Response of the Correctional Service of Canada to the Correctional Investigator’s Report a Three Year Review of Federal Inmate Suicides (2011-2014)

(February 2015)

Recommendation 1:

As a matter of immediate priority, CSC should remove all known suspension points in segregation cells across the country. Where this is deemed technically or economically unfeasible, such cells (or ranges) should be decommissioned.

Despite our best collective efforts and security measures taken to prevent inmates from taking their lives, unfortunately, there are some inmates each year who commit suicide. Any loss of life, and certainly any suicide, is an incident that detrimentally affects the entire institutional population of both staff and inmates.

Suicide prevention is the collaborative responsibility of administrative, operational, intervention and clinical staff and it must continue to be a top priority in our institutions.

CSC continues efforts to mitigate and or eliminate all known suspension points within our identified segregation units. Some examples include, utilizing collapsible coat racks, removing conduit and introducing new furnishings that limit suspension points. Notwithstanding, it is not possible to mitigate all suspension points within a cell while still providing for basic human needs. CSC continues to review the infrastructure and fixtures within its facilities and explore solutions to further reduce or mitigate suspension points that arise in order to ensure that all facilities provide a correctional environment that is safe, secure and conducive to both inmate rehabilitation and public safety.

Recommendation 2:

Long-term segregation of seriously mentally ill, self-injurious or suicidal inmates should be expressly prohibited.

Response to this recommendation was integrated in the response to the recommendations touching the death of Ashley Smith.

Recommendation 3:

CSC should immediately post the Final Report of the Second Independent Review Committee into Federal Deaths in Custody 2010-2011 as well as its response to the report's findings and recommendations on its external website.

The Final Report of the Second Independent Review Committee into Deaths in Custody (2010-2011) was posted on CSC's external website on August 14, 2014. The response to the Report's recommendations was posted on November 12, 2014.

Recommendation 4:

CSC should continue producing its Annual Inmate Suicide Reports or replace it with an annual report that includes analysis of all deaths in custody regardless of cause. This reporting mechanism would include a roll-up of significant findings and recommendations emanating from CSC boards of investigations, mortality reviews of natural cause deaths, as well as pertinent issues identified by provincial and territorial Coroner and fatality inquires involving federally sentenced inmates. Corrective measures aimed at mitigating organizational risk should be a prominent feature of these public progress reports.

CSC is currently developing a framework for an Annual Deaths in Custody report to which all CSC sectors involved in managing relevant data can contribute.  The framework will detail statistics for all deaths occurring in CSC institutions, including deaths by suicide, and will include a summary of characteristics of offenders who die in custody as well as a focus on investigation recommendations, lessons learned, and responses.  The Annual Deaths in Custody Report is being finalized and it is anticipated that it will be completed by the end of this fiscal year.

Recommendation 5:

CSC should compile and publish, in one comprehensive evergreen document, the various components of its suicide awareness and prevention program/strategy.

CSC has compiled an overview of the various components of its suicide awareness and prevention initiatives in December 2014.  This document will be included in CSC's Deaths in Custody annual report.

Recommendation 6:

A national effort, led by Health Services, should identify inmates at elevated risk of suicide who are held in long-term segregation or have a history of repeated placements and develop appropriate mitigating measures to be shared with operational sites.

CSC has taken steps to address this recommendation. Health Services is a member on CSC's National Long-Term Segregation Review Committee which reviews the cases of inmates in administrative segregation.  Health Services confirms the needs and services received by those offenders with mental health needs.  As intermediate mental health care becomes available (in fiscal year 2015-2016) placement and services for those offenders that require this level of care will be considered.

Recommendation 7:

The Regional Complex Mental Health Committees should directly oversee the treatment and management plans of inmates on active suicide watch or mental health monitoring placed in segregation, observation, psychiatric or behavioural cells.

Response to this recommendation was integrated in the response to the recommendations touching the death of Ashley Smith.

Recommendation 8:

Psychological autopsies conducted in the course of investigations into prison suicides should be expanded to determine possible underlying causes and comparative profiles of other inmates who had committed suicide.

Although the psychological autopsy is a known approach to understanding suicide, there is no standard format available for completing the process.  For several years, CSC has been including the completion of a comprehensive psychological review as part of the mandate of every Board of Investigation into a suicide. This review is completed by the psychologist assigned to the Board of Investigation.

Recommendation 9:

Beyond compliance, boards of investigation into prison suicides should be encouraged to focus on identifying organizational gaps and environmental risks (e.g. access to means to commit suicide) that could potentially prevent similar future deaths.

All Boards of Investigations (BOI) into suicides are required to explore any potential environmental risks and are encouraged to identify organizational gaps.  These are routinely discussed during the debriefing of preliminary findings and recommendations at the national level with both the Director General, Incident Investigations and policy holders.  Furthermore, discussions regarding organizational gaps also occur amongst senior management at National Investigations Meetings in order to potentially prevent similar deaths.

Recommendation 10:

CSC should routinely share boards of investigations with designated family members as well provincial and territorial Coroner and Medical Examiner Offices regardless of whether the death goes to inquest or public fatality inquiry.

CSC works with the designated family members following the death of a loved one in custody. The Director General, Incident Investigations informs the next-of-kin that, as per section 19 of the Corrections and Conditional Release Act, an investigation has been convened to determine the facts and circumstances surrounding the death and, in accordance with the Access to Information and Privacy Acts, when the report is expected to be made available. 

Board of Investigations' reports and/or other related documentation (i.e. measures and actions taken as a result of the investigation) are shared with Provincial and Territorial Coroners and Medical Examiners as appropriate.

Recommendation 11:

All staff training across the Service, including induction, refresher and upgrading, should contain more practical focus on mental health issues and concerns in corrections. In-class training should be delivered in a live and interactive manner by mental health professionals with the aim of assisting security staff to identify and safely manage self-injurious, mentally disordered or suicidal inmates.

CSC provides initial and refresher training to front line CSC staff with a practical focus on working with offenders with mental health issues. Specific courses include Fundamentals of Mental Health, a 2 day, mandatory training for correctional officers, correctional managers, primary workers, older sisters/older brothers and parole officers. The content includes activities that focus on application of policy, knowledge and skills to case scenarios that are reflective of real correctional situations. Suicide and Self-Injury Prevention Initial Training is a mandatory training for all staff in CSC. In addition, Suicide and Self-Injury Intervention Refresher Training (SSIRT) includes a one hour online component which is required yearly, and a two-hour scenario-based, in-class module to be taken every two years. The majority of training focussed on mental health issues as delivered by, or in collaboration with, health professionals, including nurses, psychologists, and social workers.