that generate more than a specified number of uses of force and that this process involve a joint review by institutional, regional and national representatives so immediate concerns can be identified and appropriate action taken to rectify them.
That the resource indicators for all disciplines at women offender facilities be reviewed and adjusted as required to ensure adequate staff coverage on all shifts. This review should give specific consideration to issues impacting safety and security (i.e. the requirement for an additional two-person patrol team).
That an immediate review of the recruitment and staffing practices at Grand Valley Institution be completed, with specific emphasis on the number of approved accommodations. This will address the instability that has been a constant for several years and ensure critical vacancies are filled, overtime utilization is decreased, ordering of staff is eliminated and operational adjustments are appropriately utilized.
That specialized training in the area of mental health be enhanced for all staff at women institutions. Specifically, the National Training Standards for Dialectical Behaviour Therapy should be reviewed to ensure management and all staff working in women's facilities are familiar with the concepts. All frontline staff who are expected to use Dialectical Behaviour Therapy in their interactions with inmates should receive more in-depth training and more frequent refresher training. General mental health training should be developed and be mandatory training for all staff working in women’s institutions.
That a review of the design of segregation units at the women institutions be undertaken with specific emphasis on the design of cells equipped with cameras and that physical changes be made to assist staff more effectively observe, manage and interact with high need offenders.
Difficult to serve women offenders with mental health problems should not be transferred from one institution to another in response to staff complaints or staffing constraints. The assumption should be that it is in the woman’s interest to remain in her home institution. Any transfers of such inmates should only be undertaken when it is clearly in the woman’s interest, and the request and rationale for such a transfer should be thoroughly scrutinized at the highest level of CSC, including the Deputy Commissioner for Women, the Manager of Mental Health Programs for Women, and Regional Headquarters.
Management of particularly difficult-to-serve women offenders with mental health problems should be supervised directly at the national level.
A pre-treatment individualized Dialectical Behaviour Therapy program should be constructed for women offenders with problems in emotion and behaviour regulation who are not able for a variety of reasons to participate in group programming, with some resources that could be used in individual sessions with mental health professionals and others that could be used by the inmate with the help of the security staff.
Security, Health Care and Psychological Services should be more integrated in the Women’s Institution to ensure best practices are carried out regarding the care of women offenders.
Structures should be put in place for all CSC sites whereby all staff have an opportunity to address issues of concern to them regarding any of the practices they are asked to carry out in the workplace, particularly when they relate to the best interests of the women offenders in their care. At all levels, staff should be encouraged to put such concerns in writing.