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Nova Institution for Women

Section 3: Duty of care

Bullying behaviour ('muscling')

Expected outcomes:
Everyone feels safe from bullying (muscling) and victimization (which includes verbal and racial abuse, theft, threats of violence and assault). Active and fair systems to prevent and respond to bullying behaviour are known to staff, inmates and visitors, and inform all aspects of the regime.

3.1

Almost half of the women believed they had been victimized by others at some time. A difficult balance between direct supervision and allowing women to take responsibility for their own lives had to be maintained, but there was no anti-muscling policy to protect vulnerable women living in a largely unsupervised environment. There was no monitoring or analysis of incidents. Investigations did not record clear outcomes to demonstrate that muscling was being addressed effectively.

3.2	In the CSC, bullying behaviour was usually referred to as muscling. We use this term in the report to refer to intimidation, victimization and harassment by other inmates, including verbal and racial abuse and threats and psychological intimidation. Such behaviour can also manifest itself in exclusion, isolation, being singled out and treated differently by other women inmates.
3.3	On the surface, Nova appeared a relaxed and safe environment for most women. However, although there had been no formal complaints about harassment during the fiscal year 2004-05, some women had felt intimidated and had been victims of muscling. In our survey, 49% of respondents said that they had felt unsafe at Nova at some point, which was significantly higher than the English comparator of 32%. And 49% said they had been victimized by another inmate, compared to 24% in England.
3.4	Incident reports in which muscling was a factor were not monitored, although this was possible through the incident reporting system. There had been no confidential surveys to indicate the extent of muscling and any trends.
3.5	There was no local policy or strategy to help staff respond to inmate-on-inmate muscling. The CSC had developed general policies in this area, but these were mainly staff-orientated. CSC staff were trained in the joint learning program on anti-harassment developed by the Public Service Alliance and the Treasury Board; 123 staff had received some anti-harassment training. The Offender Complaint and Grievance Procedures manual referred to how women could deal with harassment, and a Policy Bulletin also covered this area. Further standard guidance on harassment within the terms of the Canadian Human Rights Act was being developed for inclusion in the inmate handbook.
3.6	We reviewed 22 officer statement/observation reports where muscling was a factor. It was clear from these reports that many women had approached staff about muscling. In our survey, 32% said that they had reported the victimization they had experienced, which was more than the English comparator of 14%. These reports showed evidence of muscling such as exclusion, physical assaults, intimidation and theft. Many reports concerned suspected theft of cigarettes and incidents relating to sharing food. In our survey, 21% said that they had been hit, kicked or assaulted by another inmate, which compared poorly with 5% in the English surveys. We were also told anecdotally about women wanting to be admitted to the secure unit for protection. Some staff suspected that muscling had been a factor in a recent incident where a woman had attempted to escape and had to be cut down from the razor wire.
3.7	It was not clear that incidents of muscling were dealt with effectively. Observation reports indicated that officers were aware of the potential consequences of muscling, but others were described as 'dramas'. The reintegration operations supervisor (ROS) highlighted observation reports to staff at morning meetings. The security intelligence officer (SIO) then processed these, completed a security intelligence report and decided further action. Through her experience of investigating incidents and collating reports, she was able to identify individuals regularly involved in muscling.
3.8	Some incidents were resolved informally with the agreement of the individuals concerned, although this agreement was not often recorded. Others were referred to the inmate committee - giving women the responsibility to resolve issues without formal intervention. This was appropriate for minor incidents. Mediation was also used through case management teams or primary workers. In serious cases, bullies were reclassified and moved to the secure unit, charged with a criminal offence or, in rare cases, transferred from the institution. In most cases, victims were offered a move to a different house, rather than the bully being moved. There were no specific programs or interventions for bullies to confront their behaviour, and no established support system for victims.
3.9	We were concerned that some women were particularly vulnerable because of their age or ability, especially during their early days of custody, but there was little staff supervision. There was no reception unit to help new arrivals integrate into the community, and no formal system of peer support at this crucial time (see action point 1.36).

	Action points

3.10	All incidents of muscling should be recorded and monitored to develop a profile of this behaviour across the institution.
3.11	There should be an annual confidential survey of women's experiences and perceptions of muscling, to inform the strategy.
3.12	Investigations into incidents of muscling should show evidence of action taken, and incidents should be followed up to support victims and challenge bullies about their behaviour.

Self-harm and suicide

Expected outcomes:
Inmates at risk of self-harm or suicide are identified at an early stage, and a care and support plan is drawn up, implemented and monitored. Inmates who have been identified as vulnerable should be encouraged to participate in all purposeful activity. All staff are aware of and alert to vulnerability issues, are appropriately trained and have access to proper equipment and support.

3.13

Nova provided a non-restrictive environment for most women in which there were low levels of self-harm and a good awareness of women at risk. Case management and support were good, particularly in the SLE. But initial responses were too reliant on the use of segregation with protective clothing being used but not recorded. A good range of help and care was provided, but there was no formal peer support and no coordinated safer custody strategy to bring together all those involved.

3.14	There were low levels of self-harm. The relaxed and open environment was a significant contributory factor to this, and helped women to deal with stressful events.
3.15	Women known to be at risk of self-harm were on the computer-based offender management system. Eight incidents of self-harm, involving seven women, were recorded in the 12 months before the inspection. A report of inmate injury was completed following each incident. Most of the incidents in the previous six months had involved cutting, usually with a razor. One woman had been identified as at risk of self-harm at the time of our inspection.
3.16	One psychologist had the role of suicide prevention coordinator, monitoring the institution's suicide prevention effort and collating statistics. There was no separate log of incidents of self-harm, detailing information such as the location and nature of self-harm, to help identify any emerging trends.
3.17	There was no clear formal system for the provincial prisons to communicate information about a woman's risk of self-harm. In many cases, little information was received. However, there was no evidence that this had placed individuals at risk, as there were systems to identify those at risk on arrival at Nova although some were inappropriately placed in the segregation unit (see paragraph 1.16).
3.18	There was little published advice or information for new arrivals or visitors about what to do if they thought they or another woman was at risk of self-harm.
3.19	When staff had concerns about a woman they completed a suicide risk assessment and referral form. This included a checklist and a behaviour contract, which required the woman to agree not to harm herself before she had spoken to a psychologist or another member of staff. If she did not sign the contract staff had to call the psychologist immediately. When the psychologist was not available, at evenings or weekends, the manager in charge, or warden or deputy warden decided what action to take
3.20	Psychologists had the lead role in assessing and directing the care of women at risk of self-harm. Until a psychologist's assessment had been completed women were more likely to be placed in involuntary segregation under observation. The assessment included decisions about the length of time a woman remained in segregation or on camera watch.
3.21	While a woman was being monitored in the segregation unit a log was kept of the camera observations. Watches were made every 15 minutes and these were recorded throughout the 24-hour period and initialled by the officer completing them. Officers entered a code to indicate what the woman was doing at the time of the observation (for example, eight for standing, 12 for sleeping). There was also a written record of visits to the cell, but there was little indication of interaction or enquiry about the woman's welfare. In some cases, the records referred to women by their surname only.
3.22	There were no clear records of how often segregation was used for those at risk of self-harm, and it was not possible to know how long women were held in these conditions, sometimes observed by camera and in protective clothing. A commissioner's directive allowed security garments to be used, but only to prevent self-mutilation when all other reasonable methods of control had been tried.
3.23	The decision for involuntary segregation was taken on the basis that: 'failure to segregate could jeopardize the person's own safety or that of others'. We were concerned that segregation would do little to enhance self-esteem, could be seen as a punitive response, and might inhibit some women from disclosing thoughts of self-harm. Some women and staff believed that segregation was the usual first response to a woman who disclosed she might self-harm, mainly because of the lack of residential units with staff supervision. We did not believe that involuntary segregation was appropriate, except in carefully documented, exceptional circumstances.
3.24	There was no peer support for women at risk of self-harm as a possible alternative to the use of segregation. An informal peer support scheme had operated previously under the auspices of healthcare but had not done so for two years or so. The suicide prevention coordinator was unclear why this had been discontinued. Primary workers and other staff did not involve families or significant others routinely or actively in the care of someone at risk.
3.25	There was a good range of other support. This included some support for victims of abuse and those with problems with drugs, behavioural counsellors, the Elizabeth Fry Society and a psychiatrist.
3.26	There was good oversight of the cases of women at risk, with weekly interdisciplinary reviews for those held in the segregation unit and in the SLE and monthly reviews by the mental health committee.
3.27	There had been some incidents of self-harm among the women living on the SLE (see paragraphs 8.34-8.37). In response, the SLE had established a protocol for dealing with those at risk of suicide, including a behavioural contract and work to generate alternatives to self-injury. The woman agreed to approach staff if she felt self-injurious. If she did self-harm she completed a behaviour chain analysis analysing her reasons for self-harm and her thoughts and feelings shortly after the incident.
3.28	A mental health committee, chaired by a psychologist, met monthly and reviewed all new admissions and the care of anyone for whom there were concerns. It was attended by nurses and occasionally by a parole officer and chaplain. Its focus was appropriately on case management. There was no clear forum to debate wider policy issues, such as links between self-harm and muscling, risks in the early days of custody and the role of peer support.
3.29	All correctional officers had completed a one-day suicide prevention training as part of their correctional training program. Other staff who had not completed this program received a half-day training on the new employee orientation program. Twelve staff had completed some training in 2002 and only seven in 2003-04. Many needed refresher training. All staff were required to undergo a two-hour computer-based refresher training every two years, but this package was not yet available.
3.30	There was some awareness of contingencies for responding to women who had self-harmed. Correctional officers carried masks, gloves and ligature cutters on their belts, but there had been no simulated medical emergencies.
3.31	A nurse and primary worker facilitated an inmate suicide awareness and prevention workshop. This aimed to provide a basic level of suicide awareness for all women and to promote overall mental health and well being. This was voluntary, although those who did not attend were offered a further opportunity to do so. Seventy-seven women had completed this since 2002, but only seven during 2005.

	Action points

3.32	The records of incidents of self-harm should be improved to identify any emerging trends, and record use of segregation, protective clothing and other interventions.
3.33	The published information and advice on the help available for women at risk of self-harm should be improved.
3.34	The psychology-led behaviourist approach to women at risk of self-harm should be developed to involve primary workers in managing cases and there should be a formal support scheme with overnight facilities where peer supporters can help women at risk.
3.35	Alternatives to segregation and camera watch for those identified as at risk of self-harm should be developed, including a formal peer support scheme.
3.36	A safer custody forum should be developed to consider the relationship between the policy areas that contribute to feelings of safety. These include muscling, early days of custody, peer support and alternatives to segregation.
3.37	Families and other significant people should be contacted and involved when a woman is at risk of self-harm, where this is appropriate and with the woman's agreement.

Race relations and diversity

Expected outcomes:
All inmates experience equality of opportunity in all aspects of prison life, are treated equally and are safe. Diversity is embraced, valued, promoted and respected.


3.38	There was no overt evidence of racial tensions but there was no monitoring of outcomes for women from different racial and cultural groups. Aboriginal women were over-represented in the segregation and secure units. There was some support and recognition of the separate needs of Aboriginal women, but not enough promotion of diversity issues.

3.39	Seventy-four per cent of women were Caucasian, 9% black and 11% Aboriginal. Six per cent were registered as 'other' or had no official designation. There was an Aboriginal native sisterhood group, which was supported by a paid elder and liaison officer. This group met once a week, in addition to special events and spiritual ceremonies. There was no black women's group.
3.40	There were nationally maintained records of Aboriginal women's access to offending behaviour programs. These could be checked locally to ensure equity of access. A team leader was responsible for ensuring broader equality of service provision and treatment. Although managers believed that women of all ethnicities and cultures had equal access and opportunity and used facilities and services equally, there was no easily accessible local information to confirm this. Because there was no diversity monitoring it was not possible to know if minority ethnic women were represented disproportionately in disciplinary charges, classification level, employment, access to escorted temporary absences or use of force or segregation or if they had equity in participation in recreation, residential houses or other activities.
3.41	Aboriginal women were over-represented in the maximum security classification nationally. Although at the time this was the case at Nova with three aboriginal women in maximum security, we were told that two of the women were waiting to transfer to Fraser Valley Institution.
3.42	The Aboriginal sisterhood met once a week but had no regular meeting place. During the inspection they were told to meet in the kitchen of the leisure area, where there was insufficient room and a number of interruptions. They needed a suitable space to meet in (see action point 5.57). The elder and liaison officer had just been allocated some office space but had not yet been issued with keys for access throughout the institution.
3.43	There were no records of racist incidents or complaints, and no separate system to manage or identify them. Race, culture and other diversity issues were not promoted positively as part of the orientation program. Support for Aboriginal women was appreciated, but there was little for other minority groups.
3.44	There were no foreign national women at Nova during the inspection but there were contingency plans to provide language support.

	Action points

3.45	A system for staff and inmates to report perceived racist incidents should be introduced, with complaints about racism identified and investigated separately.
3.46	There should be ongoing promotion of race equality and diversity for staff and inmates.
3.47	The Aboriginal support group liaison staff and elder should be issued with keys to allow access through the prison and to their office space.

Family and friends

Expected outcomes:
Inmates are encouraged to maintain contact with family and friends through regular access to mail, telephones and visits.

3.48

There were good entitlement to and facilities for visits, but women had very few visits. Family days were held but there was no promotion of regular family contact and no financial assistance for visitors who needed it. There was an excellent private family visiting facility, but this was also underused. Security procedures for vetting visitors and telephone contact caused unnecessary delay for women anxious to make contact with their family and friends.

	Mail

3.49	There was no random censorship of mail, although all mail was opened to check for any unauthorized items. Two women complained that their letters had been censored as they had been sent back to senders. When we checked we were told that letters with graphically offensive material were returned in accordance with the institution's policy on offensive material, which suggested that they had been read.
3.50	Legally privileged mail was logged and women signed for it on receipt and opened it in the presence of staff.
3.51	In our survey, 53% of respondents said they had problems sending or receiving mail, which was significantly worse than the English comparator of 33%. The admissions and discharge officer collected mail daily and distributed it to inmates' individual private post boxes, and dispatched all outside post at the end of each day. The arrangements for covering this work when the officer was detailed to other tasks relied on the reintegration operations supervisor, and there were frequently delays when they were hard pressed.

	Telephones

3.52	Access to telephones was good as there was a telephone on each house, although privacy was an issue (see action point 2.17). The system to check telephone numbers through the security department was similar to that for checking visitors (see below), causing delays for women in contacting their family and friends. There was also a total restriction on calling mobile telephone numbers, which was unsatisfactory as this prevented some women keeping in contact with family or friends who did not have landlines.

	Visits

3.53	All visitors needed to have security clearance before they were put on a list of approved visitors. Women were given the relevant visitor security checking forms to complete during the reception process, but they were not given any explanation other than referral to the inmate handbook.
3.54	Part of the primary worker's role during orientation was to check that new arrivals had completed their requests to have their visitors checked and to give them help if necessary. Those who needed this help could wait up to a week (see paragraph 1.25). In our survey, only 22% of respondents said they had been given information about visits on the day of their arrival.
3.55	The completed security form was sent to the nominated visitor to add their personal details and return to the institution. It was then passed to the security intelligence officer for processing. Delays frequently occurred at this point. If the nominated visitor had not completed the form properly it was returned. Although the security information officer had a target of one week in which to process the forms, she had other priorities and sometimes could not complete visitor requests within this timeframe. The process involved checks with the Canadian Police Information Centre. In the main, concerns were about offences involving drug trafficking or family violence. Following the checks all requests were brought to the weekly institutional review board for discussion and approval.
3.56	The process was rarely completed in less than three weeks, and on average it took over a month. Women who wanted and were able to have visits were frustrated by the time it took to get security clearance for their visitors. However, there was some flexibility in special circumstances, and we were given examples of some visits being allowed when the checks had not been completed.
3.57	In our survey, only 56% of respondents said they had the opportunity to have the number of visits to which they were entitled, which was significantly less than the English comparator of 71%. We were not able to obtain statistics from the institution on the number of visitors who had been refused. We examined a sample of requests and the minutes of the institutional review board, and it appeared that a reasonable approach was taken in individual cases. However, we questioned the need for security clearance of all visitors.
3.58	Visits had to be booked by telephone a day in advance, and visitors could book their next visit at the reception desk before they left the institution. Once confirmed, a package of information was sent to all visitors. This included information about a drug information tip line to enable visitors to report on anything relating to passing drugs into the institution.
3.59	Entitlement to visits was good and up to five visitors could attend together on a single visit. Visits were scheduled on two evenings during the week for a three-hour session, and at weekends there was a two-hour session in the mornings and a three-hour session in the afternoons. There was no upper limit to the visits that women were entitled to within that schedule. There was also a flexible approach to accommodating visitors outside normal visiting times by request.
3.60	Women received very few visits. Staff said that women tended to be abandoned by their families when they came into custody. Yet there was no family support work to actively encourage or facilitate family contact, and correctional plans did not cover the need to maintain family ties.
3.61	There was no financial assistance available for visitors who had significant travelling expenses, apart from the John Howard Society who provided some assistance for visitors from Newfoundland through a historical charitable arrangement. The lack of financial assistance was likely to have affected the ability of family and friends to visit women in Nova.
3.62	Inmates were frisk-searched before and after the visit. Visitors could be frisk searched but we were told that in practice other methods such as the use of the X ray machine, ION scanner and visual examination of baggage were used. Visitors also had a drug swab before entering the visits area. If the reading was positive, the security information officer carried out a threat risk assessment. In the absence of any other intelligence, the usual procedure was for staff to observe the visit discreetly. There was a small room for closed visits, although these were very few. There had been no closed visits during the previous 10 months. All closed visits were reviewed regularly at the institutional review boards but there was no aggregated data or overall monitoring.
3.63	Facilities for visits were good. The visits area was just beyond the reception desk. It was comfortable, refreshments were available and there were a few toys in reasonable condition. Visitors' toilet and nappy changing facilities were available in the visits area and there was a separate toilet for inmates. The toilets were shared by staff and were kept in good condition. Observation by staff from the reception desk area was discreet. Women on the secure or segregation units had their visits in a room on the unit, which was reasonably private and comfortable.
3.64	There was a private family visiting facility, which was a separate house in the main grounds. This offered women the opportunity to have their partners, children, parents, siblings or grandparents spend up to 72 hours with them as a family unit once every six weeks, or every three weeks for lifers. Women could also apply to use the house on their own for some personal quiet time, for which they had to undergo a psychological test beforehand. The private family visits facility was an excellent resource to promote family ties but, as with regular visits, the facility was much underused.
3.65	Family days were organized twice a year in the summer and at Christmas. As with other aspects of family contact the response was disappointing. Although 60 visitors were approved to attend the last family day, only 13 came.

	Action points

3.66	The process of security checks on telephone contacts and visitors should be revised, and speeded up especially for those visiting minimum-security women.
3.67	Women should be given basic information about their entitlements to visits during the reception process.
3.68	The importance of maintaining family contact should be recognized in correctional plans.
3.69	Financial assistance should be provided to visitors who are not able to visit due to financial hardship.
3.70	Detailed data on the imposition of closed visits should be collected and routinely aggregated to ensure that the system is operating correctly.

	Housekeeping point

3.71	Arrangements for distribution of mail should ensure that there are no delays.

Requests and complaints

Expected outcomes:
Effective request and complaint procedures are in place, are easy to access, easy to use and provide timely responses. Inmates feel safe from repercussions when using these procedures and are aware of an appeal procedure.

3.72

Women were well informed about how to make requests and complaints, understood the processes, and could speak to the warden in confidence by visiting her office. Access to procedures was less good for those in the segregation or secure unit. Complaints could not be posted confidentially as they were dealt with as part of the general post. The timescales for investigating complaints and reporting back were too long. There was no quality assurance and no analysis of patterns or trends of complaints.

3.73	Information on how to make requests was set out in the inmate handbook. There was also a detailed section describing the four levels of the complaints and grievances process. The grievance coordinator presented a session on complaints to new arrivals during their orientation. In our survey, 59% of respondents said that they were given information about how to make an appeal/file a grievance, which was significantly better than the English comparator of 30%.
3.74	Request and complaint and grievance forms were readily available from a well-stocked display in the leisure area, and there was a similar display in the secure unit. Women in the segregation unit had to ask staff for a request or complaint form.
3.75	There was a huge range of different request forms, which suggested overuse of the formal system of requests. The admissions and discharge officer dealt with requests through the normal internal mail system. Although all requests were photocopied and date stamped there was no central log. Consequently, there was no clear audit trail and it was difficult to track what had happened to requests when women complained of delays, which was often.
3.76	There was a good system of confidential access to the warden, who had an open door policy, and women often approached her directly . Such access was not available to women in the segregation or secure unit who had to apply to see the warden. However, the warden toured the segregation unit weekly which provided an opportunity for women to raise concerns.
3.77	Complaints were also dealt with through the normal mail system - women used the general post box and the admissions and discharge officer took the complaints to the grievance coordinator each day. This included complaints about staff. The lack of confidentiality was inappropriate.
3.78	All complaints and grievances were processed through the grievance coordinator, who also offered help in completing the forms when necessary. If a complainant wished to speak to someone from outside the institution about their complaint they were usually referred to the Citizens Advisory Committee or the Elizabeth Fry Society, who visited regularly.
3.79	If the complainant was not satisfied with the response to an initial complaint the process moved to the first level grievance stage, which was investigated by the team leader for management services at Nova. Appeals against first level grievances became second level grievances, which were referred to regional headquarters. Third level grievances were dealt with by national headquarters. Complaints and grievances were designated by the grievance coordinator as routine or high priority, and this set the timescale for investigation and reporting back at 25 days and 15 days respectively. These timescales were too long.
3.80	Fifty complaints had been submitted in the 10 months since the beginning of 2005. We examined a sample of complaints and first level grievances. The institution had no quality assurance system for such matters as consistency in responses and appropriateness and politeness of replies. The quality of responses varied considerably.
3.81	The grievance coordinator kept track of individual complaints though a running log, and the progress of individual complaints was monitored through monthly managers' meetings. We asked for some analysis of the complaints made during the previous 12 months, but we were told that it was not possible to produce data or analysis as records were only available for women who had made complaints and were still at the establishment. Following our enquiry, the complaints clerk requested some analysis from regional headquarters but they were only able to produce raw data. It was clear that neither the establishment nor regional or national headquarters analysed complaints for patterns or trends, although regional and national headquarters carried out an annual audit and occasionally asked for information on specific areas such as performance on timeliness of handling of complaints about staff harassment.
3..82	Complaints concerning allegations of victimization and/or harassment by staff were immediately treated as a first level grievance, were always designated high priority (bypassing the complaints stage) and referred immediately to the warden. The grievances against staff that we examined were investigated thoroughly and at an appropriate level of seniority. The complainant was given copies of statements collected and any other documents that had supported the response.
3.83	Complaints about lost or damaged personal effects were dealt with through a different process as claims against the Crown and submitted via the warden. There had been six such claims since the beginning of 2005. All had been investigated thoroughly and dealt with appropriately.
3.84	In our survey, 29% of respondents said that they had been made to or encouraged to withdraw a complaint, which was significantly more than the comparator of 12% in English prisons. We did not find evidence to suggest that women were coerced to withdraw complaints. It seemed possible that complaints dealt with appropriately by managers had been accepted by the complainant as satisfactorily resolved and subsequently withdrawn - a matter of interpretation.

	Action points

3.85	Primary workers should take verbal requests daily to reduce overuse of the formal system.
3.86	Requests to all departments should be logged so that there is an audit trail.
3.87	There should be a separate post box for complaints, and access to it should be restricted for confidentiality.
3.88	All complaints should be responded to within seven days, with either a resolution or an interim reply explaining what is being done.
3.89	Complaints should be quality assured to ensure that responses are timely, respectful, legible, and address the issues raised.
3.90	There should be regular analysis of complaints to identify patterns and trends.
3.91	Managers should satisfy themselves that women are not being pressured to withdraw complaints and a written record, signed by the complainant, should be kept on the complaint form explaining the reasons for it being withdrawn.
3.92	A supply of request and complaint forms should be freely available to women in the segregation unit.

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