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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 CSC National Board of Investigation into the Death of an Offender at Grand Valley Institution for Women – December 18, 2009

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.


  • CSC has revised its dynamic security policy to clarify staff and manager responsibilities. The revised policy will take effect on December 30, 2009. Dynamic security is a key method of ensuring safety within CSC institutions. It requires that CSC staff members observe, speak with, and interact with offenders in a meaningful way on a daily basis to develop and maintain their knowledge of behaviours or factors that may compromise the safety of staff, offenders, or the institution at large. (Rec. 2 OCI)
  • CSC has revised its use of force policy to include a requirement that the review of a use of force incident be expedited in cases where the institutional head has identified a serious violation of legislation or policy. (Rec. 1 OCI, Rec. 6 CSC)
  • CSC is confident that its current policy ensures any complaints or grievances related to segregation or cell confinement status are reviewed and addressed in a timely manner. While CSC does not agree with the OCI recommendation that all grievances related to the conditions of confinement or treatment in segregation be referred to the institutional head as a priority, CSC has amended its offender complaints and grievances policy to ensure that complaints and grievances connected with segregation/cell confinement status are reviewed daily. Furthermore, those complaints and/or grievances which significantly impact or infringe on an offender's rights and freedoms will immediately be brought to the attention of the Institutional Head. (Rec. 13 OCI)
  • CSC amended its use of force policy to allow Correctional Managers, Crisis Managers, or Institutional Heads to develop an “intervention plan” to respond to inmate behaviour. This plan can use front-line officers as an alternative to the deployment of the formal Emergency Response Team to quickly respond to an incident. This alternative is used only in cases where it is safe to do so and provides managers with another tool to address inappropriate inmate behaviour quickly and effectively. (Rec. 1 OCI)
  • A case management bulletin on the prevention, management and response to suicide and self-injury was issued to ensure that mental health needs are explicitly considered in all transfer decisions. (Rec. 1 & 4 OCI; Rec. 1 Rivera)
  • CSC does not support the OCI’s recommendation that Wardens of women’s institutions report directly to the Deputy Commissioner of Women, independent of Regional Deputy Commissioners. Recognizing the need for a strong and effective governance structure for women offenders, CSC is confident that the current reporting structure is the best one. It ensures that the Deputy Commissioner of Women provides strong leadership on issues related to women offenders, while Regional Deputy Commissioners remain responsible for the day-to-day operations of all institutions, including women’s institutions, within their regions. Making the Deputy Commissioner of Women responsible for the day-to-day operations of women’s institutions would result in a duplication of efforts and confusion over accountabilities. (Rec. 3 OCI; Rec. 2 CSC)

Mental Health

  • CSC is now using an enhanced mental health screening tool at each of its 16 intake sites to screen offenders for possible mental disorders, depression, suicide risk and feelings of hopelessness. (Rec. 2 OCI)
  • CSC has developed an internal Mobile Interdisciplinary Treatment Assessment and Consultation Team (MTAC) to assist staff in effectively supervising and assisting offenders exhibiting complex mental health issues. MTAC is an on-demand, mobile team, comprised of CSC experts from various backgrounds, representing psychology, case management, and security. It is available to assist with female and male offenders. (Rec. 1 OCI; Rec. 2 Rivera; Rec. 3 CSC)
  • CSC has provided operational staff with tools and guidelines to use when developing plans for dealing with offenders who self-injure, including Clinical Management Plans. (Rec. 6 OCI)
  • CSC is implementing a comprehensive recruitment and retention strategy to attract more Psychologists and health care workers. However, we continue to be in competition with other sectors that remunerate these professionals at higher rates than the federal public service. (Rec. 2 OCI)
  • CSC is working closely with its federal, provincial, and territorial partners, as well as stakeholders, to address mental health issues as they relate to corrections. CSC brought international and Canadian experts together at a Symposium on Mental Health where practical solutions for improving the delivery of health services were examined. CSC also hosted a forum that explored the nexus between Canada's mental health and criminal justice systems and examined the system-wide challenges to addressing mental health issues within the criminal justice system. CSC has also shared with its provincial and territorial counterparts a document highlighting good practices to take into consideration when managing an offender who self-injures. (Rec. 15 & 16 OCI)
  • CSC has developed a web-based interactive training tool, called the Responsivity Portal. This tool assists staff to identify, accommodate, and adapt training to offenders of different age groups, those with learning delays or disabilities and offenders with mental health problems. (Rec. 1 OCI)


  • To verify the safety of offenders inside institutions, CSC has added a second “stand-to inmate count” at all maximum, medium, and multi-level institutions between the hours of 6 p.m. and 12 a.m. and introduced a stand-to inmate count at minimum-security institutions between the hours of 6 p.m. and 12 a.m. (Rec. 2 OCI)
  • CSC has also increased the number of security patrols at all maximum, medium, and multi-level institutions (excluding women's institutions) to provide more opportunities to detect changes in offender behaviour and attempts to intervene at the appropriate time. (Rec. 2 OCI)
  • To ensure effective levels of front-line staff within its institutions, CSC has implemented new deployment standards that result in a greater level of standardization in the staffing of posts in similar institutions. (Rec. 2 OCI; Rec. 7 & 8 CSC)
  • The preservation of life is CSC’s paramount duty when dealing with offenders under our care and custody. This responsibility has been and will continue to be communicated to all levels of staff within the organization and preservation of life is the guiding principle behind CSC’s current Situation Management Model. It requires that CSC staff consider an offender’s history of self-injury and potential for future self-injury when intervening in cases of inappropriate inmate behaviour. (Rec. 1 & 11 OCI)
  • CSC issued a Security Bulletin to clarify “immediate intervention” in response to suicidal and self-injurious offenders. Specifically, any item used by an offender to inflict or attempt to inflict self-injury requires an appropriate and immediate intervention by staff that is both safe and reasonable in order to seize / retrieve the item. The bulletin emphasized that preservation of life is the primary goal of the intervention. (Rec. 1 & 4 CSC)

Administrative Segregation

  • Administrative segregation is a tool used to ensure the safety of staff and inmates, as well as the security of the institution. It is intended to be used for the shortest period of time deemed necessary. CSC has strengthened its policies to ensure the segregation process is safe, humane, and subject to appropriate review. Under CSC policy, Regional Segregation Review Boards and Regional Segregation Oversight Managers ensure that each case of an inmate remaining in segregation is reviewed regionally every 60 days. A National Population Management Committee was established and provides national monitoring of the use of administrative segregation and, in cases where the regions deem it appropriate, they may also refer cases to the Senior Deputy Commissioner or Deputy Commissioner for Women for review or advice. (Rec. 8 OCI)
  • CSC also amended its policy on segregation to ensure an offender's state of health and health care needs are explicitly considered and documented when making a segregation decision. (Rec. 4 OCI)
  • CSC has also clarified and more precisely defined the role of Health Care and Psychology in the review process prior to and during segregation placements. (Rec. 4 OCI; Rec. 4 Rivera)
  • CSC has produced a segregation handbook for staff to clarify policy requirements for the timely review of segregation cases. (Rec. 4 OCI)
  • CSC has established secure interview rooms in the Secure Units of women's facilities, where offenders with mental health and/or behavioural needs can meet with staff or stakeholders in a secure setting. These rooms also provide women offenders with time out of cell to focus on programs and leisure activities. (Rec. 1 OCI, Rec. 10 CSC)
  • CSC has adapted elements of the Women's Violence Prevention Program so that women offenders incarcerated within Secure Units or segregation units can receive programming. To date, the revised program has been piloted in two of five women's institutions. (Rec. 2 OCI)
  • Work is underway to establish an external review board which will conduct an operational examination of long-term segregation using a representative sampling of cases where offenders with mental health and behavioural needs have been placed in long-term segregation. A report will be presented to the Commissioner in early fiscal year 2010-2011. (Rec. 5 OCI, Rec. 5 CSC)
  • CSC does not fully support the OCI’s recommendation that a psychological review of an inmate’s current mental health status, with a special emphasis on evaluating their risk for self-injury, be completed within 24 hours of admission. That said, CSC does agree that early assessment is essential and policy requires that an offender’s mental health and physical needs are assessed by a medical professional within 24 hours of admission to segregation. Following this assessment, the medical professional makes any appropriate referrals to psychology as required. CSC will continue to ensure that nursing staff are available to provide this initial assessment. (Rec. 9 OCI)
  • CSC does not support the OCI’s recommendation that CSC immediately implement independent adjudication when an inmate with mental health concerns is placed in segregation. The current CSC policy includes safeguards to ensure that all mental health issues are considered and documented before an inmate is placed in segregation. CSC is mandated under its governing legislation to make decisions regarding segregation placements that maintain a safe, secure, and humane environment for staff, offenders, and the public. Any adjustment to CSC’s authority would require a change in legislation. CSC does not believe that such a change would improve the safeguards that are now in place. (Rec. 10 OCI)


  • CSC is training front-line staff in mental health awareness. To date, approximately 400 institutional staff (mostly nurses and parole officers) have received training. As well, more than 1,300 front-line staff working in the community have received training. (Rec. 1 OCI, Rec. 9 CSC)
  • CSC is providing training in mental health and dialectical behaviour therapy to both managers and staff that work with high-needs women offenders. (Rec. 9 CSC, Rec. 3 Rivera)
  • More than 300 CSC Psychologists have received additional training in suicide risk assessment from an expert in forensic suicide assessment and prevention.(Rec.1 OCI)
  • CSC's training program for Correctional Officers has been changed to put more emphasis on dynamic security. It is being implemented through the new recruit training program and will be reinforced through future refresher training. (Rec. 1 OCI)

Capacity at Women's Institutions

  • CSC has added 45 beds at its women's institutions in general population to address the increasing number of women offenders sentenced to a federal institution. (Rec. 1 OCI, Rec. 1 Rivera)
  • CSC is pursuing funding to implement short and long-term strategies developed to address the specific service, support, and accommodation needs of women offenders with mental health and behavioural needs. (Rec. 1 OCI, Rec. 1 CSC)


  • The quality and timeliness of CSC's investigations into deaths in custody and other incidents have continued to improve during the past year. CSC has eliminated a backlog of investigations and the majority of routine investigations are completed within the prescribed six-month timeframe. (Rec. 2 OCI)
  • CSC is sharing quarterly summaries highlighting all pertinent issues and statistical information around deaths in custody (excluding deaths by natural causes) with the Office of the Correctional Investigator and all CSC staff. (Rec. 2 OCI)
  • CSC is establishing an independent review group to meet annually to assess its actions and responses to deaths in custody and identify any gaps in responses and any best practices for sharing across the country. (Rec. 2 OCI)
  • CSC does not support the OCI’s recommendation that all CSC National Boards of Investigation into suicides or self-injury be chaired by an independent mental health professional. Under current policy, investigations into incidents involving health care issues normally include a registered health professional. Where necessary, CSC’s Boards of Investigation augment their investigative teams with external experts or specialists. (Rec. 7 OCI)


  • Complaints and grievances submitted by segregated offenders are identified daily and monitored daily. (Rec. 2 & 13 OCI)
  • CSC is undertaking an external review of the offender complaints and grievance process that will be tabled with the Commissioner early in fiscal year 2010-2011. (Rec. 14 OCI)
  • CSC has completed a review of all known complaints and grievances filed by Ms. Smith. (Rec. 12 OCI)

Values and Ethics

  • CSC has communicated to staff its new Internal Disclosure Policy, introduced a new Director of Internal Disclosure, and explained their function and responsibilities. (Rec. 1 OCI, Rec. 5 Rivera)
  • The Service is enhancing awareness and monitoring of values and ethics through actions such as workshops for staff and managers, ethical climate surveys, establishing local ethics committees at select sites, and inviting unions to make presentations to the National Ethics Advisory Committee. (Rec. 1 OCI)


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.


Recommendations from the 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

Recommendation 1: (Supported)

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:

  • 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
Recommendation 2: (Supported)

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:

  • Dynamic Security
  • Ongoing Assessments
  • Need to Enhance Provision of Intervention Services
  • Physical Infrastructure Deficiencies
  • Strengthening Managerial Accountabilities
  • Additional Actions
Recommendation 3: (Not Supported)

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.

Recommendation 4: (Supported)

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.

Recommendation 5: (Supported)

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.

Recommendation 6: (Supported)

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.

Recommendation 7: (Not Supported)

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.

Recommendation 8: (Supported in part)

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.

Recommendation 9: (Supported in part)

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.

Recommendation 10: (Not Supported)

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.

Recommendation 11: (Supported in part)

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.

Recommendation 12: (Supported)

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.

Recommendation 13: (Supported in part)

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.

Recommendation 14: (Supported)

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.

Recommendation 15: (Not directed to CSC)

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.

Recommendation 16: (Supported)

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.



Recommendation 1: (Supported – overall direction)

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.

Recommendation 2: (Supported)

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.

Recommendation 3: (Supported in principal)

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.

Recommendation 4: (Supported in part)

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.

Recommendation 5: (Supported)

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.

Recommendation 6: (Supported)

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.

Recommendation 7: (Supported)

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).

Recommendation 8: (Supported)

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.

Recommendation 9: (Supported in part)

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.

Recommendation 10:(Supported)

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.

Recommendation 1 – Psychological Resource (Rivera): (Supported in principle)

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.

Recommendation 2 – Psychological Resource (Rivera): (Not supported)

Management of particularly difficult-to-serve women offenders with mental health problems should be supervised directly at the national level.

Recommendation 3 – Psychological Resource (Rivera): (Supported in part)

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.

Recommendation 4 – Psychological Resource (Rivera): (Supported)

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.

Recommendation 5 – Psychological Resource (Rivera): (Supported)

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.