The Final Report of the Independent Review Committee into Federal Deaths in Custody 2010-2011

Acknowledgements

As Chair of this Independent Committee, I would like to first acknowledge the great work of Director General Lynn Garrow, Incident Investigations Branch and her staff Michael Olotu and Julie Staples in recruiting, orienting and providing support to our committee. They provided a thorough project overview, were patient and diligent in answering questions or providing additional information when needed. As our primary contact, Mr. Olotu was impressive in his knowledge of each case and helpful in determining a reporting strategy. The Wardens and staff of the Regional Psychiatric Centre, Matsqui, Mountain and Kent Institutions in the Pacific Region were most welcoming during our initial orientation. Howard Sapers, Correctional Investigator and his staff are impassioned advocates for federal offenders and we found them most helpful in providing information and a synopsis of their issues and current concerns with Correctional Service of Canada.

I would also like to recognize the exceptional contribution of my colleague Dr. Tristin Wayte. Through her efforts, our report outlines both a general perspective and specific practices from the health field that we believe can be helpful and successfully applied to correctional settings. She outlines productive strategies from health that serve to prevent deaths and more effectively deal with their aftermath, and proposes some methods that corrections organizations can use to effectively incorporate them. Traditionally, many advances in corrections have been based on new developments in other fields, what some call "knowledge transference." Examples of transference might include therapeutic communities, stages of change theory and use of psychopharmacological medication, all innovations derived from other fields such as mental health, addictions and psychiatry. We believe that Dr. Wayte’s recommended methodologies, derived from the health field and others, can work as a useful form of «knowledge transference« and assist in improving Correctional Service of Canada practice.

I appreciate the contribution by committee member Dr. Julio Arboleda-Florez, although his involvement in the report was unfortunately limited due to travel and other work commitments.

Lastly, on behalf of the committee I would like to thank Mr. Don Head, Commissioner of Corrections for initiating this process. Frankly, it is unusual for senior public servants to invite independent reviews, particularly any that might be on-going. This speaks well of CSC’s interest in improving practice and continuing to develop as a «learning« organization.

Dr. Michael Weinrath,
Chair, Independent Review Committee
Federal Inmate Deaths in Custody, 2010-2011

Executive Summary

This report represents the second annual review of federal deaths in custody by an Independent Review Committee (IRC). The IRC was appointed by the Correctional Service of Canada’s (CSC) Commissioner of Corrections. The deaths reviewed here all took place during the 2010-2011 fiscal year (April - March) and were investigated by CSC’s Incident Investigations Branch, through Boards of Investigation (BOI). The deaths are categorized as drug overdoses, suicides, deaths where the cause is unknown, homicides and deaths due to staff intervention. Deaths by natural causes are not considered in this report. The IRC is expected to review the BOI reports and any other information it finds pertinent, to assess CSC’s performance. The mandate of the committee is set out in nine terms of reference, as follows:

1. The appropriateness and adequacy of the corrective measures and management action plans in response to those investigations;

   For this section, our independent committee primarily examined the Executive Committee Grid, which tracks BOI recommendations and findings, and ensures that satisfactory responses are received from local (i.e., institution) and Regional levels. The appropriateness of the recommendations to address the issues at hand, and the adequacy of responses from local and Regional levels, were evaluated by the committee.

   In addition, we rated the efficacy of CSC recommendations using methodology borrowed from health care organizations, the Canadian Patient Safety Institute’s (CPSI) Hierarchy of Effectiveness Scale. We summarize the CPSI-based evaluations in chapter nine.

2. An analysis of trends in contributing or precipitating factors to the deaths;

   In this section we took significant latitude in noting any trend that might contribute significantly or in part to the inmate death in question. Such trends might include precipitating events that immediately or proximately linked to a death, such as inmate conflict with staff or other inmates, bad news from family, or a security or parole denial. Trends might also include long-standing problems such as poor health, substance abuse, or negative family history.

3. An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths;

   Here we focused on an inmate’s mental health history such as past records of suicide, self-harm, depression and other conditions. We also reviewed more recent treatment, including mental health treatment plans and regimes, medication, adequacy of treatment, and follow-up.

4. An analysis of any trends in case management practices prior to the inmates' deaths;

   Case management includes assessment of staff work on program planning, security reviews and release preparation. We also reviewed the adequacy of inmate contact, report preparation and overall adequacy of the timeliness, and thoroughness of documentation.

5. An analysis of any trends in security practices such as staff presence and monitoring of inmate activities;

   Correctional officer staff plays a critical role in preventing inmate deaths through dynamic and static security measures.

6. An analysis of any trends in the management of and response to those emergencies in response to the inmates' deaths;

   Emergency response trends of concern included assessment of correctional staff response time after an inmate was found in distress and adequacy of response by correctional officers or health care staff in administration of medical assistance.

7. An assessment of information sharing among key players during the incident;

   Knowledge of the potential risk of overdose, suicide, or conflicts leading to violence are not of much use if not shared with other correctional staff.

8. An assessment of support provided to staff members and inmates after the incidents;

   We examined whether or not the Critical Incident Stress Debriefing was offered and/or conducted with staff, and what kinds of support were provided to inmates after the event.

9. Any successful and best practices in other international correctional jurisdictions with respect to deaths in custody.

   The IRC considered this parameter fairly broadly to include best practices found in other jurisdictions and related empirical research, including health care and criminology.

Introduction

In several reports produced by the Office of the Correctional Investigator (OCI) office, concerns were raised with CSC’s handling of suicides in recent years. The OCI were displeased with prevention efforts, quality of investigations and post incident measures to reduce the likelihood of suicides in the future. The Ashley Smith case, summarized in the OCI report A Preventable Death, alleged broader system wide failures and an organizational culture that did not make preservation of life a high priority. The Commissioner of Corrections responded to the OCI by identifying several priorities: dynamic security, improvement of counts and rounds, standardizing suicide risk assessment protocols, improving intervention services for vulnerable inmates, correcting physical infrastructure deficiencies, and improving managerial accountabilities by use of a quarterly summary of lessons learned to be shared at the national, regional and local level.

Despite several action plans and improved performance monitoring on the part of the CSC, the OCI remains concerned that not all their recommendations have been implemented, and feel that mental health services at CSC remain underfunded. The OCI acknowledge that some promising steps had been taken, particularly CSC’s willingness to generate key performance indicators. However, they remain concerned over the number of potentially preventable deaths in custody, and still advocate for a number of changes. Critical improvements include: having a single national coordinator to monitor safe custody, provide 24 hour nursing coverage at all institutions and better educate staff on management of inmates at risk of self-injury or suicide.

CSC also indicated that they would have an annual independent review committee assess all deaths in custody. The first IRC (2009-2010) operated from May 2010 to February 2011 and provided eleven recommendations, some similar to those made in previous reports by the OCI. Prominent amongst these recommendations were the improvement of sharing mental health information, development of better conducted round and patrol practices, and development of a Performance Measurement Framework by the Correctional Operations and Programs Branch. Documenting success stories was also a key recommendation. CSC responded to these recommendations, but at the time of this writing it is still early for this year’s 2010-11 committee to assess.

Best Practices

Best practice has emerged as a strategy to promote effective practice in human services. Practices are identified in fields as diverse as health, mental health, addictions, policing, courts corrections and social services. Ideally, a "best" practice is based on peer-reviewed literature and provides a clear amelioration of a condition or problem validated in an empirical study.

Applying a best practice to reduce the number of deaths in custody is problematic, because such deaths are statistically rare. For example, best practices to reduce institutional violence or manage gangs are more likely to reduce murders than anything aimed specifically at homicide. Similarly, a reduction in the number of positive drug tests might be more likely to reduce drug overdose deaths than any specific intervention.

Best practices in suicide risk management provide some promising avenues that may reduce deaths in custody. Indeed, the IRC found a couple of empirical studies, one that found less juvenile suicides in institutions where 24 hour suicide screenings were done (Gallagher & Dobrin 2005), the other summarizing the US federal corrections system progress in reducing inmate suicides from 1972-1992 (White & Schimmel, 1995). Of course, White & Schimmel’s study compared the impact of a suicide risk management protocol to a previous period where no such protocol existed. The study demonstrated that having any kind of protocol was better than none at all, but does not provide a controlled comparison of different management strategies.

How does CSC compare to other jurisdictions in their efforts at inmate suicide prevention? We compared CSC current policies and procedures to a recent set of international best practices developed by nine nations that included Canada (Konrad, et al. 2007) for the World Health Organization (WHO). We found that CSC protocols and policies are consistent with all of the WHO best practices. The uptake and quality of those protocols and policies in practice can only be demonstrated through appropriate audit activities and performance measures. However, there does not appear to be any broad practice that CSC currently is missing from their operations.

Overdose in the Community

Recent studies have shown that the first two week period of release is a particularly high risk period for drug overdose. In a recent WHO report (2010), the distribution of and education about naloxone is an emerging promising practice to prevent death by overdose during the high-risk period post-release. Naloxone hydrochloride is an opiate antagonist that can reverse an opioid overdose. In Canada, naloxone is a "Schedule F" drug under the Food and Drug Act, which requires prescription and practitioner supervision. However, work at provincial and community levels have improved access to naloxone for those using prescribed and/or illicit opioids. Given the known risk period, and the effectiveness of naloxone to reverse overdose and prevent deaths, CSC should consider developing programs and access protocols to naloxone for offenders transitioning between custody and the community.

Organizational Culture and Investigations

Given the paucity of criminal justice literature to guide suggestions for the CSC to prevent deaths, the IRC looked to other disciplines for guidance. One such area is the concept of High Reliability Organizations (HRO; Perrow, 1999). HROs operate through the theory and practice that complex organizations are inherently error-prone, and organizational accidents (including death) can be prevented through systems-focused management of that error. Since the 1980’s, a broad range of organizations and agencies adopting HRO principles have seen remarkable improvements in safety and a reduction in numbers of deaths in nuclear power plants, health care, chemical plants, firefighting units, and aviation (Bourrier, 2011; Perrow, 1999, Roberts & Bea, 2001; Roberts, Stout & Halpern, 1994; Weick & Sutcliffe, 2001). HRO principles are especially useful for organizations that are both error-prone and responsible for individual and public safety, like criminal justice organizations.

Doyle (2010) argues cogently that criminal justice organizations can work toward a systems approach to safety through continuous quality improvement and by viewing errors as organizational accidents. The reduction in numbers of deaths in aviation, nuclear power and health care are due to these industries adopting this approach, and seeing organizational accidents as combinations of small mistakes that combine together and lead to a catastrophic event (McElhinney & Heffernan, 2003; Henriksen, et al., 2006; Potylycki et al., 2006; Sammer et al., 2010; Trucco & Cavallin, 2006).

The CSC has already begun adopting the principles of a systems approach to safety by its commitment to adopting a "learning perspective" into in-custody harm and death investigations. However, there are aspects of the BOI investigation reports and follow up that could be more systems-focused in its management of any problems that are identified. The CSC can improve their safety record (as did the aviation, health care and nuclear power plant industries) by moving away from a "personal approach" in investigations and follow up, and toward a more integrated systems-approach.

Correctional Officer Patrols and Deaths in Custody

The responsibility of CSC and by delegation, correctional officers to ensure public safety and maintain proper care of inmates is required legislatively by the CCRA, section 5, and is outlined in Commissioner’s Directive 566-4. The policy requires correctional officers to conduct regular counts, rounds and patrols on a regular basis (at least every hour) and to ensure that inmates are alive and breathing. These counts can be a particularly important function on night shift, when inmates are secure in their cells but may encounter medical distress or attempt suicide, or be victimized in a double bunking situation. Despite these efforts, in many deaths inmates are discovered by staff long after they are dead, despite official patrols, counts and checks being recorded as complete.

Alternative means of ascertaining that an inmate is alive and breathing are being examined by other correctional jurisdictions. Heat sensing technologies are being developed that can alert staff to an inmate whose body goes below a certain temperature. Such a technology offers a method to respond more quickly to a medical emergency. Even in the case of a correctional officer who is diligent in his or her duties, the time between expected rounds may allow an inmate who is intent on suicide to be long deceased by the time he or she is found. As a best practice the committee observes that such technology bears further investigation by CSC.

Methodology

There were 25 cases of non-natural deaths in 2010-11. The IRC utilized Board of Investigation Reports provided by the Incident Investigations Branch. Each overdose, suicide, unknown cause death, suicide, murder and death by staff intervention was assessed against the nine terms of reference. They are discussed in the narrative text and presented in table form.

Yes – Problem(s) identified.
No – No significant problems identified.

BOI recommendations emanating from each death were also assessed against the Canadian Patient Safety Institute’s six point Hierarchy of Effectiveness Scale. We define effectiveness here as the likelihood that a recommendation will bring about a meaningful reduction in deaths in custody. Generally, recommendations that eliminate human error through "forcing functions" or by automation are likely to be most effective, because they have the best chance to eliminate human error. Education/Information recommendations are rated lower, because unless there is a genuine organizational gap in education, the possibility of a recurrence of human error is likely. These assessments are summarized in chapter nine.

Study Sample Description

The study sample this year was all male, their age averaged just less than 40 years and about a third were Indigenous (36%). Twenty-eight percent were classified as maximum security, around half were in medium security custody and 20% were in the community on Day Parole or Statutory Release with a Residency condition. Considering the various Regions and the size of their inmate populations, Quebec is under-represented in overall deaths this year, while the Prairies Region is over-represented. The high number of custodial deaths in Prairie institutions is not surprising, as they have a high concentration of Aboriginal inmates and prison gangs. This over-representation while in prison reflects the experiences Aboriginal peoples in the community, such as poor health, criminal victimization, addictions and high suicide rates. Just over a quarter of the study group were serving a life sentence (28%).

Trends

Homicides generally average two to three per year from 2001-2011. The recent year (6) and 2003-2004 (8) bear further investigation, as those were much higher than usual. Suicides show a remarkable downward trend since 1992 (16). The last five years shows an average of seven per year, a considerable decline. Overdose deaths range from 1-6 from 2001-2011, but typically "official" numbers are 2-3. The committee has little confidence in these figures, as Coroner’s reports are needed to validate drug overdose deaths, regrettable as these are a potential outcome to assess CSC’s drug interdiction efforts. A longitudinal study for both homicides and drug overdoses (e.g., 20 year retrospective) is recommended to improve our general knowledge of these phenomena, and, in the case of overdose, to provide some accurate trend information.

Comparisons

The committee compared nineteen cases 2010-11 in custody at the time of their deaths to results from Gabor’s 2007 study of 82 CSC deaths from 2001-2005. The 2010-11 group had a larger proportion and number of homicides than usual, 26.3% to the 20.7% in Gabor’s fiver year study. Suicides were a much lower proportion, 21.1% of deaths compared to 61% previously. Accidental deaths made up the largest grouping, 52.7% this year, compared to only 18.3% in the past. Moreover, known (or suspected) drug overdoses made up a much smaller percentage of the Accidental category: 33%, compared to 80% counted in Gabor’s analysis.

Reviews by Type of Death

The IRC reviewed all BOI reports and summarized their findings for each term of reference, according to five categories: Overdose, suicide, murder, deaths by unknown cause, and death by staff intervention.

Overdose Deaths

In the 2010-2011 fiscal year there were four confirmed deaths in custody by overdose. Two offenders were on statutory release at the time of their deaths, and two were in medium security. All four men died from ingesting opiates alone or in one case, multiple drug toxicity of heroin and diazepam.

Issues related to the CSC’s response were identified in two out of the four cases of death by overdose. There were no significant problems identified in any of the cases in regards to pre-incident trends, mental health, case management, information sharing, or best practices. In two out of the four cases, there were issues identified in relation to security and patrols. There were emergency response problems identified in two out of three relevant cases. Significant problems were identified in three these cases in relation to support provided to staff and inmates after the event.

Suicide

There were six confirmed deaths by suicide under CSC’s jurisdiction in the 2010-2011 reporting year.

Issues related to the CSC’s response were identified in three out of the six cases of death by suicide, and pre-incident trends raised concerns for the IRC in four out of the six cases. Issues related to mental health care, emergency response and information sharing were identified in half the cases within each of these categories. The case management and security and patrols was adequate in four of the deaths by suicide, while two cases raised concerns. Support to staff and inmates were all completed according to policy and none of the cases raised any concerns. The area of greatest concern was issues related to best practice (issues raised in four cases).

Deaths Unknown Cause

There were no pre-indicators in all relevant cases, mostly indicative of health concerns that were being managed by staff. Mental health concerns were noted in three cases, problems in case management in only two and in security/patrols and emergency response only one. Information sharing was an issue in two cases, and CISD support was not offered in two cases. Responses overall by CSC were suitable in all nine cases, with a particularly thorough report by the BOI in case #2, where considerable clarification was required on responsibilities in a CSC mental health facility. As well, CSC clarification in responsibilities in contracting with Community Residential Facilities (CRF) now outlines more clearly CRF responsibilities in prevention efforts. Best practices were not observed in any of the cases reviewed or in any CSC recommendations. Recommendations that were policy or training based, were somewhat useful but could not be considered a "best" practice.

Homicides

There was believed to be pre-incident factors in two of five murders. Mental health problems were evident in two of five cases, with changes in medication possibly contributing to homicidal behaviour. Case management and emergency response was problematic in two of five cases, while security patrols were at issue in three of five cases. Information sharing was an issue in one of five cases. Staff and inmate support after the incident was good. There were no incidents that involved any best practices.

In some instances staff response was very good, particularly in cases #10 and #19, where large groups of inmates were threatening others. Staff acted courageously and swiftly to limit the possible harm to inmates being threatened. Medical responses in most cases were well done. The BOIs were generally very thorough, with insightful findings and implementable recommendations.

Death Due to Staff Intervention

There was one case involving the death of an inmate through staff intervention in 2010-11. The inmate (A) was shot by correctional officers while he was attempting to kill another inmate (B) in the recreation area. The staff involved fired a number of warning shots, but inmate A persisted, and he was shot and died. The BOI in this case carefully considered the question of alternatives to the use of deadly force in such situations.

CSC performance was overall satisfactory, with some exemplary performance observed in places. There were no forewarnings of the incident, security surrounding the event was satisfactory, information sharing appropriate, and the security and emergency health response was excellent. No critical incident stress debriefing was offered to the Warden or Deputy Warden, and this is a procedural matter that should be corrected. Recommendations by the BOI were effective, with a particularly helpful recommendation on the introduction of an additional alternative to lethal force.

Assessing Efficacy of CSC Response To Deaths In Custody

Figure 1: IRC Evaluation of CSC Performance Against Terms of Reference

In this section the committee summarizes CSC performance against our Terms of Reference (TR), essentially compiling information presented in chapters 4, 5, 6, 7 and 8.

The committee found that the overall CSC response to deaths in custody, TR1 was satisfactory in most cases (78%). Pre-death indicators or trends were evident in over half of the cases (60%). This includes a significant number of factors, however, ranging from mental health, a history of excessive substance abuse, changes in medication, severe medical problems to inmate unrest or conflicts with other inmates. Focusing on just mental health, (TR3), just under one in three (32%) cases had a mental health problem of some kind.

The BOIs found about a quarter of cases involved problems in case management (24%), and around a third for security patrols and monitoring (32%) and the emergency responses (33%). There were no clear trends from this one year of data, and caution should be taken into reading too much into the presence of problems. Many of the difficulties observed in case management, security or emergency response were not serious and would not have impacted the deaths involved. On the other hand, there were a few serious errors that do warrant follow-up.

Information sharing was a concern in just under a quarter of all deaths (20%). While critical incident support to inmates and staff was evident in most cases (80%), there seemed to be some confusion at times about the degree of follow up required by institutions, to make sure everyone had an opportunity to receive counseling. The committee did not find many instances where CSC could have made better use of best practices (16%) but we did use a narrow definition of this term. We did find considerable evidence of good correctional practice, of dynamic security, of excellent follow-up on inmate problems, and of courageous and active medical response.

The committee found the traditional method of investigation following an incident somewhat limiting in helping CSC push forward to improve as an organization. Thus we reintroduce our Hierarchy of Effectiveness grid from chapter three as a strategy by which CSC can incorporate a greater "learning" approach towards serious incidents.

Efficacy of CSC BOI Recommendations Using the CASPI Hierarchy of Effectiveness

Rather than using a traditional organizational policy, training, staff counseling/discipline approach to managing deaths in custody, the IRC encourages CSC to consider alternative methods from other disciplines to improve organizational performance. Towards that end, we use the Hierarchy of Effectiveness tool and assess the strength of BOI recommendations from all 25 cases. Recall that the lower the score, the most likely the recommendation is to be effective.

Figure 2: Percentage of recommendations and findings at each level of effectiveness

As seen in Figure 2 above, over half of all recommendations and findings are ranked 6. While there are some recommendations and findings that are ranked higher in effectiveness, we suggest that BOIs explore ways to develop recommendations so that, as much as possible, the remedies constrain human error through forcing functions, automation, and standardization.

The primary reason for the large number of 5s and 6s is that a large number of findings and recommendations are related to policy development (rated 'five') and reminders to staff about existing policy or other job requirements (rated 'six'). Policy and education are an essential component of a well-functioning organization, and ensures standardized procedures across geographically diverse facilities. While adherence to existing policy, fixing policy gaps, and education critical and important first steps during an investigation; the second is to explore why compliance issues occur, or why human error occurred, which can expose the organizational gap and risk that led to the error.

The IRC suggests that the CSC continue to explore alternatives to corrective measures when there are compliance issues. It was encouraging to see coaching put forward as an alternative to disciplinary measures for non-adherence to policy (Recommendation #5 in the CSC’s Corrective Measures and Management Action Plan into the 2010 Independent Review Committee into Deaths in Custody).

Chapter 1 - Introduction

This Report covers the activities and findings of the Independent Review Committee 2010-2011 struck by the Correctional Service of Canada in order to find out factors pertaining to deaths of inmates while in custody.

The Issue of Deaths in Custody, the Office of the Correctional Investigator Position and the Response by the Correctional Service of Canada

As noted in its Mission Statement, the Correctional Service Canada (CSC) contributes to public safety by actively encouraging and assisting offenders to become law-abiding citizens, while exercising reasonable, safe, secure and humane control. Maintaining reasonable, safe, secure and humane control of its offender population requires that evidence-based policy and procedures are developed, implemented, and adhered to consistently across the service to minimize the risk of harm.

In June 2007, the Office of the Correctional Investigator (OCI) released a report on 82 deaths in custody from 2001 to 2005. The study was initiated due to a concern that similar conclusions and recommendations show up repeatedly in the Board of Investigations (BOI) and Coroner’s reports. The review looked critically at all relevant reports, action plans, and correspondence. It explored CSC’s response to recommendations, including their capacity to prevent offender deaths, and their response to situations of imminent harm. The findings of that report are damning. Recommendations and concerns were raised repeatedly across different investigations, the CSC had not improved its capacity to prevent deaths, and disagreed with or took no action on Coroners’ recommendations. The report also noted significant time gaps between an incident and the adoption of mitigating strategies to prevent similar events. Most concerning was that some of the deaths could have been prevented had there been in place appropriate risk assessments, preventative measures and more timely and competent responses by staff.

CSC responded to the OCI’s report by developing an action plan in three primary areas: improving the timeliness and effectiveness of the investigation process, enhancing CSC’s mental health services capacity, and improving CSC’s operational responsiveness to incidents.

Four months later, on October 19^th, 2007, a tragic death by suicide occurred at the Grand Valley Institution for Women in Kitchener, Ontario. The circumstances of Ashley Smith’s death are well documented in the OCI’s June 20^th, 2008 report A Preventable Death. The conclusion of that report was that system-wide failures contributed to the death of Ms. Smith, and immediate actions were required to ensure better coordination between correctional and mental health systems across the country.

In a letter to the Correctional Investigator, CSC Commissioner, Don Head outlined the service’s response to the OCI’s Ashley Smith report. Mr. Head identified several priority actions. : Dynamic security was to be improved through use of training modules, refresher training and improving accountabilities for such. A more rigorous approach to rounds and counts was to be implemented by using aide-memoires, accountabilities, and exploring technology to monitor life signs. Standardizing of suicide risk assessment protocols, including effective tools and sharing of information between staff was to help improve safety. Intervention services were to be enhanced by reallocating resources and identifying alternative service delivery models for vulnerable inmates. Physical infrastructure deficiencies that might contribute to staff deaths were to be dealt with by developing appropriate criteria for future facilities, and developing a response plan to mitigate deficiencies in existing facilities. Finally, managerial accountabilities in relation to deaths in custody were to be strengthened at local, regional and national levels by producing a quarterly summary of lessons learned, and implementing a review mechanism to ensure oversight.

In addition to these important actions, CSC initiated additional measures to improve their response to deaths in custody. One of these measures was to implement an independent review committee to conduct an annual review the CSC’s actions and responses to deaths in custody reports.

In their February 10^th, 2010 Initial Assessment of CSC’s Response to the Deaths in Custody and A Preventable Death, the OCI noted that a significant number of initiatives were undertaken by the Service, and the Service was clearly committed to preventing deaths in custody. However, the OCI brought forward three main areas of contention. First, they remained concerned by the lack of integration, communication, and implementation of CSC’s actions across its Service. Second,

"It is our opinion that unnecessary punitive and potentially harmful practices, including segregation, isolation, use of restraints and the withholding or withdrawing treatment as a consequence of negative behavior, continues to be too commonplace when dealing with mentally disordered offenders"

(OCI, February 10th, 2010, P. 1)

Thirdly, the OCI expressed concern that a number of recommendations that are critical to improving accountability and governance were either rejected or only supported in part by the Service, including those in the CSC’s BOI report on the death of Ashley Smith.

The OCI released two quarterly reports on progress (December 18^th, 2010 and March 25^th, 2010), which describe the commitment and progress made by CSC in regards to preventing deaths in custody. At these time points, CSC had implemented external reviews of long-term segregation, an inmate complaint and grievances system, a national verification team to ensure resources had been appropriately deployed for the targeted initiatives and an annual independent review committee on in-custody deaths. These quarterly reports noted some encouraging steps taken toward transparency and accountability, including CSC’s commitment to reporting key performance indicators and benchmarks. Indicators include a number of deaths by suicide, serious self-injury, drug overdoses, days spent in segregation, and use of force on offenders with serious mental health issues.

The OCI remained concerned that intermediate mental health care remained unfunded, thus impacting the capacity, resources and options to manage vulnerable inmates. As noted in the 3^rd quarterly assessment (March 25^th, 2010, p.1), "[r]esources will continue to be scarce, but this cannot be used as an excuse for a lack of action." The OCI also remained concerned about the Mortality Review process, especially in regard to the Service’s response to unexpected and rapid deterioration in physical health, and continuing problems with the flow of information between mental health professionals and front line staff.

In May, 2010, CSC released its Verification of Progress: Correctional Service of Canada Key Commitments Relating to Deaths in Custody, prepared by the National Verification Team. The Team visited 11 maximum and medium security facilities to determine the uptake of commitments and policy directives at the select institutions. Specifically, the verification team reported on how effective resources were deployed to support initiatives to prevent deaths in custody and the uptake of dynamic security principles and adherence to relevant security policy. The verification team also commented on adherence to administrative segregation policy, and the effectiveness and integration of mental health services into practice.

CSC’s Verification of Progress report highlights the many areas of new and continuing good practices. These include formal shift briefings where offender-related concerns are communicated between staff (in all sites but one). They also identify an excellent on-site mentoring system at most institutions for new correctional officers. Important practices such as administrative segregation reviews and stand-to inmate counts (completed according to policy) and giving priority to Use of Force Reviews are acknowledged. Important practices in medical emergency situations include equipping front line officers to respond quickly to suicidal and self-injuring inmates, and involving of health care at the beginning and during segregation placements (completed according to policy). Improving communication can be accomplished using a colour-coded notice system, observed at several institutions to communicate an offender’s monitoring status across all departments.

The Verification of Progress highlighted a number of areas for improvement: Resources for the recruitment and retention of correctional and psychology staff was needed, and more importance placed on inter-disciplinary teamwork between intervention and security staff. Greater use of dynamic security could be improved by integrating the Correctional Officer II into case management and communications. Segregation practices needed to reflect a standard national decision template, a review of deployment standards and examination of space available to see if it was suitable for interventions. Mental health services could be enhanced by improving the uptake of Responsivity Protocols, clarification regarding roles and responsibilities of the mental health initiative, involvement of all key staff and use of enhanced monitoring, particularly when inmates spent time out of their cell and on the range.

For their final quarterly assessment (September 2010), the OCI reviewed 9 case studies of inmates who had died between 2008 and 2010. The cases were selected due to their recurring themes and patterns. The OCI’s reported that, despite the demonstrated improvement in key areas, they remain concerned about:

• Inappropriate or inadequate response to medical emergencies,
• Failure of information sharing between clinical and front line staff,
• Recurring and deficient monitoring of suicide pre-indicators,
• Inadequate compliance to security patrols, rounds and counts,
• Overuse of security responses in place of health care and treatment for mentally ill offenders
• Lack of consistency in CSC investigative reports and processes, which require improvement.

Based on these concerns, the OCI recommended that CSC:

1. Develop a comprehensive public accountability and performance framework that tracks performance indicators related to deaths in custody.
2. Strengthen CSC’s internal investigation framework by appointing an external health care professional to chair reviews related to suicide and serious self-injury, and report publicly.
3. Create a senior management position to promote and monitor safe custody practices.
4. Stop the prolonged segregation of mentally ill offenders or those at risk of suicide or self-injury.
5. Enhance the quality of security protocols to ensure rounds and counts are completed in accordance with preservation of life principles.
6. Provide 24 hour health care at all maximum, medium and multi-level institutions, to facilitate better response to medical emergencies.
7. Share, and make easily and readily accessible, basic information and instructions for managing inmates at risk for suicide and self-injury.

Independent Committee 2009-2010

The first Independent Review Committee (IRC) into Deaths in Custody was convened by the Senior Deputy Commissioner of Corrections in June 2010. The first committee was created as part of a number of initiatives in response to the concerns raised by the Office of the Correctional Investigator over deaths in custody. As an independent entity, the IRC was to provide an impartial, external perspective on deaths in custody by experts who could provide suitable advice and suggestions to prevent and reduce these deaths. The first Independent Review Committee comprised of a criminologist from the University of Ottawa, a provincial corrections senior executive and provincial chief coroner. The Committee reviewed 18 non-natural deaths from the April 1, 2009 to March 31, 2010 fiscal year, using official documents from the Correctional Service of Canada Board of Investigation (BOI) reports, corrective measure grids, and closure memos. The CSC provided the Committee with the executive summary of 51 investigations from 2005-06 to 2009-10, and statistical information for that same period. The Committee was given from May 2010 to December 2010 to complete its report, and then had an extension to February 2011. The process included a debriefing with executive management, and a copy of the report was provided to the Office of the Correctional Investigator.

The Committee submitted eleven recommendations. They focused on improving communication between staff and between institutions, improving quality of and training for conducting patrols, rounds and counts, and communicating the consequences for non-compliance. Some of these recommendations were relatively similar to those made by the Office of the Correctional Investigator in previous reports on suicide and in their Annual Report.

The Committee also recommended the communication of "success stories" of staff intervention and dynamic security. They identified a need for better incident data for long term trend analysis, outlined a number of different issues in data collection and suggested that special studies be initiated. In addition, a surveying and collection of "best practices" from other jurisdictions was endorsed by the Committee. Most significantly, they recommended a better link between BOI’s and policy development. In essence, the report shifted the thinking from a narrow response to an individual incident, to broader methods of improving service, which is consistent with a learning organization.

The Correctional Service of Canada responded to the first Independent Review Committee. The Committee’s recommendations include the following:

• Improve staff communication by developing mental health information sharing guidelines, revising Commissioner’s Directives (CD), standardizing treatment discharge summaries, and requiring use of Health information when making Administrative Segregation decisions;
• Provide clearer operational guidelines to staff on triage processes by a review through the Regional Suicide/Self-Injury Committees and revising the relevant CD.
• Develop the notion of quality in patrols, rounds and counts by issuing a clarification security bulletin.
• Improve capacity to monitor frequency and quality of patrols, rounds and counts through a quarterly review of a random sample of patrols. A legal opinion and staff agreement is being sought for use of cameras for quality assurance.
• Develop a Performance Measurement Framework through the Correctional Operations and Programs (COPS) Branch, in collaboration with the Incident Investigations Branch, with measures and a methodology for data collection. Through this Framework, the success of interventions to prevent deaths can be monitored.
• Implement a performance measurement system to pro-actively monitor progress, again with the COPS branch taking the lead, in collaboration with the Investigations Branch.
• In other cases, more general feedback was provided on recommendations. These included:
  • Document dynamic security success stories by consulting with SIO’s, developing a survey tool and working with Public Affairs on a communication plan.
  • Expand dynamic security by liaising with Citizen Engagement and Aboriginal Initiatives Branches to develop collaborative relationships and strengthen communications.
  • Link incident-driven investigations by the Investigations Branch to policy and procedure, increase the use of lessons learned and promising practices from other jurisdictions, and develop collaboration between the Investigations Branch and the Evaluation and Audit Branch.

In response to the IRC’s global recommendation #11, CSC indicated that the Investigations Branch was developing an Incident Investigations Case Management System that will enable more complex analyses. CSC also cited several reports conducted by its own Research Branch that addressed suicide and self-injury, as well as other self-injury research initiatives. The response by CSC here was somewhat limited, as much of the Research Branch’s initiatives focus on self-injury as opposed to deaths in custody.

Recommendation #5 asked CSC to explore opportunities to use its disciplinary process to reward good performance and educate staff, and look for more innovative approaches to balancing training and coaching with disciplinary interventions. CSC responded that they already shared BOI results and best practices with employees through semi-annual reviews. CSC did not commit to any other action, indicating that their semi-annual review process gave them sufficient latitude for coaching, training and alternatives to discipline. In the 2010-11 IRC’s view, the CSC response here was defensive, as they did not wish to work outside of their current employee management system and explore innovative approaches, as suggested by the first IRC. At this time, it is premature to assess the adequacy of efforts of CSC to address the recommendations of the first IRC. Certainly their efforts are unlikely to have had much, if any impact on the deaths in custody for 2010-2011. We will return to the first IRC’s recommendations and CSC responses when we come to our own recommendations at the conclusion of this report.

The first Independent Review Committee went through a learning curve with respect to CSC, including its investigative processes and the state of information available to allow them to complete their task. It provided a foundation on which the current 2010-11 Committee expects to build. Our committee found key information fairly readily available, and were pleased that the Incident Investigation Branch provided a detailed orientation for committee members. As well, the outline from the first report provides a reasonable template from which to work. On the other hand, this committee had a more challenging task insofar as it has had more deaths to review, had much less time to complete the report, and incurred the additional task of providing a best practice literature review. In particular, we had limited time to review broader responses and initiatives by CSC to reduce deaths in custody. We will discuss these issues further and possible ways in which to structure the committee in chapter ten, our summary and conclusion.

Structure of this Report

This report has begun by reviewing the recent history around federal inmate deaths in custody, including concerns by the Office of the Correctional Investigator, and responses by the Correctional Service of Canada. We have summarized the first iteration of the Independent Review Committee, its recommendations, and CSC responses. The rest of this report seeks to fulfill the mandate set out in the terms of reference, and will first review the literature on deaths in custody, then set out the study methodology, provide a sample description and brief study group comparison and trend analysis. The report will assess the factors around deaths in custody in 2010-11, Boards of Investigation recommendations, and CSC responses to recommendations. The conclusion of the report will consider carefully the results from this year’s independent review, but will also seek to integrate its recommendations and suggestions with past empirical research and investigations into deaths in custody. The Independent Review Committee of 2010-2011 will seek to identify systemic concerns, build on lessons learned here and elsewhere, and identify some progressive paths for the development of policy and contribute to CSC as a learning organization.

Chapter 2 - Best Practices Literature Review

Best Practices has emerged as a strategy to promote effective practice in the human services. Essentially, this consists of identifying practices in fields as diverse as health, mental health, addictions, policing, courts corrections and social services. Ideally, a "best" practice is based on peer-reviewed literature and provides a clear amelioration of a condition or problem validated in an empirical study. For example, imagine a new method of police investigation increased the solved rate of break-ins from the typical average of 19% to 30%, and this was proven in a study by an external researcher. This case would clearly be considered a best practice. Such examples are hard to find in the corrections literature, however, and some so-called "best practices" are based on expert opinion or indirectly related to other research. Often articles that summarize effective prevention practices simply describe existing practices in many jurisdictions that appear progressive but are not necessarily proven effective through social science research methods (e.g., Camilleri & McArthur, 2008; Daniel, 2006; Konrad et al., 2007).

A recurring theme in our report is the difficulty in establishing definitive causal links between an intervention and a death in custody, because of the statistical rarity of such deaths. In addition (as we shall discuss further in chapter three), overdose deaths are not accurately counted, hence whether drug interdiction efforts are having an impact is difficult to ascertain (Powell & Zevitz, 2011). For drug overdoses, aside from the adequacy of the medical response, the number of positive drug tests nationally may be a better test of the efficacy of CSC efforts to battle illicit drug use in prison. In the case of homicide, these acts are connected to broader issues of control of violence in prisons, dynamic security, and inmate management. Again, reductions in rates of violence in prison may be a better indicator of the relative success of inmate risk management strategies.

Suicide offers a better opportunity to apply practices adopted in other jurisdictions that have achieved a significant reduction in facility-based deaths. However, the rarity of suicides and the small number in recent years (about a six a year) makes it difficult to monitor the effectiveness of interventions over a short period of time. To confirm the impact of a policy, the recent average of six suicides would ideally have to be cut at least in half to three, and it would be preferable to see such a trend persist for a few years. The Correctional Service of Canada has training, policies, equipment, isolation areas, and monitoring protocols, so to introduce one or two adjustments to existing practices is unlikely to exert such a change, unless they are doing very poorly in some areas.

Consequently, in this chapter we devote considerable time to reviewing organizational practices, particularly in the health field, as we feel this offers the largest opportunity for CSC to initiate changes that will have a substantial impact on deaths in custody. Prior to this, we review some of the suicide prevention literature, take a look at technology that better identifies inmates in critical condition and identify some medical advances in the care of overdoses that we feel may be of benefit for recently released inmates.

Some suggestions may well be unpalatable because they conflict with other organizational priorities or treatment principles. For example, a consistent finding in the suicide literature is that inmates who share a cell are less likely to commit suicide, as this tends to occur only in single cell situations (Daniel 2006, Camilleri & McArthur, 2008). Of course, CSC currently is directing its energies to limiting its use of double-bunking in the face of population pressures, and is coming under criticism regardless. As an organization CSC is committed to providing as many private cells as possible, providing privacy and dignity for individual inmates. Thus promoting double bunking to reduce suicide risk is something that is inconsistent with that principle. Further, in his qualitative comparison of five federal and provincial correctional facilities, Weinrath (2009) argued that allowing only glass visits would reduce the amount of drugs in federal institutions, as this practice had proven successful in provincial facilities. Again, CSC is committed to allowing inmates to have access to family and close personal visits are an important part of this, although it does create more opportunity to bring drugs into facilities. So, best practices must also be consistent with the mission and principles of an organization.

In-Custody Suicide

Can prevention programs reduce the number of suicides in custody? A recent youth based study (Gallagher & Dobrin, 2005) and one based in US federal prisons (White & Schimmel, 1995) over fifteen years ago show that implementation of prevention programs can reduce self-harm and suicide. However, these studies also benefit from poor performance by some agencies and past weakness in existing systems. For example, Gallagher and Dobrin compared youth facilities that suicide screened all new arrivals within a 24 period versus those that did not, finding that suicide rates were lower for institutions that screened for this risk. For organizations that are already doing proper screening, this information is not as helpful, though it is affirming of good practice, and supports suicide screening within 24 hours of admission and even for transfer cases who have been in the system. In the case of White and Schimmel, they charted a strong reduction in suicide rates in the US federal prison system with the introduction of what today might be considered a fairly basic suicide prevention scheme: 1) initial screening of all inmates; 2) treatment and housing criteria for suicidal inmates; 3) development of standardized record keeping, follow-up procedures, and systematic data collection; 4) staff training; and 5) periodic reviews and audits. Their reported reduction of suicide rate per 100,000 inmates went from 35 (1970-1982), to 24 (1983-87) to 16 (1988-92), which is a laudable accomplishment. Of course, these changes are most dramatic when there were no prevention efforts in place prior to their intervention. Nevertheless, this study does support efforts to have a comprehensive suicide risk management plan in place, because deaths will certainly occur when there are no such efforts in place.

Suicide has been an area of active interest by correctional jurisdictions the world over, with a robust literature in the US, Britain and Australia (Daniel, 2006; Camilleri and Arthur, 2008; Hayes et al., 2011). Daniel for the US, and Camilleri and Arthur for Australia recently attempted to summarize "best practices" for suicide prevention in custody, essentially summarizing many of the recent initiatives put in place in various jurisdictions. The broadest based study of this type is an international study involving Canada.^{Footnote 1} As part of a nine member consortium, Konrad et al. (2007) completed a review of best or preferred practices in correctional facilities. The nine nations included Canada, the US, Britain, Australia, Austria, Germany, the Netherlands and Italy. Their findings were distilled into a summary report by the World Health Organization, and we outline them below.

Suicide Prevention in Prisons: Summary of Best Practices

First of all, staff culture and cooperation seem to be critical to the successful implementation of prison suicide prevention programmes. Best practices for preventing suicides in jail and prison settings are based on the development and documentation of a comprehensive suicide prevention plan with the following elements:

• A training programme (including refreshers) for correctional staff and care givers to help them recognize suicidal inmates and appropriately respond to inmates in suicidal crises.
• Attention needs to be paid to the general prison environment (levels of activity, safety, culture and staff-prisoner relationships).
• In particular, the quality of the social climate of prisons is critical in minimizing suicidal behaviours. While prisons can never be stress free environments, prison administrators must enact effective strategies for minimizing bullying and other violence in their institutions, and for maximizing supportive relationships among prisoners and staff.
• The quality of staff-prisoner relationships is critical in reducing prisoners’ stress levels and maximizing the likelihood that prisoners will trust staff sufficiently to disclose to them when their coping resources are becoming overwhelmed, feelings of hopelessness, and suicidal ideation.
• Procedures to systematically screen inmates upon their arrival at the facility and throughout their stay in order to identify those who may be at high risk.
• A mechanism to maintain communication between staff members regarding high-risk inmates.
• Written procedures which outline minimum requirements for housing high-risk inmates; provision of social support; routine visual checks and constant observation for acutely suicidal inmates; and appropriate use of restraints as a last resort for controlling self-injurious inmates.
• Inmates with mental disorders in need of treatment should receive it (pharmacological or psychosocial interventions) and be kept under strict observation.
• Development of sufficient internal resources or links to external community-based mental health services to ensure access to mental health personnel when required for further evaluation and treatment.
• A strategy for debriefing when a suicide occurs towards identifying ways of improving suicide detection, monitoring, and management in correctional setting.

(World Health Organization, 2007, Preventing Suicide in Jails and Prisons, PP. 21-22)

Where does Canada rank in its implementation of these practices, and are there specific things that might be done? The international committee did focus on federal Canadian practice in their second report (Daigle et al. 2007) but did not provide much detail. The best practices literature currently available on suicide simply reiterates most of the things that CSC is currently doing. Strategies of how to do these things more effectively are more difficult to find, but might be part of an ongoing independent review.

Prevention of Death by Overdose

The majority of research related to prevention of death by unintentional overdose^{Footnote 2} in correctional settings (as well as nonfatal overdose) focuses on risk and protective factors, and preventative strategies that target those recently released from prison. Men who are recently released from prison are 29 times more likely to die, and women are 69 times more likely to die when compared to the general population, and death from overdose is the most common cause (Farrell & Marsden, 2007). A recent meta-analysis of studies of drug-related deaths demonstrated that the immediate post release period (within 2 weeks) is associated with 3 to 8 times higher risk of death by overdose (Merrall et al., 2010). Both retrospective and prospective studies have confirmed that the first two to four weeks post-release is a particularly vulnerable period for offenders (Binswanger et al., 2011; Binswanger et al., 2007; Farrell & Marsden, 2007; Hobbs et al., 2006; Kinner et al., 2012; Kinner et al., 2011; Ødega, Amundsen Mundsen, Kielland, & Kristoffersen, 2010). This risk then declines over the following 10 weeks. For example, in a national sample of released prisoners from the United Kingdom, of the 442 deaths during the five years of study, 59% of deaths were drug-related (Farrell & Marsden, 2007), and of those who died within two weeks of release, 95% died by overdose. Reasons for this heightened risk period are still uncertain, but commentators have suggested it may be due to decreased tolerance to drugs after less frequent use while in custody (Enteen et al., 2010).

In response to this well-documented risk of death, prevention efforts have targeted this immediate post-release period. The World Health Organization (WHO, 2010) released a report with strategies to reduce drug-related mortality in prison populations in the immediate post-release period. Among the key recommendations in this report are:

1. Ensure Principles of Service Delivery and Programs — to include equity of access to care between prison and the community, opioid substitution therapy and other evidence-based practice, and continuity of care and treatment stability between prison and community integration.
2. Develop Interagency Partnerships and Networks — while in prison, building healthy therapeutic relationship through client-centered treatments, effective and appropriate referral systems, and formal and informal community social support structures. Education should focus on drug use prevention, risk behaviour and overdose prevention for all stakeholders (especially prisoners, families and other supporters) on post-release risk of overdose, and teaching first aid through administration of naloxone. As well, decrease post-release vulnerability through holistic programs that address physical, practical, psychological, and social needs.
3. Develop a comprehensive national framework for drug treatment at all levels of the criminal justice system — integrate into community-based drug treatment strategies within the public health system, and where possible, those with substance use disorders should be sent to a treatment facility rather than prison.
4. Clarify responsibility for duty of care and accountability for prisoners post-release — identify service gaps, analyze legal frameworks and develop service agreements between agencies that make these duties and accountabilities understood and clear.
5. Recognize and address needs of subgroups and integrate standardized risk assessments to identify these subgroups.
6. Monitor, assess and evaluate interventions — including baseline mortality rates, prisoner needs, implementation and success of interventions, and identification of service gaps.

Efforts to prevent death by overdose within prison settings and in the community post-release primarily focus on opioid substitution therapies, and expanding access to, and peer administration of, naloxone for those in the community (Kinner et al., 2011; Anex, 2010; Australian National Council on Drugs, 2001; US Centres for Disease Control and Prevention, 2012; Enteen et al., 2010; Wakeman et al., 2009; Wermeling, 2010). As noted in the WHO (2010) report, the distribution of and education about naloxone is an emerging promising practice to prevent death by overdose during the high-risk period post-release. A brief overview of that evidence is provided here.

Naloxone hydrochloride is an opiate antagonist that can reverse an opioid overdose. Naloxone is indicated for numerous patient populations at risk for overdose, including those on methadone therapies, high-dose opioid prescriptions, those released from hospital after opioid poisoning, those suspected of a history of illicit or non-medical use of opioids, concurrent use of opioids with antidepressants, benzodiazepines, or alcohol, opioid use among those with major organ dysfunction, and those released from opioid detoxification programs (Wermeling, 2010). While it can cause withdrawal symptoms in the user, it produces no psychoactive effects or symptoms of dependence or tolerance. It has been used by US emergency medical personnel in response to opioid overdose since it received US Food and Drug Administration approval in 1971 (Wermeling, 2010), and is an effective and legal remedy to prevent overdose deaths (Wakeman et al, 2009; Anex, 2010). Surveys of substance users show that about half of respondents inject or use substances in the company of others (Wakeman et al., 2009). Naloxone can be administered after a person has fallen unconscious due to hypoxia but before death by cardiac arrest, which provides a one to three hour window of opportunity for intervention (Enteen et al., 2010).

While medical personnel have been administrating naloxone since its development, harm reduction strategists have argued that the broad distribution of prescription naxolone to opiate users will prevent many overdose deaths. These take home Naloxone Prescription Programs (NPP) began in 1996 in the United States, and have been launched in many major cities in that country (Enteen et al., 2009; US Centers for Disease Control and Prevention, 2012). The reasoning behind this strategy is that many overdoses are witnessed by peers, who may be reluctant to alert authorities or medical personnel (Heller & Stancliff, 2007; US Centers for Disease Control and Prevention, 2012; Wakeman et al., 2009). NPPs distribute the antagonist widely to those who may witness an overdose event, including users and their family and friends.

In Canada, naloxone is a "Schedule F" drug under the Food and Drug Act, which requires prescription and practitioner supervision. However, work at provincial and community levels have improved access to naloxone for those using prescribed and/or illicit opioids. In 2004, the city of Edmonton began distributing naloxone through a needle exchange program.^{Footnote 3} In Toronto, efforts to improve access of naloxone began in 2005, when Toronto Public Health developed a program model and consulted broadly about dispensing naloxone to a 3^rd party, liability issues, and authorization to distribute (Shahin & Hopkins, 2012). The program received broad support from the College of Nurses of Ontario, and the College of Physicians and Surgeons of Ontario (including the Physician Advisory Service and the Physicians Methadone Committee). While liability issues were identified, the outcomes associated with the program outweigh the liability concerns, and injection of naloxone into a 3^rd party would be exempt from provisions under the Regulated Health Professionals Act because if they were doing so in an emergency situation (Shahin & Hopkins, 2012). Likewise in British Columbia, the BC Center for Disease Control is developing education programs for peer administration, developing a provincial decision support tool for nursing, and adding naloxone to Pharmacare to decrease its financial burden (Buxton, Pussell, Gibson, & Tzemiz, 2012).

In the United States, the Drug Overdose Prevention Education (DOPE) project of San Francisco distributes naloxone broadly to those at high risk for opioid overdose, provides education on recognizing the signs of overdose, and how to intervene with naloxone (Enteen et al., 2010). A report on a 6-year evaluation of the DOPE program examined the prevalence and reasons for administration of naloxone, reports the numbers and reasons for prescription refills, and outcomes of administration. Eleven percent of nearly 2000 participants to receive a prescription reported using it to reverse an overdose. Outcomes were monitored among those who returned for a refill (n = 399). Among these participants, there was an average of 80 annual administrations in the city, 83% of which successfully reversed the overdose. The most common adverse events were vomiting (13%) and anger/discomfort reported by victim upon waking (9%). Of the 399 who returned for a refill, four reported a death after administration; however three of these victims were unconscious for an undetermined amount of time.

A summary of findings from 48 United States programs that distribute naloxone was reported in a recent Morbidity and Mortality Weekly Report (US Centers for Disease Control and Prevention, 2012). These 48 responses represented data from 188 local programs. From 1996 to June 2010, there were 10,171 overdose reversals reported through these programs. While some of these overdoses may not have been fatal without naloxone intervention, these outcomes provide support for broad distribution of the antagonist. In summary, the evidence is mounting that improving the accessibility of naloxone to those at risk for overdose saves lives and that the concerns about misuse, serious adverse events, and liability have thus far been unfounded (see also, Lenton et al., 2009; Kim, Irwin & Khoshnood, 2009; Maxwell et al., 2006).

This section began with a discussion about a particularly high-risk and vulnerable time period for those in the criminal justice system. The first 2-4 weeks after release from prison puts offenders with substance use histories at particularly high risk of death by overdose. Given the known risk period, and the effectiveness of naloxone to reverse overdose and prevent deaths, CSC should consider developing programs and access protocols to naloxone for offenders transitioning between custody and the community.

Organizational Culture And Investigations

Given the paucity of criminal justice literature to guide suggestions for the CSC to prevent deaths, the IRC looked to other jurisdictions for guidance. One such area is the concept of High Reliability Organizations (Perrow, 1999). HROs operate through the theory and practice that complex organizations are inherently error-prone, and organizational accidents (including death) can be prevented through systems-focused management of that error. Since the 1980’s, a broad range of organizations and agencies adopting HRO principles have seen remarkable improvements in safety and a reduction in numbers of deaths in nuclear power plants, health care, chemical plants, firefighting units, and aviation (Bourrier, 2011; Perrow, 1999, Roberts & Bea, 2001; Roberts, Stout & Halpern, 1994; Weick & Sutcliffe, 2001). HRO principles are especially useful for organizations that are both error-prone and responsible for individual and public safety, like criminal justice organizations. Criminal justice organizations involve complex, interrelated processes and procedures, they are responsible for a vulnerable (and sometimes litigious) population, and they rely on humans to manage this complex, error-prone system (Bogue, 2009).

The application of a "learning from errors" perspective into criminal justice organizations has improved since the US Department of Justice report, Convicted by Juries, Exonerated by Science (Conners, Lundregan, Miller, & McEwen, 1996), which reviewed twenty-eight wrongful convictions as determined by DNA testing. Doyle (2010) claims this report was a call to arms for many practitioners in criminal justice who understood first-hand the impact of human error within large, complex systems. The report, which came to be known as the "Green Book," was the starting point of a movement within criminal justice to incorporate best practices and "learning from error" initiatives across the United States. A slow but promising shift has occurred in the US, from an adversarial, inspection based model of error investigation to one of continuous quality improvements. While Doyle (2010) acknowledges more work is needed to create a true cultural shift, there is evidence that change is happening at a local, state and national levels (for example, see Giacomazzi & Steiner, 2004). In his paper, Doyle (2010) draws extensively on the patient safety culture literature, including James Reason’s (1996, 2000) influential work. Reason (1996) advocated that any large, complex organization such as health care [and criminal justice, according to Doyle (2010) and Bogue (2009)] must adopt a systems-thinking approach in order to learn from its errors. Human error is, indeed, "human," and any complex system that depends on people to function perfectly, all the time, will eventually fail.

Doyle (2010) argues cogently that criminal justice organizations can work toward a systems approach to safety through continuous quality improvement and by viewing errors as organizational accidents. The reduction in numbers of deaths in aviation, nuclear power and health care are due to these industries adopting this approach, and seeing organizational accidents as combinations of small mistakes that combine together and lead to a catastrophic event (McElhinney & Heffernan, 2003; Henriksen, et al., 2006; Potylycki et al., 2006; Sammer et al., 2010; Trucco & Cavallin, 2006).

The CSC has already begun adopting the principles of a systems approach to safety by its commitment to adopting a "learning perspective" into in-custody harm and death investigations. However, there are aspects of the BOI investigation reports and follow up that could be more systems-focused in its management of any problems that are identified. The CSC can improve their safety record (as did the aviation, health care and nuclear power plant industries) by moving away from a "personal approach" in investigations and follow up, and toward a more integrated systems-approach. A personal approach to organizational safety follows a predictable course: A bad outcome is discovered (death of an inmate), the person who was at fault is identified (usually somebody on the front line of care), that individual is blamed, told not to do it again or is provided remedial training, and policy language is strengthened (Reason, 1997).

A systems approach to death investigations requires examining a negative event in the context of the complete organizational structure in which it took place. If a human error is discovered as part of an investigation, the investigation should learn more about why that error occurred. Similarly, if policy was not complied with, the investigation should try to understand why the policy was not adhered to. The answers to those why questions will help identify the systemic errors that can be remedied through recommendations that are more effective than policy and education alone. In an HRO, human error is viewed as a symptom of trouble deeper inside the organization or system, and should be viewed as a starting point for a more complete, systems-based investigation (CPSI, 2011; Dekker, 2011).

Disciplinary measures for human error are antithetical to a learning approach to investigations (Reason, 1997; 2000). These measures provide staff with greater motivation to cover up their errors than to discuss or report them, and the organization has no way of understanding the nature and extent of the problems on the front lines. Unless an organization understands the extent and nature of its human errors, it cannot track and manage that error in a systemic way. A focus on disciplinary measures leaves the organization prone to the same human error in the future, and the opportunity for learning from error is lost (Blake et al., 2006; Reason, 2000).

Correctional Officer Patrols and Deaths in Custody

The responsibility of CSC and by delegation, correctional officers to ensure public safety and maintain proper care of inmates is required legislatively by the CCRA, section 5, and is outlined in Commissioner’s Directive 566-4. The policy requires correctional officers to conduct regular counts, rounds and patrols on a regular basis (at least every hour) and to ensure that inmates are alive and breathing. This can be a particularly important function on night shift, when inmates are secure in their cells but may encounter medical distress or attempt suicide, or be victimized in a double bunking situation. Despite this, in many deaths inmates are discovered by staff long after they are dead, despite official patrols, counts and checks being recorded as complete. This has lead the Correctional investigator to question the quality of patrols and the willingness of staff to properly check inmates. Indeed, in response to concerns raised by the OCI, CSC has endeavoured to promote better practice in this area. Despite this, deaths are still being discovered where inmates have been deceased for some time, and as we shall see, this was observed again in two of the deaths in custody in 2010-11.

What is not discussed when this issue is raised is the difficulty in ascertaining whether or not an inmate is breathing at night. Correctional officers do not go into cells on night shift, so must observe at a distance, and try to ensure inmates are breathing. This may be done by noting the rise and fall of their chests, which is difficult if their blanket is over their heads or they are sleeping on their stomachs. In some cases correctional staff may tap on a cell door or shine a flashlight into a cell to get an inmate to move. This can create friction between staff and inmates, who may feel harassed by staff if they are awoken at night. Indeed, one of the committee members remembers this being an ongoing issue at one correctional institution where he worked. The inmate committee would complain about officers deliberately waking them up at night, while the officers insisted they were just trying to do their jobs credibly.

Some have discussed relations between correctional officers and inmates as having certain friction points, usually when staff must get inmates to do certain things they may not wish to do, but are necessary for the smooth operation of the institution. Getting inmates up in the morning is one of these friction points, and indeed in most institutions across the country inmates are not required to get up for breakfast, they can sleep in and skip this meal. "Stand to" counts (inmates are required to be up and standing by their cell door) are another potential area of contention, because inmates might be sleeping or ill, lying on their beds. This problem also arose in a couple of cases included in this review.

The right of correctional staff to do what they need to do to ascertain inmates are alive and breathing was partly upheld by Wild v. Canada (2004). The judge ruled that the correctional staff did have a duty to conduct their rounds on night shift, and went so far as to acknowledge that inmates might be woken up from time to time. In this particular case, however, he ruled that the staff had deliberately woken up the inmate, and that CSC management had not properly supervised or held staff accountable when the inmate complained.

Despite this ruling, it remains that correctional officers are in some ways dissuaded from conducting proper rounds. If they are diligent in their compliance with policy, inmates may complain. The committee also acknowledges that it is difficult to ascertain if inmates are breathing. Promotion of better patrol practice is important, and correctional officers should be a presence on the units. Dynamic security, ensuring that COs are knowledgeable of which inmates bear watching, is also an important means to promote diligence.

Alternative means of ascertaining that an inmate is alive and breathing are being examined by other correctional jurisdictions. Heat sensing technologies are being developed that can alert staff to an inmate whose body goes below a certain temperature. Such a technology offers a means to respond more quickly to a medical emergency. Even in the case of a correctional officer who is diligent in his or her duties, the time between expected rounds may allow an inmate who is intent on suicide to be long deceased by the time he or she is found. As a best practice the committee observes that such technology bears further investigation by CSC.

Chapter 3 - Methods

Inmate Sample

There were 25 cases of non-natural deaths in custody in 2010-2011. All 25 cases were subject to Boards of Investigation inquiries under sections 19 and 20 of the Corrections and Conditional Release Act (CCRA), including 19 as national tier I investigations, five reviewed as tier II investigations, and one death convened under local review. The four general categories of deaths are murder, suicide, drug overdose and death, unknown cause. The unclassified deaths are those for which the cause of death was uncertain at the time of the Board of Investigation (BOI) report, and a Coroner’s report was not yet available. Deaths, unknown cause were included in this review because the Incident Investigation Branch decided there were sufficient concerns about the circumstances of the death, or the organizational response to those deaths, to warrant a more detailed review. For example, a death involving an inmate with a pattern of high drug use might not provide enough evidence to warrant a suspicion of overdose, but one could not be sure until toxicology reports and/or a Coroner’s report had been received.

In-custody deaths deemed "natural" were not included in this review. Natural deaths are examined by CSC through an elaborate mortality review of each case.

Materials

The BOI reports (n = 25) were the primary data source used for this review. Each report provides a rich source of information on each death, including offender characteristics, criminal history, risk and precipitating factors related to the event, conclusions and recommendations. These reports also provide demographic background, criminal history and case management summaries.

Procedures

Terms of Reference

Assessment procedures were based on the terms of reference (TR) in the IRC’s convening order. There were nine terms of reference and they provided the framework to govern our review. The deaths in custody were divided into five categories: suicide, death by overdose (or suspected), homicide, deaths unknown cause, and one unusual death was rated on its own, a unique staff intervention death.

Each BOI report and related information was assessed and each reviewer compiled their rough notes and observations in an excel spreadsheet. Each death in custody category is summarized in a chapter which gives a narrative assessment of CSC’s performance according to the terms of reference. For example, the six suicides recorded in 2010-11 are presented in chapter five, suicides.

The nine terms of reference were assessed and interpreted as follows:

1. The appropriateness and adequacy of the corrective measures and managment action plans in response to thos investigations;

   For this section, we primarily examined the Executive Committee Grid, which tracks BOI recommendations and findings, and ensures that satisfactory responses are received from local (i.e., institution) and Regional levels. The appropriateness of the recommendations to address the issues at hand, and the adequacy of responses from local and Regional levels, were all taken into account.

   In addition, we rated the efficacy of CSC recommendations using methodology borrowed from health care organizations, the Canadian Patient Safety Institute’s (CPSI) hierarchy of effectiveness. We summarize the CPSI-based evaluations in chapter nine.

2. An analysis of trends in contributing or precipitating factors to the deaths;

   We took significant latitude in noting any trend that might contribute significantly or in part to the inmate death in question. Such trends might include precipitating events that immediately or proximately linked to a death, such as inmate conflict with staff or other inmates, bad news from family, or a security or parole denial. Trends might also include long-standing problems such as poor health, substance abuse, or negative family history. In some chapters and when appropriate, TR2 was overlapped with TR3 (mental health) and TR4 (case management).

3. An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths;

   Here we focused on an inmate’s mental health history such as past records of suicide attempt, self-harm, depression and other conditions. We also reviewed more recent treatment, including mental health treatment plans and regimes, medication, adequacy of treatment, and follow-up.

4. An analysis of any trends in case management practices prior to the inmates' deaths;

   Case management includes assessment of staff work on program planning, security reviews and release preparation. We also reviewed the adequacy of inmate contact, report preparation and overall adequacy of the timeliness, and thoroughness of documentation.

5. An analysis of any trends in security practices such as staff presence and monitoring of inmate activities;

   Correctional officer staff play a critical role in preventing inmate deaths through dynamic and static security measures. Dynamic security and communication with inmates can lead to discovery of precipitating factors or changes in inmate moods. Static security practices such as meticulously conducted rounds and counts may also lead to observation of deteriorating health, presence of drugs or unusual behaviours that are risk factors. Staff performance in these areas, and their reaction to such cues are critical in prevention and preservation of life. Well conducted rounds will result in swifter identification of inmates in life threatening circumstances, which will improve response times and the ability to preserve life. The IRC examined quality of staff performance in all these areas.

6. An analysis of any trends in the management of and response to those emergencies in response to the inmates' deaths;

   Emergency response trends of concern included correctional staff response time after an inmate was found in distress, and response by correctional officer or health care staff in administration of medical assistance. Responses may include first aid and/or cardio-pulmonary resuscitation, deployment and appropriate use of emergency medical equipment, and contacting, liaising, and assisting outside medical staff to access the facility. In some situations, the securing of incident scene (e.g., murder) and restraining of possible assailants was appraised.

7. An assessment of information sharing among key players during the incident;

   Knowledge of the potential risk of overdose, suicide, or conflicts leading to violence are not of much use if not shared with other correctional staff. If inmate A is depressed over receipt of a "dear John" letter from an ex-partner, it is of little use to the oncoming shift if this information is not shared. Similarly, knowledge of severe depression or mood swing by health care staff must be shared with correctional officers if they are to provide extra attention to an inmate. Finally, security information about a conflict between two violent inmates must be communicated effectively between staff in order for adequate monitoring, inmate placement or more immediate preventative action to ensue.

8. An assessment of support provided to staff members and inmates after the incidents;

   We examined whether or not the Critical Incident Stress Debriefing was offered and/or conducted with staff, and what kinds of support were provided to inmates after the event.

9. Any successful and best practices in other international correctional jurisdictions with respect to deaths in custody;

   The IRC considered this parameter fairly broadly to include best practices found in other jurisdictions and related empirical research, including health care and criminology.

Use of Narrative Assessment and Table Summary of Terms of Reference

In Chapters 4, 5, 6, 7 and 8, we provide a narrative assessment of each term of reference, using sub-headings. After reviewing the BOI reports, we go through each term of reference and highlight what we feel are key points from the BOI. At the end of each chapter, we provide a table to summarize CSC performance. This strategy is illustrated here by a fictitious example of three inmates who died after imbibing too many potato products.

Example Summary

The table identifies each inmate by case # for confidentiality, and lists type of death (e.g., murder, suicide, in this case French Fry). In TR1, there are three "no" responses, which indicate that CSC’s responses to French Fry-related incidents were appropriate overall. This might mean that, among other suggestions, the BOI recommended reducing potatoes in offender’s meals, and the institutions and Regions agreed. In TR2, it was noted that trends were only evident for inmate#1, not all three (in this case obesity problems). In TR3, a mental health concern is observed for inmate#1, in this case an addiction to French Fries, but not the other two inmates. TR4 notes a "yes" concern for inmate#1 because his program plan included work in the kitchen, which offered easy access to French Fries and other foods, despite his addiction and weight problems. TR5 notes problems with security for inmates #2 & 3, because for both cases medical problems were observed by staff in the evening but the inmates were not immediately referred to health care staff. As well, these inmates were not discovered in distress until the night shift. There were no problems with the emergency response, TR6. For TR7, inmate#2 had confessed to his psychologist that he was hoarding French Fries in his cell but this was not passed onto other staff. For TR8, all staff and inmates involved in the deaths were offered CISD support. Finally, in terms of best practice one institution stood out by not adopting best practices of limiting French Fries as an item on monthly menus, and limiting the use of grease in French Fry cooking.

Each table also attempts to summarize the extent of trends, or satisfactory versus unsatisfactory performance. For example, TR1 and TR8 shows no problems in all three CSC responses. On the other hand, TR5 shows security problems in two of three cases. Identification of overall trends have implications for IRC recommendations and prioritizing by CSC on necessary action on deaths in custody.

While each chapter by death type contains a table summary at the end; this table includes all 25 cases for an overall assessment of CSC performance as per the terms of reference.

Yes - Problem(s) identified.
No - No significant problems identified.

Canadian Patient Safety Institute’s (CPSI) Hierarchy of Effectiveness Tool

In our literature review in chapter two, we outlined the benefits of organizational risk management practices from the healthcare field. We build on this analysis to outline our use of the Hierarchy of Effective tool to evaluate CSC organizational responses to deaths in custody.

In light of concerns raised by the OCI regarding the recurrence of similar events and similar gaps in services, the IRC was interested in rating the level of effectiveness of the BOI recommendations. We define effectiveness here as the likelihood that a recommendation will bring about a meaningful reduction in deaths in custody.

To our knowledge, a method for rating recommendations in this way is not established within the criminal justice literature, thus we turn to other areas for guidance. In an effort to prevent unexpected (i.e., not disease-related) deaths, many health care organizations have adopted principles from High Reliability Organizations (HRO; Perrow, 1999). HROs operate through the theory and practice that complex organizations are inherently error-prone, and organizational accidents (including death) can be prevented through systems-focused management of that error. Since the 1980’s, a broad range of organizations and agencies adopting HRO principles have seen remarkable improvements in safety and prevention of deaths in nuclear power plants, health care, chemical plants, firefighting units, and aviation (Bourrier, 2011; Perrow, 1999, Roberts & Bea, 2001; Roberts, Stout & Halpern, 1994; Weick & Sutcliffe, 2001). HRO principles are especially useful for organizations that are both error-prone and responsible for individual and public safety, like criminal justice organizations. Criminal justice organizations involve complex, interrelated processes and procedures, they are responsible for a vulnerable (and sometimes litigious) populations, and they rely on humans to manage this complex, error-prone system (Bogue, 2009).

The Canadian Patient Safety Institute (CPSI) provides health care organizations with the tools and methodologies (such as the hierarchy of effectiveness) to adopt HRO principles. The hierarchy of effectiveness tool was therefore adapted for the current review. Measuring and tracking the effectiveness of BOI recommendations is one important way CSC can begin to adopt the principles of a HRO.

Once an investigation has determined the root causes of an event, recommendations should be developed to mitigate the risk of those problems recurring again in the future. Recommendations related to training and policy should be developed when gaps are identified, but those alone do not resolve the underlying issues that lead to a serious incident.

The key features of effective recommendations are those that:

• Provide a solid and sustainable barrier or signal to stop the risk associated with the actionable contributing factors identified (see Table 2, hierarchy of effectiveness);
• Have Specific, Measurable, Attainable, Realistic, Timely (SMART) elements;
• Target the right level of the organization ;
• Assign responsibility to the right individual;
• Are based on evidence (where possible); and,
• Provide enough context (explanation, facts) (CPSI, 2011, p. 24).

An organization can adopt this coding scheme as a routine part of investigations and reports. The effectiveness of recommendations can be tracked over time, and organizations can set targets to improve scores. As noted above, when gaps in education and policy are discovered, these should be remedied through education and policy development efforts. Policy and education recommendations are therefore always expected; however investigations should always aim to develop recommendations that reflect as many of the 6 key features (CPSI, 2011) as possible. The more key features a recommendation contains, the more effective it will be in preventing deaths.

Study Sample Description

The small sample size from this year’s review does not allow for inferential statistical analyses, so descriptive statistics are presented.

The study sample reviewed consists of 25 federal offenders who had died in fiscal 2010-11 of murder, suicide, staff intervention and unclassified deaths, which are termed deaths by cause unknown as per past practice. Causes remain "unknown" in the sense that a final medical determination of death has not been made, and autopsy and/or a final Coroner’s reports can take two years or longer. An inmate with past drug involvement may pass away due to apparent natural causes, but this is not clear until an autopsy is done to ensure an overdose had not occurred. Of the 25 total deaths, seven were classified maximum security, thirteen were classified medium, two inmates were on Day Parole and three were on Statutory Release with Residency. The largest category of deaths was "Death Cause Unknown" (9), followed by Suicide (6), Murder (5), Death by Overdose or Suspected Overdose (4) and one case due to Staff Intervention (Table 3).

The study sample this year was all male, their age averaged just under 40 years and about a third were Indigenous (36%). Twenty-eight percent were classified as maximum security, around half were in medium security custody and 20% were in the community on Day Parole or Statutory Release with a Residency condition.

A recent one day snap-shot of CSC offenders provided to the committee of Aboriginal federal offenders put them at 19.2% of the total population, thus this year they were almost twice as likely to die while under CSC supervision. This over-representation while in prison reflects the experiences Aboriginal peoples face in the community, such as health concerns, criminal victimization, addictions and high suicide rates (Allard, Wilkins & Berthelot, 2004; Brzozowski, Taylor-Butts & Johnson, 2006).

Considering the various Regions and the size of their inmate populations, Quebec is under-represented in overall deaths this year, while the Prairies Region is over-represented. The high number of custodial deaths in Prairie institutions is not surprising, as they have a high concentration of Aboriginal inmates and prison gangs.

Just over a quarter of the study group were serving a life sentence (28%).

Trends

The number of murders per year in the past decade has varied considerably, making trends difficult to ascertain (Figure 4). The highest number of homicides during this period took place in 2003-2004 (n = 8), while generally the totals range from only one to three per year. This year’s number of five homicides is the second highest in the past ten years. Factors associated with the high number of deaths in certain years merit further study. The perpetrators as well as the victims are suitable subjects for scrutiny. This past year, two of the five perpetrators had previously killed another inmate while in custody. Likewise, one of the victims had previously killed another inmate himself.

Figure 3: Inmate Murders 2000-01 to 2010-11 (Source: CSC Annual Performance Reports)

The best trend data made available to the committee is for suicides in custody, which ranges back to 1991-92. The total in custody suicides (n = 5) this year is much lower than was observed last year (n = 9), and is part of an overall downward trend across time (Figure 2). Consider that for the following five year periods:

• 1991-92 to 1993-95 averaged slightly over sixteen per year (16.25);
• 1995-96 to 1999-00, suicides averaged thirteen per year;
• 2000-01 to 2005-06, suicides averaged eleven per year, and;
• 2006-07 to 2010-11, suicides averaged eight per year.

So, suicides have been cut in half by CSC since the early 1990’s. We are not suggesting that there is not more work to be done in reducing this number, but a clear trend is evident.

Figure 4: Federal Inmate Suicides 1991 to 2010-11 (Source: CSC Annual Suicide Report)

The most problematic data provided to the Committee by CSC is on drug overdoses or suspected deaths in custody related to drugs. The numbers for this type of death differ across sources, such as annual performance reports and research studies such as Gabor’s recent project. This reflects the problematic nature of defining and validating drug overdoses. Coroner’s reports are not available for up to two years or more after the event, thus a final confirmation (or rejection) of a Board of Investigation’s suspicion of a drug overdose cannot be finalized for some time. Figures can change, and recent years may be under-represented or over-represented. For the 2010-2011 year, we simply went with the BOI narrative and where it appeared there was a drug overdose, we recorded it as such. Looking back over the past decade (see Figure 3), the drug overdose totals seem to fluctuate wildly, ranging from one to six in a given year. The data validity problem makes generalizations difficult, but it appears that there has been little change in the number of overdose deaths in custody of over the past ten years. The data problems make evaluation of CSC efforts to reduce deaths in custody difficult to assess; accurate numbers are crucial. For example, the organization’s interdiction efforts to reduce drug use in penitentiaries could possibly be connected to a reduction in such deaths, but only if overdose numbers can be looked at with confidence.

Figure 5: Inmate Drug Overdoses and Suspected 2000-01 to 2010-11 (Source: CSC Annual Performance Reports)

Study Group Comparison with General In-Custody Death Populations

Finally, the committee would like to provide some context in assessing the 2010-2011 study group by comparing it with the research summary of cases by Gabor from 2002 to 2007 (Table 6). This comparison allows us the ability to gauge if this year’s numbers are typical or atypical. This method is far from perfect and does not allow us to consider anomalies (e.g., this year’s homicides are high, but they are unlikely to be as high next year), but we feel it offers the reader some basis for comparison. In an effort to compare apples to apples, we reference only the 19 cases in custody at the time of death: the one staff intervention case and five conditional release cases are not included. We also collapse Drug Overdose and Suspected Overdose and Death Cause Unknown categories into an Accidental Death category used by Gabor.^{Footnote 4}

The 2010-11 group had a larger proportion and number of homicides than usual, 26.3% to 20.7% in Gabor’s fiver year study. Suicides were a much lower proportion, 21.1% of deaths compared to 61% previously. Accidental deaths made up the largest grouping, 52.7% this year, compared to only 18.3% in the past. Moreover, known (or suspected) drug overdoses made up a much smaller percentage of the Accidental category: 33%, compared to 80% counted in Gabor’s analysis.

Males predominated this year, consistent with past years (100% to Gabor average 99%). The 2010-11 group was older; only 15.8% were under 30, compared to 29.3% in the Gabor study period. The proportion of Aboriginal deaths in custody appears to have increased: 22% in Gabor’s study to 31.6% in ours.

Gabor found just under one third of deaths (29.3%) occurred within the first 30 days of admission to an institution, but we only found this in one case in our samples (5.9%). The 2010-2011 study group all had prior criminal histories and almost all had committed violent crimes, quite consistent with results in Gabor’s study. Gabor found that those serving a life sentence comprised about a third of inmates who die each year in custody, roughly consistent with this year’s results (31.6%).

To summarize this comparison, this year’s homicides are higher than other years. Suicides are lower, and this appears to be part of a downward trend. Accidental deaths make up a higher proportion of this year’s deaths in custody. Drug overdoses appear to be the most difficult type of death to determine accurately, and we have the least confidence in the trend data that was made available to us. A separate study is likely necessary, considering the lag for Coroner’s reports, to improve the quality of drug-related death information. The IRC also takes the view that inmate homicides also merit a separate, longitudinal analysis.

Limitations of the Independent Review and this Form of Research

There is a fundamental methodological problem with the type of review we are conducting. Essentially, it is a causal problem of overgeneralization: making attributions to the whole group on the basis of a few examples. This review takes a small group of statistically rare events, attempts to identify recurring problems in a few cases and then infer back to the operation of the whole organization. This problem is exacerbated by reviewing cases over the course of one fiscal year. For example, if a few cases involving deaths in custody show a poor emergency medical response by CSC staff, then it is assumed that emergency response is a large problem, perhaps due to inadequate training of staff, inadequate equipment, or they are not taking their jobs seriously, or that procedures should be standardized . However, there may be a large number of medical emergencies over the course of the year where CSC staff performed in an exemplary fashion, potentially saving inmate lives.

Deaths in custody, however, are a "negative reporting" structure where-in only deaths are studied, not near deaths or suicide attempts averted through staff intervention. It may be that most of the time, staff respond promptly or heroically, but data is not systematically collected and analyzed to assess the prevalence of successful staff intervention. The committee views the data collection initiative by the Corrections Operational Branch as critical to correctly evaluating CSC performance in this area. Data on successful interventions, or those that resulted in injury but not death, should provide an evidence base that from which CSC can gauge a relative level of staff performance, calculation of error rates or estimates of relative areas of strength and weakness.

That is not to say that concerns about staff performance in situations involving inmate death are not valid to examine, or that improvement and learning should not be a goal. Self-scrutiny is an important feature for any organization seeking to perform at a high level. Recurring problems are obviously important to address. However, this type of approach over a single year can lend itself to over-generalization. We return to this issue in our chapter nine conclusion.

Chapter 4 – Overdose Deaths

In the 2010-2011 fiscal year there were four confirmed deaths by overdose. Two offenders were on statutory release at the time of their deaths, and two were in medium security. All four men died from ingesting opiates alone or in one case, multiple drug toxicity of heroin and diazepam. It is worth noting that at the time of the death in case #24, there was a "bad batch" of heroin in British Columbia (where the inmate was housed), which was reported by the RCMP to media outlets in January 2011.^{Footnote 5} In May 2011 the BC Coroner Service released an Information Bulletin warning that there had been 20 overdose deaths in the first 4 months of that year, which is double the number from the year before.^{Footnote 6} The BOI report also made note of the coincidental timing between the death in case #24 and the warnings being issued by police and the Coroner’s Service to drug users.

The appropriateness and adequacy of the corrective measures and management action plans in response to overdose-related investigations.

It is not possible to analyze the appropriateness and adequacy of the response to case #25 because it was a local investigation, and thus not submitted to EXCOM. For the remaining three BOI reports related to overdose deaths, there were six recommendations, one of which was supported by the organization. Five recommendations were not supported for a variety of reasons, including a concern that the recommendation was a duplication of other efforts already in place, incompatibility between clock systems, and disagreement with the findings. The recommendation to install range and unit vestibule cameras with a time mark, in order to evaluate the quality of rounds, was supported. There were fifteen findings across the BOI reports on overdose deaths, many of which dealt with compliance issues. A detailed analysis of the CSC response to these recommendations and findings is provided in Chapter 9.

An analysis of trends in contributing or precipitating factors to the deaths

Not surprisingly, all four offenders who died by overdose had substantial histories of substance use problems, which contributed to the criminality of each offender. Three of the four offenders in this section had completed or were actively involved in substance use programming during their incarceration. When case #25 admitted he had used morphine three days before his release, the parole officer appropriately provided additional support to address relapse. Overall, none of the BOIs identified any gaps in the response to the inmates’ substance use problems.

In two cases, the BOI did not identify any precipitating factors to the incidents, and a request to provide a urine sample for urinalysis was considered a proximal factor in case #25. Pain management (from chronic back pain and recent dental work) was considered a pre-incident indicator in case #8, and this offender’s atherosclerotic cardiovascular disease was a contributing factor to his death.

An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths

Three of the four offenders who died by overdose had documented mental health problems. In case #25, the offender had a history of suicide attempts, and in case #24, the offender was diagnosed and treated for Borderline Personality Disorder and schizoaffective disorder. The offender in case #8 had a history of depression. In all of these cases, the mental health needs of the offenders were well managed. Medication issues were appropriately managed and monitored for cases #8 and #24. For case #25, his suicide history was documented, and his current risk was not an issue during his last incarceration.

An analysis of any trends in case management practices prior to the inmates’ deaths

With the exception of some timeframe issues related to planning in cases #24 and #25, there were no serious concerns raised in regard to case management among those who died by overdose in the 2010-2011 fiscal year. Case preparation was noted to be thorough and appropriate, and some time lags that were identified did not impact the overall management of the offenders. In three cases, the security classification and placement of each of the offenders aligned with policy. A compliance issue was noted for case #8, as his double bunking assessment was not completed according to policy. In all four cases, each offender was supplied with a robust plan to address his needs.

An analysis of any trends in security practices such as staff presence and monitoring of inmate activities

Issues related to supervision and monitoring of inmate activities were raised in two cases. In case #24, the offender was found dead in his bedroom at the Community Centre in rigor mortis. He was last seen that morning for his breakfast, and was checked again when he failed to show up for his community maintenance program. Through the investigation, the BOI raised issues related to urinalysis testing and the consistency of rounds and counts in the Centre. At the time of the inmate’s death, the facility conducted urinalysis on reasonable grounds only, rather than by frequency. As well, this facility did not adhere consistently to Post Orders. The BOI judiciously made recommendations to improve monitoring of inmates through consistent rounds and counts, and conducting urinalysis by frequency.

In case #13, the BOI noted concerns with the wooden window coverings on the cell doors, which inhibited the informal observation of inmates in their cells. As well, the lack of video recordings at the facility meant that the quality of rounds could not be assessed. These cases illustrate that the consistency and quality of rounds and counts remain an area for improvement across facilities.

An analysis of any trends in the management of and response to those emergencies in response to the inmates’ deaths

Three of the overdose cases occurred while the offenders were in their respective facilities, and one overdose occurred while the offender was Unlawfully at Large (UAL) from his residential facility. For those who were in custody, the staff responded immediately to the event and gathered other staff support for the emergency. For case #8, another inmate found the inmate unresponsive in his cell and asked for help from another inmate before notifying staff. Unfortunately in two cases (#13 and #24), CPR was not implemented according to Health Services CD 800. In case #13, the inmate was transported to Health Care before CPR was initiated. In case #24, CPR was not administered at all because the staff found the deceased in rigor mortis. While it is understandable that in the latter case, staff believed the inmate was beyond therapeutic intervention, the CD is clear that CPR should be administered regardless. This directive provides for circumstances when staff are mistaken in their belief that the person is beyond therapeutic intervention, and by starting CPR, the staff can ensure they are doing all they can to preserve life.

Case #25 died by overdose while UAL from his residential facility, and was pronounced dead at the hospital. Therefore, the CSC was not involved in the emergency response to this case.

An assessment of information sharing among key players during the incident

The most consistent trend in communication among key players during the incidents was that information was shared regularly among the relevant individuals and agencies involved with the offenders’ cases. All communications and reports were done according to stipulated policies in two cases (#13 and #24). One issue related to the timing of communication did not have an impact on the case (#25) or the incident. One volunteer who was close to inmate #24 was not informed of his death for three days, and in case #8 one reporting form was completed twice, and there were inconsistencies in the categorization of death after the incident.

An assessment of support provided to staff members and inmates after the incidents

In three cases, Critical Incident Stress Management (CISM) was offered to all staff and provided as needed. In case #8, there is record of the CISM team being notified of the incident and to attend, but the uptake of that support was not reported in the BOI. Follow up support through the institutional Elder may have been provided, but it was not reported in the BOI. Support was offered to other inmates in case #25, but the support to inmates was not reported for cases #8, #13 and #24. Overall, it appears there was a missed opportunity for the BOI to learn about why the support was not offered or provided, and develop remedies and recommendations to ensure that inmates and staff receive the appropriate support after a traumatic event.

Summary of Overdose Deaths

Yes – Problem(s) identified.
No – No significant problems identified.
N/A Not Applicable.

Issues related to the CSC’s response were identified in two out of the four cases of death by overdose. There were no significant problems identified in any of the cases in regards to pre-incident trends, mental health, case management, information sharing, or best practices. In 2 out of the four cases, there were issues identified in relation to security and patrols and in the emergency response to the deaths. Significant problems were identified in three of these cases in relation to support provided to staff and inmates after the event.

Chapter 5 - Suicide in Prisons

In the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors (2003), the authors note that the statistical rarity of suicide events makes them difficult to predict on the basis of risk factors. In complex environments such as correctional settings, even best practice suicide risk management strategies are unlikely to predict and prevent all suicides. Risk factors are often additive, but also may be interactive and produce unique levels of risks across individuals. As noted in the Harvard Medical School Guide to Suicide Assessment and Intervention (Jacobs, Brewer, & Klein-Benheim, 1999, p. 4), "The goal of a suicide assessment is not to predict suicide, but rather to place a person along a putative risk continuum, to appreciate the bases of suicidality, and to allow for a more informed intervention."

Suicide risk management in correctional settings can be especially challenging for a number of reasons. First, in a U.S study Jenkins and colleagues (2005) demonstrated that those in pre-trial are 7.5 times more likely to attempt suicide compared to the general population, and those in jail are six times more likely to attempt suicide. This is likely because incarcerated individuals bring with them into the prison setting a cornucopia of risk factors, which put them at greater risk for suicide compared to the general population (Jenkins et al., 2005; Konrad et al., 2007). Risk factors may be static, for example, historical issues such as childhood sexual abuse, or dynamic, for example ongoing substance abuse. These "imported" risks are then exacerbated by the stress of incarceration itself and deprivation of liberty and, for some, the loss of protective factors such as employment and stable housing. Suicide risk management strategies within criminal justice organizations should aim to mitigate suicide risk as much as possible through the use of best practice assessment and interventions, by implementing environmental safeguards that limit access to means for those at immanent risk of suicide and other safety strategies known to reduce the risk of suicide in institutional settings.

There were six confirmed deaths by suicide under CSC’s jurisdiction in the 2010-2011 reporting year. This section will review the circumstances related to the deaths by suicide, with the intent of identifying trends in how the system may have failed, what gaps were identified, and the effectiveness of the suggested remedies in the BOIs.

The appropriateness and adequacy of the corrective measures and management action plans in response to suicide-related investigations.

Boards of Investigation (BOI) conduct a thorough investigation of the circumstances and outcomes related to each death. The results of the investigations are separated into findings (compliance and non-compliance) and recommendations. The findings and recommendations are then supported, supported in part, or not supported by the institutions involved in the incident, and leadership of related services, sectors, programs or policy holders. Then, action plans to address the supported findings and recommendations are developed and overseen by the executive committee.

Out of the six deaths by suicide, one report had two recommendations, and two other reports had one each, for a total of four recommendations. One of these recommendations was not supported: That CD 800 Health Services be changed so that the AED is deployed even when it reads, "No shock advised." The Assistant Commissioner, Health Services argued that according to the directive, the AED in fact should have been applied during the incident. From the documents provided to the IRC, it appears that remedial education was provided to nursing staff on the appropriate deployment of the AED. A more effective organizational response to this incident would be to determine how to simplify the instructions on the deployment of the AED during a crisis. It is clear to the IRC that the staff involved believed they were following the procedures correctly; remedial education about the policy does little to address a knowledge gap (indeed, reminders and memos are least likely to lead to effective change). Simplification of procedures and instructions, if possible in that case, would have been a much more effective organizational response.

An analysis of trends in contributing or precipitating factors to the deaths

Every inmate who died by suicide had a history of suicidal ideation, and all but one had serious mental health problems, primarily depression and one case of paranoid schizophrenia. Four out of the six deaths by suicide had a history of suicide attempts, and all these inmates died repeating the same suicide attempt method. There were no clear trends related to long-standing factors among those who died by suicide: The reports identified psychiatric and psychological issues such as poor coping skills, distress from illness, accumulated personal losses, long-standing grief, and chronic pain. None of the investigations uncovered immediate precipitating factors (within 24 hours of death).

Proximal factors were identified in three of the deaths. These factors were changes in ADHD medications, death of family members and the denial of leave to a funeral, multiple institutional transfers, and distress from schizophrenia (auditory hallucinations).

A notable trend among those who died by suicide was that the inmates’ psychotropic medications had been changed, initiated or discontinued two to six weeks prior to their deaths. This change was noted in five out of the six deaths by suicide; however none of the respective BOIs identified medication change as a contributing risk factor to the deaths and side effects from changes in psychotropic medication can last one or two months. As such, medication change may be a precipitating factor in these deaths. It is reasonable for an investigative committee to explore whether a change in an inmate’s psychotropic medications were appropriately monitored according to best practice. An analysis of the organizational response to medication management is explored in greater depth in the next TOR section, related to the mental health care for offenders.

Case #21 had Type 1 diabetes, thus requiring blood sugar monitoring and insulin injections. This inmate was under community supervision at the time of his death, and the health records of his stay in custody were not reviewed in detail in the BOI. The extent to which the health care staff assisted this inmate with his blood sugar monitoring, including managing hypo- and hyper-glycemic episodes, is unclear. This offender (committed suicide by insulin overdose. This offender also suffered from chronic pain. In the past, his community general practitioner had prescribed him Oxycontin, which provided effective pain management. His GP stopped prescribing the medication prior to his incarceration, and the offender was not able to access this highly regulated opioid in custody. Efforts were made to provide alternative forms of pain management (both in the community and in custody), but he remained in severe pain, which exacerbated his depression. In this case, his chronic pain and lack of effective pain management were proximal causes to his death by suicide.

An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths

Tread in Medication Management

As indicated above, a notable trend among those who died by suicide was that the inmates’ psychotropic medications had been changed, initiated or discontinued two to six weeks prior to their deaths. This change was noted in five out of the six deaths by suicide, and the most troubling of these cases is seen in #16.

Inmate #16 had his Celexa (a powerful antidepressant medication) discontinued six weeks prior to his suicide because "he refused to attend clinic" in accordance with the Reception Awareness Program (a health education program). The psychiatrist who was interviewed after the event said this practice is "consistent with community" standards. These circumstances raise flags for the IRC. This was an inmate with a history of chronic depression and suicide attempts, who would not engage with mental health care. It seems irresponsible to then withdraw psychiatric medications as a consequence for that disengagement. In addition, sudden withdrawal of powerful antidepressants may lead to a discontinuation syndrome, in itself a medical emergency. This practice is especially problematic considering this man was receiving treatment for an illness in which disengagement/isolation is a symptom of worsening disease. If is it routine practice in CSC facilities to withdraw medications as a consequence for not attending clinics, this practice should be re-examined in regard to psychotropic medications. Specifically, the Reception Awareness Program should reflect best or promising practice related to treating and monitoring depression in custody or within an institution, and not in the context of community standards. The IRC is confident there was a way for the organization to continue psychiatric medications and monitor for symptoms and side effects without requiring the inmate to actively engage health services.

With the exception of case #9 (the offender with paranoid schizophrenia), it is unclear from the BOI the degree to which inmates are monitored for withdrawal or side effects. Given that five out of the six inmates who died by suicide had psychiatric medications initiated, changed or withdrawn two to six weeks prior to their deaths, this is an area of practice that deserves attention from the CSC.

Cases #4 and 16 have a notable similarity: In both cases the intervention staff had great difficulty engaging the offender, both of whom were in segregation. In the reports related to these cases, the BOI and CSC go to considerable lengths to explain how the staff engaged, or attempted to engage, each offender. One notable comment from a psychologist that was cited in the Grid, "Availability (of mental health care) means nothing if the person wants none of it." The organizational gap in these cases is not the efforts of the intervention staff. The gap is whether the existing practices or interventions reflect best practices and whether the intervention staff requires other mechanisms for meeting the needs of offenders who are disengaged from services. In the future, CSC will continue to house disengaged, suicidal offenders in its facilities, and is responsible for mitigating the risk of death. While it is important to ensure that staff complied with established policies and procedures, the next step is to determine how the organization can improve its response to depressed and disengaged offenders. The action plan in Case #4 provides an example of this type of improvement; it specified that the psychologist will attempt to engage the offender every other day. The deficiencies of the organizational response to case #16 are noted above.

Tread in Care by Type of Facility

Of the six deaths by suicide, four took place in maximum or medium security facilities. Of those, two BOI reports identified gaps related to Mental Health Committees. Case #3 noted that the Committee had yet to be set up at the time of the inmate’s death. Case #4 noted that there was no referral process established in order for the Committee to review a particular case. The implementation of Mental Health Committees across the Service is a promising practice that supports communication across multiple players, sharing information and expertise, and discussion of complex cases. These Committees were in the process of roll out during the time frame of the current review, but the incidents provide opportunities to see how these committees can best meet the mental health needs of the inmates. In response to the gaps identified in cases #3 and 4, management action plans and procedures were developed to address the identified gaps; the Committee at one facility was established, and a referral process was developed and implemented at the other.

Case #3 makes reference to the inmate "promising" corrections staff not to commit suicide. This is evidence that no-harm contracting is used as part of mental health interventions by staff. The IRC did not have the opportunity to review the suicide education or awareness programs provided to staff. However, if suicide education and awareness condones the use of no-harm contracting, these should be removed and revised to reflect best practice in the field. No harm contracts are generally discouraged by professional and academic associations, including the American Psychiatric Association (2003), for a number of reasons. First and foremost, there is no evidence that they prevent suicide and do not protect clinicians from malpractice litigation (McConnell & Lewis, 2007; Steele & Doey, 2007). They are especially discouraged for those who are agitated, psychotic, impulsive, or under the influence of intoxicating substances (APA, 2003). Instead, a collaborative and pragmatic Safety Plan is an emerging, leading practice among mental health and addiction service providers. The Safety Plan is developed collaboratively between the inmate and professional, tapping the inmate’s available coping strategies and avenues of support. The safety plan covers access to means to attempt suicide, and ways to access support during a crisis. The professional and inmate can also problem solve regarding potential barriers or obstacles of using the plan.

The mental health care provided to the inmates on day parole (n = 2) was comprehensive and supportive of recovery. For example, case # 21 received a constellation of support services aimed at addressing mental health and substance use issues. His history of suicide and depression was identified appropriately and information was documented and communicated across team members. Community supervision provides a much broader range of treatment options, many of which are not feasible or funded within maximum or medium security facilities. This offender (case #21) was a provincial offender who died by suicide in a federal community residential facility, and so was not subject to the same mental health process or protocol as federal offenders. Even though this offender’s mental health care was responsive and comprehensive, the BOI judiciously recognized this organizational gap in relation to provincial offenders. The BOI recommended clarifying the roles and responsibilities during release planning and appropriate assessment and documentation of provincial offender's suicide and self-injurious behavior (SIB). The CSC’s support and comprehensive action plan for this recommendation is a promising and effective response to an organizational gap.

An analysis of any trends in case management practices prior to the inmates’ deaths

The most notable trend related to case management is that it was well coordinated and executed in four out of six cases reviewed in this section. In these four cases, the inmate’s case management teams were lauded for their seamless communications and coordinated care.

The exceptional cases were #3 and 4, which noted some gaps in case management, such as poor communication between team members and lack of clarity around role responsibilities. The BOI for case #4 provided recommendations to address this gap: That policy is developed for the chief psychologists at different institutions to share information about inmates’ mental health needs prior to transfer for those with suicide or SIB. This recommendation was appropriately supported by the CSC via amendments to CD 710-2, Transfer of Offenders. The changes include requirements to have a case conference between mental health teams of the sending/receiving facilities prior to the transfer of an offender identified at such risk. Additionally, within seven days of the case conference, the receiving facility will be required to complete an interim plan for managing the offender. These policy-related changes are important first steps in addressing the identified gap; implementing automated procedures to ensure the conferences and interim plans are completed would improve the effectiveness of the response. For example, a computerized mechanism could be developed that requires the chief psychologist to enter the date and time of the case conference, without which the transfer cannot go forward.

An analysis of any trends in security practices such as staff presence and monitoring of inmate activities

For those on community supervision (n = 2), all assessments for supervision frequency were completed according to policy, and met or exceeded minimum contact requirements. In these cases, breaches were appropriately addressed in a timely manner, and frequency of contact was adjusted accordingly. Among those in medium or maximum security facilities (n = 4), all counts were done according to policy in two of these cases. In the other two cases, there were some missed punches on other units, but these had no impact on the monitoring of the inmates who died by suicide. The quality of supervision was noted to be adequate and effective in these cases.

Trend in Monitoring of Inmate Activities

Among the deaths reviewed in this section, three took place on a segregation unit in a maximum security facility, one occurred in a general population unit in a medium security unit, one took place in a community residential facility, and one man’s body was discovered in the mountains months after he had left without authorized permission (AWOL) from community supervision.

It is disconcerting that three offenders were in segregation when they died by suicide. These cases, alone and in combination, illustrate serious organizational gaps in suicide risk management. The BOI in two of these cases noted that the security and segregation reviews were done according to policy, but one identified significant gaps in the process of the inmate’s security placement:

"(The BOI) disagreed with the inmate’s security classification to maximum and found that the inmate should not have been transferred to [XXXXX] Institution. Attempts to assess his deterioration and intervene to meet his mental health needs could have been made at [XXXXX} Institution."

"A psychological assessment (as per Commissioner’s Directive 710-6, Review of Offender Security Classification, paragraph 29) should have been considered at the time the inmate’s security reclassification was completed; the decision was made to override the Security Reclassification Scale result to maximum, given the inmate’s intensive mental health needs and the fact that a Psychological Assessment had not been completed since March 2008."

Unfortunately, the CSC response to these findings was contrary to an organizational learning approach to safety. In the EXCOM Grid of organizational responses for this review, the warden of the institution noted that the cited policy does not stipulate that an updated Psychological Assessment is required in order to assess the inmate’s security level. The Director of Correctional Operations and Programs (COP) acknowledged it could have been beneficial to request a new psychological assessment; however he or she noted that several case conferences occurred with psychological staff at the institution, and that the psychological needs of the offender were taken into consideration while determining his security classification. It should have been clear to the CSC that the findings quoted here represent an organizational gap. The current process to ensure the safety and preserve the life of inmates failed in this case. The fact that case conferences with the psychological staff occurred for this offender is moot; the organizational gap remains in place and puts CSC at risk for recurrence.

Trend in Environmental Hazards and Safeguards

It is understood that examining environmental hazards and implementing safeguards is a routine part of operational practices for the CSC. It is therefore surprising to the IRC that this examination was not integrated into the investigations process. None of the BOI reports examined the environmental hazards where the offender died, which is especially important for segregation units. In this context, environmental hazards are those features in a facility that offenders may use to harm themselves. Environmental safeguards are features on a unit that limit a person’s access to the means for self-harm and suicide (Cardell, Bratcher & Quinnett, 2009). A series of reviews noted that hanging was a common method to commit suicide while in a facility, and restricting access to ligature points and related means should be an organizational safety priority (Daigle, 2005; Hawton, 2007; Lieberman, Resnik & Holder-Perkins, 2004; Mills, DeRosier, Ballot, Shepherd & Bagian, 2008; Yeager et al., 2005). These types of environmental safeguards are most appropriate for units that manage those at high or immanent risk of suicide, such as those seen in assessment and stabilization units, or acute inpatient units. In the current context, these safeguards are most appropriate for segregation units, and not general population units or community facilities. While these safeguards make units more "suicide proof" (Cardell, Bratcher & Quinnett, 2009), they also make units very sterile and stark, and are not conducive to long term recovery from mental health problems.

Separately and in combination, that fact that three inmates had access to the means to commit suicide (two by hanging, and one by suffocation) while in segregation reflects a gap in the routine organizational practice to examine and remove environmental hazards. As previously noted, one inmate had Type 1 diabetes and died by insulin overdose. This death occurred in a community setting, which is a much more difficult environment to regulate for safety. Similarly, one inmate died by hanging in his general population cell, in which environmental safeguards may not be appropriate. However, four inmates died by suicide in medium and maximum security facilities, three of whom died by hanging, and one inmate asphyxiated using a plastic bag and ligature. Three inmates were able to access the means to commit suicide while in segregation, which represents a serious organizational gap in suicide risk management. While it is unknown why these questions were not explored by the BOI or the CSC, it is highly recommended that access to means becomes a required component for all investigations of death by suicide, especially those that occur in administrative segregation.

A more proactive and preventative method to ensure that facilities are consistently identifying and removing hazards is to mandate the use of and reporting on an environmental hazards checklist. Mills and colleagues (2010) reported on the development of an environmental safeguards checklist, based on an aggregated review of forty-two deaths by suicide within institutions, as well as one hundred forty three serious suicide attempts. Of the 2,192 serious and critical hazards identified within these facilities over the two year time frame, the most common hazards were anchor points (which were also rated the most dangerous hazard), followed by plastic liners in trash cans, which can be used for suffocation. These hazards were prioritized for removal according to their risk hazard, and facilities were required to report on their removal. The article provides an excellent example of how to develop, implement, and ensure compliance to an evidence-base suicide risk management strategy across geographically diverse facilities.

An analysis of any trends in the management of and response to those emergencies in response to the inmates’ deaths

Overall, the emergency medical response to the inmates’ deaths by suicide was quick and efficient, and none of the BOI raised concerns that the deaths could have been averted by the attending staff. No medical care was required in one of the deaths reviewed in this section, as he was found months after he had died in the mountains. In four of the remaining five cases, there were no serious issues identified in regard to the medical care provided. The response of the COs was timely, efficient, and in accordance with policy. CPR was administered as appropriate, and the care was well coordinated between the COs, health care staff, and ambulance crews.

The emergency response to case #21 raised concerns with the IRC. This inmate was found in his community residential facility unresponsive but breathing after a massive overdose of insulin. The attending staff alerted 911 immediately, and turned him over on his side (he was laying on his back with vomit on his chest). His insulin vial and syringes were on his chest. The paramedics arrived within ten minutes and took over medical care. An hour later he was transported to hospital, still breathing, but was removed from life support the next day.

While the medical care provided by the paramedic staff is out of scope of the current review, it is unclear whether the community residential staff injected him with emergency glucagon^{Footnote 7}. This raises questions about the capacity of facilities to respond to medical emergencies, save for basic first aid training. A medical bag that carries life-saving essentials (such as glucagon or epi-pens) is a small investment that could save lives. These simple medical emergency tools can be administered by anybody, and do not pose risks for overdose or abuse. The offender was breathing and his vital signs were stable when the paramedics arrived, which leaves open the possibility that his life could have been saved if the staff had these life-saving options available. In many contexts, people with severe allergies and Type 1 diabetes can and should be responsible for maintaining their own emergency kits, and instructing those around them on how to use them. However, these facilities will continue to house depressed and potentially suicidal offenders who lack motivation to live, let alone manage chronic health issues. Building the capacity of facilities to respond to medical emergencies with these types of items may prevent similar deaths in the future.

Trend in Response Time

In two cases (#9 and 16), the inmates were discovered during routine checks, and the COs did not have means of communication with them at the time. In both these cases, the COs who made the discovery yelled for assistance and for the door to be opened. In case #9, the second officer arrived but carried OC spray with him, rather than the 911 tool (knife). The second officer had to run back to Control the retrieve the tool, which caused a thirty second delay. The BOI team did not believe this delay made a difference between the life and death of the offender. The warden of the facility also believed that the delay in opening the door was minimal. However, nobody can know for certain that the delay had no bearing on the outcome of this case. Thirty seconds of suspension from the neck can mean the difference between life, serious brain damage, or death. Fortunately, in cases #9 and 16, the number of radios was increased on the units, which reduces the likelihood that the same communication problem will recur. It does not, however, resolve potential shortages of radios in other facilities. An audit of the number of communication devices in all facilities, and whether this number meets the security needs of the units, would provide assurance that these two cases are isolated incidents.

An assessment of information sharing among key players during the incident

Trend in Communicating Suicide Risk

The suicide history of three offenders who died by suicide was not flagged in the Offender Management System (OMS), which is intended to communicate the inmate’s risk to all those charged with his or her safety. In two of these cases, the BOI determined that the error did not contribute to the death of the inmates, because their histories were known to those involved in their cases. The rationale of the BOI, on this issue, is concerning. This finding should be used as an opportunity to explore the circumstances that led to the gap. While it is comforting to know that the error did not contribute to the death of the inmate, it is still important to gain an understanding of how flags are missed in the first place; as it was left, the organizational gap remains. If the flag was missed due to human error, an exploration should have taken place to determine how the error was made, and what mechanisms could be implemented to reduce the likelihood of the same error recurring in the future.

In the third case, the missed flag in OMS was considered a proximal cause to his death by suicide. In this case, the terms of responsibility to activate and deactivate the Alerts Flags and Needs (AFN) was completed by a working group and implemented in OMS in June 2011. Tables on AFN were also developed, which describe the appropriate use of the AFN, indicate who is responsible for activation and deactivation, and identifies the exact review period for each AFN. This change is an excellent example of a system improvement that may reduce the likelihood of recurrence.

Post-incident reporting requirements were met in the majority of the deaths by suicide. There were some compliance issues identified in the community residential facilities; in two of these cases, the incident reports were not submitted in a timely manner, as required. In one case, the manager’s observation report was not completed prior to his or her leaving the facility. In one other case, the DVR was not obtained as per policy. Unfortunately none of these findings were explored in any more detail, which would provide a better understanding of why these forms were not completed. Understanding these reasons would provide the organization with better information with which to develop intervention strategies. As reported in the EXCOM grid, the staff were counseled about the policy. This type of remedial education may stop these individuals from making the same error in the same type of event in the future, but is unlikely to improve compliance across the organization.

An assessment of support provided to staff members and inmates after the incidents

Critical incident stress management (CISM) was provided to involved staff in all of the in custody deaths reviewed in this section. Within the medium and maximum security facilities, clergy visited all the inmates on the range, or who associated with the deceased. An Elder provided support and ritual to inmates and after an aboriginal offender died by suicide, as did the aboriginal liaison officer and the clergy. There were no issues identified in any of the deaths by suicide in regards to the quality or quantity of the post-incident support.

Summary of Suicide Deaths

Pre-incident trends raised concerns for the IRC in 4 out of the 6 cases, as each of these inmates had a significant past history of suicidality. Issues related to mental health care, CSC’s response, emergency response, and information sharing care were identified in half the cases within each of these categories. The case management, and security and patrols, were adequate in 4 of the deaths by suicide, while 2 cases raised concerns. For example, in cases 3 and 4, information sharing between staff were noted to be inadequate. Support to staff and inmates were all completed according to policy and none of the cases raised any concerns. The area of the greatest concern was issues related to best practice (issues raised in 4 cases).

Yes – Problem(s) identified.
No – No significant problems identified.

Chapter 6 - Deaths Unknown Cause

Within Canada’s prisons each year a number of deaths in custody occur that might involve natural causes, but still raise sufficient questions that a problematic cause cannot be ruled out, at least not until a detailed Coroner’s report is available. For example, in a case where an inmate dies with drugs found in her cell and she has a history of heavy drug use, it is natural to assume that it is an overdose death. However, the inmate may instead have died by natural causes, thus a final determination must wait until a medical determination eliminates the possibility of death by overdose. In other cases, inmates with health problems may die and a recent physical trauma (such as an assault) was found to be related to or at least a partial cause of death. Again, as criminal or civil responsibility may be at issue, final determination in such a case must be made by the Coroner. As mentioned earlier, this makes tracking any trends in drug overdose death difficult.

In contrast to drug-using inmates with signs of overdose, other inmates who die of apparent natural causes may still pass away as a result of drug use or licit medication misuse. Again, a Coroner’s final determination is key. Assessing deaths of unknown cause are problematic because many inmates have not engaged in health lifestyles. Offenders involved in a crime focused, drug involved lifestyle when in the community come into an institution with considerable problems that worsen as they get older. In a British study, it was found that prisoners released into the community had much higher mortality rates than the general population (Farrell & Marsden, 2007). Many inmates bring chronic conditions into prison with them, including HIV, Hepatitis B or C from intravenous drug use and livers damaged by excessive alcohol use. An aging population of inmates with less than healthy lifestyles will pose further challenges for CSC in the years ahead.

The appropriateness and adequacy of the corrective measures and management action plans in response to investigations.

Board of Investigations and subsequent responses by Regional and local management were generally appropriate in all eight of the cases that the IRC had information available.

Case #2 involved a considerable number of recommendations by the BOI into the administration and case management by a mental health focused CSC facility, which houses admittedly difficult cases, such as those who chronically self-harm. Responses were generally favourable to changes in orientation, management of critical incident stress (including episodes of self-harming) training and treatment strategies. A recommendation of rotation of correctional officers for extended periods into the facility for continuity in inmate management was also met favourably.

The IRC did not find recommendations or responses of note in other cases.

An analysis of trends in contributing or precipitating factors to the deaths

Given the health related problems in most of the deaths, it is not surprising to find that there were substance abuse pre-indicators in eight of nine cases. Cases, #1, #5, #6, #14 and #20 had multiple medical problems such as high blood pressure/cholesterol, asthma, arthritis, lung disease, Hepatitis C and liver cirrhosis. Medical follow-up by CSC was generally well done.

An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths

There were mental health problems in four of nine cases. Case #1 had a history of psychiatric and mental health issues, including auditory hallucinations. In case #2 the inmate had a history of self-harm, a condition that he was being treated for at the special CSC facility where he was placed. Case #6 had prior emotional health issues, a history of self-harm, suicide attempts and personality disorders, Case #11 had a history of suicide attempts in the community. With the exception of case #2, mental health did not factor significantly into any of the deaths in the "unknown cause" category.

An analysis of any trends in case management practices prior to the inmates’ deaths

Case management was generally well-handled, and concerns were noted in only two of nine cases. Case #2 appeared to have had his security over-ridden to maximum previously for 2-3 years without sufficient cause, and the BOI team felt restraints had been over-used. Case #22 had reports submitted late onto his file. Better case management in case #2 might have reduced the amount of self-harm that ultimately led to his death.

An analysis of any trends in security practices such as staff presence and monitoring of inmate activities

Patrols were generally conducted as per policy, with the exception of case #14 where it was apparent that the rounds were run too quickly to be effective (i.e., spend sufficient time in front of cell to observe signs of life). It should be noted, however, that dynamic security in case #14 led to the officers noticing that the inmate was in distress, and initiating the medical response. Case #2 saw regular patrols but the frequent rotation of correctional officers in the CSC mental health facility resulted in unit observations and recordings the BOI felt were less than ideal. Finally, in case #22, which involved a death in a Community Residential Facility (CRF), regular checks occurred properly during the day, but they were not conducted at night. This resulted in some changes in contracting arrangements between CSC and CRF’s around the country.

An analysis of any trends in the management of and response to those emergencies in response to the inmates’ deaths

The emergency response to all eight situations in custody was appropriate, while the death in the community was not managed that well. In case #22 the CRF staff member did not administer CPR when they arrived on the scene and found the inmate not breathing. There were several smaller problems observed in two cases, but these did not impact the death of the inmates. For example, in case #5, a new nurse had not been properly oriented and grabbed the wrong medical bag, so had to go back to get it. In case #11, the correctional staff did not advise emergency medical technicians who had arrived on the scene that the inmate did not have a pulse, delaying the onset of CPR administration.

An assessment of information sharing among key players during the incident

Information sharing was not satisfactory in two of nine cases. In case #2 there was a clear lack of file documentation that would be available to both case management and various health care staff and communication between health care and correctional officer staff, important when monitoring inmates with a history of self-harm. In case #14 there was a lack of communication between correctional staff and health care staff, and one omission of facial injury information that should have been passed on to the security intelligence officer.

An assessment of support provided to staff members and inmates after the incidents

Critical Incident Stress Debriefing was offered in seven of nine incidents to staff and support was offered to inmates. In two cases, #2 and #14 it was missed or not offered to all staff.^{Footnote 8}

Summary – Deaths by Unknown Cause

As outlined in the summary table below, CSC performance was overall satisfactory in the management of deaths, unknown cause. There were few significant concerns noted by the BOI reports, recommendations were few and the follow-up from the field was generally supportive and compliant. The BOI were diligent in noting errors or compliance problems, but serious issues such as unmet mental health needs, medication, security classification errors, poor case work, inadequate security patrols were generally not problematic among these cases. This finding likely reflects the nature of the majority of these deaths: there are few pre-indicators, long term or proximal, aside from a history of alcohol/drug abuse and medical problems. Prevention in these cases is difficult, and even the best medical response might not be enough.

There were pre-indicators in eight of nine cases, mostly indicative of health concerns that were being managed. Mental health concerns were noted in three cases, problems in case management in only two and in security/patrols only one. Information sharing was an issue in two cases, and CISD support was not offered in two cases. Responses overall by CSC were suitable in all nine cases, with a particularly thorough report by the BOI in case #2, where considerable clarification was required on responsibilities in a CSC mental health facility. As well, CSC clarification in responsibilities in contracting with Community Residential Facilities outlines more clearly their responsibilities in prevention efforts. Best practices were not observed in any of the cases reviewed or in any CSC recommendations (i.e., recommendations that were policy or training based were useful but not necessarily a "best" practice).

Yes – Problem(s) identified.
No – No significant problems identified.
N/A Not Applicable.
*There is disagreement between BOI staff and the Regional staff on this issue.

Chapter 7 - Homicides

In 2010-11 five federal inmates died by homicide in custody. Five homicides in one year are high for CSC, as murders in federal penitentiaries in the last ten years have ranged from one to three per year (please refer to chapter three, sample description). Like all deaths in custody, however, homicides are statistically rare events, and their numbers can fluctuate from year to year. This section reviews the five deaths as per the terms of reference.

The appropriateness and adequacy of the corrective measures and management action plans in response to suicide-related investigations.

A number of findings and recommendations were made by the BOI teams to improve operations. Responses by CSC management were generally supportive of the BOI, although there was disagreement on policy in some cases. A more detailed review of the CSC response is outlined in Chapter eight.

An analysis of trends in contributing or precipitating factors to the deaths

There were no clear trends in contributing or precipitating factors noted in the deaths. There were no physical health problems noted in this group. Cases #10 and #17 involved gang activity, an issue of particular concern on the Prairies. Cases #7 and #12 involved mental health concerns, which are discussed in greater detail below.

An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths

Concerns were evident in some cases, but most mental health problems showed no clear link to the eventual homicides. For instance, two victims and one perpetrator had histories of self-harm, while two perpetrators and one victim had records of past suicide attempts. However, there was no apparent connection observed between these conditions and the murders. The inmates’ mental health concerns appeared adequately cared for by health services.

There were two cases that raised mental health "flags" of note. In case #7, the perpetrator had a history of mental health issues and had to be transferred from a psychiatric facility while awaiting a court appearance because of violent behaviour towards other patients. He was placed in a CSC mental health facility (where he had resided previously) and he appeared to be adequately cared for. Shortly after transfer the attending psychiatrist thought he was over-medicated and he was taken off six different medications which had been prescribed in the psychiatric facility, including Gabapentin, Clonazepam, Lithium, Seroquel, Celexa and Pantoloc. The BOI consulted National Guidelines and concluded that the perpetrator in case #7 was tapered off and discontinued his medications too quickly. Although the BOI acknowledged that the attending psychiatrist was allowed some discretion, he did not follow the "best practice" recommendation of the National Guidelines. In case #12, the perpetrator had his prescription filled by the institutional physician instead of a psychiatrist. Medication and mood of the perpetrators may have been an issue in those two deaths, although a direct link is difficult to ascertain.

An analysis of any trends in case management practices prior to the inmates’ deaths

Proper case management was significantly lacking in one of the five homicides. A perpetrator (#12) was rescored downwards on his security rating and moved from maximum to medium security as a result. The BOI found that the score was not accurate, which was a significant error because the perpetrator was incarcerated for multiple murders. Further, he was not adequately monitored subsequent to placement in medium security. This is not indicative of a trend but underscores the need to be thorough in moving higher risk inmates downwards in security level. In case #18, the BOI believed the case management team should have spent more time with the perpetrator, given his risk level. In the other three homicides, inmates were properly classified and case management was either satisfactory or any concerns were considered minor.

An analysis of any trends in security practices such as staff presence and monitoring of inmate activities

Security practices were deficient in three of the five homicides, and two cases were particularly serious. In case #7, a correctional officer was forewarned of a possible confrontation between the victim and perpetrator just prior to the incident but did not share the information or follow-up and monitor. In case #12, a proper screening was not conducted prior to double-bunking the perpetrator with the victim. The perpetrator was a multiple murderer.

In case #18 the BOI found that the institution’s security intelligence capacity was weak, but it is not clear whether better intelligence performance would have prevented the murder. In the two other cases there was little in the way of forewarning. The two gang-related homicides appeared to arise out of tensions within the institution, but these had not been sufficient to cause alarm. These two deaths, however, do lend support to CSC putting efforts into developing and implementing a national gang strategy.

Rounds, counts, and patrols appeared to be satisfactorily conducted in four cases, as indicated by the documented logs. Case #7 did not have security reports properly logged.

The quality of the patrols was lacking in two cases. The institution housing case #18 did not conduct adequate and regular searches of their units, and staff did not have proper quality control in place to evaluate rounds and counts.

In case #12, the victim was discovered dead in his cell at about 10:00 am, after the perpetrator alerted staff. The victim had likely been dead since around 22:00 hours the night previous, meaning the staff had not noticed he had stopped breathing. The victim slept with his head facing down and blanket way up over his head, making him difficult to see on night shift rounds. Regardless, it is the responsibility of correctional officers to make sure that inmates are alive when they do their rounds or counts.

When these homicides were uncovered, it was generally because the victims were observed being assaulted and alerted the correctional staff themselves, or the perpetrator alerted the staff. Perpetrators usually committed their murders in cells when staff were not present, or when inmate numbers supporting perpetrators were large enough to deter staff from intervening quickly, as in case #10 (killed in recreation area).

An analysis of any trends in the management of and response to those emergencies in response to the inmates’ deaths

Emergency Response, First Aid

First aid was administered relatively quickly in four of the five deaths reviewed here. In case #7, nursing staff reported being so shocked at the injury to the victim (shank protruding out of neck) it took them six minutes to initiate first aid. While the psychological impact of seeing such an injury is understandable, the staff performance in this case was extremely disappointing. Emergency response training modules for nursing staff perhaps could be reviewed to assess how they deal with simulations of the truly gruesome situations that they might actually face. In case #18 the officers did not apply first aid as per policy, as they decided to move the inmate first.

Emergency Response, Cardio-Pulmonary Resuscitation/Defibrillators

In case #7 correctional staff did not assist nursing staff in moving an inmate out into the common area to administer CPR, slowing down its initiation. In case #18 staff attendance at the scene and administration of CPR was impeded while they waited for inmates to lock up. Otherwise, CPR was appropriately deployed and staff were certified according to requirements. Defibrillators were deployed appropriately.

Other Responses

Post-incident compliance for follow up on security purposes (e.g., CO observation reports, document use of restraints and reading of charter rights) and health care reports were missing in some instances. A few reports were missed and then handed in late. In case #7 the perpetrator did not have his Charter Rights read when questioned about the murder, however this did not impede the police investigation.

An assessment of information sharing among key players during the incident

Information sharing was deficient in one of the five cases (#7). This occurred in a facility focused on providing mental health services. There were a number of concerns identified with respect to information sharing and team work between correctional staff, and treatment and health care staff. This includes the aforementioned Correctional Officer who did not alert others when he was informed of the possibility of a confrontation between the victim and the perpetrator. The inmate was transferred from a health care facility on remand to CSC, and not federally sentenced. The institution was not advised by the transferring the health care facility that he had attempted to kill two other patients in that facility. He was placed with CSC because they could provide more security. The SIO was also not advised of this inmate status upon admission.

Otherwise, there was adequate information sharing prior to incidents in the majority of cases, or we considered the concerns minor.

An assessment of support provided to staff members and inmates after the incidents

Critical Incident Stress Debriefing was offered in all instances to staff and inmates. In one instance there was concern that some staff may have been missed. Generally good attention was paid to this area.

Summary – Homicides

Yes – Problem(s) identified.
No – No significant problems.

Table 10 shows that CSC staff response to the murders was appropriate in all five cases. There was believed to be forewarning in two of five murders. Mental health problems were evident in two of five cases, with changes in medication possibly contributing to homicidal behaviour. Case management and emergency response were not appropriate in two of five cases, while security patrols were at issue in three of five cases. Information sharing was a serious issue in one of five cases. Staff and inmate support after the incident was good. There were no incidents that involved or resulted in any best practices.

In some instances staff response was very good, particularly in cases #10 and #19, where large groups of inmates were threatening others. Staff acted courageously and swiftly to limit the possible harm to inmates being threatened. Medical responses in most cases were well done. The BOIs were generally very thorough, with insightful findings and implementable recommendations.

In three cases, staff performance was less than optimal, and there appeared to be a number of things that went wrong. This suggested that not only were there multiple human errors, but the entire institution was not run well. The perpetrator in case #12 was not very well screened for his return to medium security, the double bunking screen was not properly done, and the victim was not found for hours after being killed. In case #7 the information sharing and general recording was below standards and the medical response disappointing, although quicker responses were unlikely to have made much difference.

Board of Investigation recommendations, analysis and findings were reasonable and responses generally appropriate. Many compliance-based recommendations will necessitate administration working with staff to more clearly understand their roles and for individual correctional institutions to develop better emergency preparedness.

Chapter 8 - Death Due to Staff Intervention

In Canada, only the militia and state authorized agents such as police and correctional officers have the legitimate authority to use force on others, including lethal force involving firearms. The use of deadly force by any peace officer is heavily scrutinized, however, and can be a trying experience. Compared to police officers, correctional officers may be more closely inspected because of the large amount of control custodial environments can wield over inmates. There are theoretically many things that could be done in an institution to prevent an incident that results in deadly force. Thus cases involving the shooting or threatened shooting of an inmate inevitably raise questions about how such a situation might have been avoided, or the incident handled better. Consequently, correctional officers facing a situation where use of force with a firearm might be required must move prudently through CSC’s Situation Management Model, prior to discharging a firearm. This Model ensures all other options to deadly force are considered unless imminent serious injury or death of another is at risk. Warnings, chemical agents (e.g., tear gas, pepper spray) and the threat of deadly force by staff are preferable, so long as these methods prove effective in stopping dangerous behaviour by inmates. Under highly stressful and difficult circumstances, the officers must consider how immanent is another person’s injury or death, prior to using lethal violence.

There was one case involving the death of an inmate through staff intervention in 2010-11. The inmate (A) was shot by correctional officers while he was attempting to kill another inmate (B) in the recreation area. A large group of inmates crowded around and two other offenders incited inmate A. The staff involved fired a number of warning shots, but inmate A persisted, and he was shot and died. Another inmate involved was also shot and injured. The BOI in this case had to consider the aforementioned dilemma for staff, as restraint to save the life of inmate A may have risked the life of the apparently innocent inmate B who was being stabbed. The BOI in this case also carefully considered the question of alternatives to the use of deadly force in such situations.

The appropriateness and adequacy of the corrective measures and management action plans in response to suicide-related investigations

The IRC reviewed the responses by CSC and were impressed by the appropriateness and adequacy of the response to this case. The BOI identified a number of changes that are likely to improve the ability of the organization to respond to such life-threatening situations in the future. General suggestions such as increasing the availability of radios, provision of loud hailers to better issues orders to misbehaving inmates in recreation areas, and use of louder weapons for warnings were all strategic and indicative of good practice. Of particular importance, in our view, was the BOI recommendation to revise the Scale of Issue to allow the use of less lethal weapons in such situations. The use of a weapon that involves serious but less lethal force can serve to deter disobedient, threatening inmates. The opportunity to use less lethal weapons may constrain staff behaviour in such situations; they have one more alternative to try before using lethal force, and they can exert non-lethal force prior to -using (or over-using) warning shots in dire circumstances. As this option will change staff behaviour, it falls under our definition of a "best practice."

An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths

In considering TR2 and TR3, there were no warning signs for this case. There were no physical or mental health problems on the part of the four principal inmates involved in the melee precipitating the shooting. At the institutional level, there was no known tension preceding the incident.

An analysis of any trends in case management practices prior to the inmates’ deaths

The BOI observed that the inmate A was missing a casework report, otherwise there were no substantive issues with any of the four inmates involved. Security placement was accurate and case management appropriate.

An analysis of any trends in security practices such as staff presence and monitoring of inmate activities

Staff presence, monitoring and patrols were all conducted in accordance with policy. Correctional officers involved responded appropriately to suspicious activity. One officer was absent from his post without authorization, but this was not critical to the management or prevention of the incident (he returned quickly after being called back).

An analysis of any trends in the management of and response to those emergencies in response to the inmates’ deaths

Use of Force

The BOI found that staff applied the Situation Management Model appropriately, using verbal warnings, chemical agents and warning shots before using lethal force. Five warning shots were fired, while only one warning shot was required. They extricated the deceased and injured inmates in reasonable time, and negotiated the release of inmate B from the recreation area. Because there were still a 100 inmates in the gymnasium, the BOI indicated a call out of the Emergency Response Team was appropriate. Institutional staff also spent time with the Inmate Committee post-incident to try and ensure that the inmate population and staff could move forward after this incident (shooting of two inmates by correctional staff).

There were several post-incident compliance issues raised by the BOI involving proper completion of procedures, or paperwork verifying those procedures were followed. None of these issues were significant in our view.

The BOI report expressed concern over the ability of staff monitoring the recreation area to communicate effectively with inmates or other staff in the institution as the situation escalated. They also raised concerns over the use of warning shots to intimidate the inmates and lack of alternatives to lethal force. Neither of these issues were linked to any substantive concern over staff performance, but the BOI recommendations did offer some promising directions to improve practice. We will consider these suggestions in more detail when we assess the CSC response to this incident.

Emergency Response, First Aid

The emergency response to this situation was appropriate, and nursing staff did all they could to prevent the death of inmate A. Use of force physical assessments were offered by nurses to all inmates who had been in the recreation area.

An assessment of information sharing among key players during the incident

There were no concerns with information sharing with the staff involved.

An assessment of support provided to staff members and inmates after the incidents

Critical Incident Stress Debriefing was offered in all instances to staff and inmates, with the exception of the Warden and Assistant Warden. The BOI noted that appropriate support was provided to the two officers who had discharged their firearms.

Summary - Staff Intervention Deaths

Yes – Problem(s) identified.
No – No significant problems.

As outlined in the summary table above, CSC performance was overall satisfactory. There were no forewarnings of the incident, security surrounding the event was satisfactory, information sharing appropriate, and the security and emergency health response was excellent. No critical incident stress was offered to the Warden or Deputy Warden, and this is a procedural matter that should be corrected. Recommendations by the BOI were effective, with a particularly helpful "best practice" recommendation on the introduction of an additional alternative to lethal force.

Chapter 9 - Assessing Efficacy of CSC Response to Deaths in Custody

In this chapter we summarize CSC performance against our Terms of Reference, essentially compiling information presented in chapters 4, 5, 6, 7 and 8. While this review gives us a general idea of how to appraise the CSC response and a means to suggest possible ways to improve, the committee found this traditional method somewhat limiting in helping CSC push forward to improve as an organization. Thus we reintroduce our Hierarchy of Effectiveness grid from chapter three as a strategy by which CSC can incorporate a greater "learning" approach towards serious incidents.

Chapter 9 - Time Response to Incidents

Table 12 is provided as a baseline of the CSC’s response to deaths in custody. When an inmate’s death is by natural or expected causes (e.g., stroke, heart attack or cancer), an extensive mortality and morbidity review is completed. When there are circumstances of a death that warrant concern, or he or she dies by suicide, murder or overdose, it sparks an investigation under ss. 19 or 20 of the CCRA. Of course, there are often delays in determining the cause of death, and there are circumstances when a death initially deemed natural was in fact caused by other factors. Case #8 provides such an example. This offender died in September 2010 and the preliminary coroner’s report indicated moderate to severe atherosclerosis of two coronary arteries. Nine months later, the CSC received the complete Coroner’s report, which indicated that the cause of death was in fact acute morphine toxicity, or by overdose. We do not see this type of unavoidable delay in cases of murder, as the cause of death (and the appropriateness of a BOI) is clear from the beginning.

In last year’s report, significant progress was observed since Gabor’s study in CSC response time after an incident. The incident to BOI completion time was reduced from 165 to 105 in 2009-10, a large decline.

This past year saw an increase in response time, it took 143 days from incident to BOI. Similarly, the BOI to ExCom response declined from Gabor’s study to 2009-10, but increased again in 2010-11. It should be noted that 2010-11 response times were still better than the average from Gabor’s review, particularly the ExCom Response (from 310 to 163). We would expect some fluctuations from year to year, but it may be worthwhile for CSC to set some targets for average completion times each year.

Summary of CSC Performance Against Terms of Reference.

Table 13 is a summary table that outlines all death types and assesses CSC performance against our terms of reference, essentially compiling information presented in chapters four to eight. Figure 7 graphs the presence of trends or problems by each TR.

The committee found that the overall CSC response to deaths in custody, TR1 was satisfactory in most cases (78%). Pre-death indicators or trends were evident in over half of the cases (60%). This includes a significant number of factors, however, ranging from mental health, a history of excessive substance abuse, changes in medication, severe medical problems to inmate unrest or conflicts with other inmates. Focusing on just mental health (TR3), just under one in three (32%) cases had a mental health problem of some kind.

Figure 6: Comparison of Any Problems in Cases by Terms of References

The BOIs found about one in four cases involved problems in case management (24%), and about a third showed problems with security patrols and monitoring (32%) and the emergency response (33%). There were no clear trends from this one year of data, and caution should be taken into reading too much into the presence of problems. Many of the difficulties observed in case management, security or emergency response were not serious and would not have impacted the deaths involved. On the other hand, there were a few serious errors that do warrant follow-up. Specific examples are outlined in our final chapter that presents conclusions and recommendations.

Information sharing was a concern in just under a quarter of all deaths (20%). While critical incident support to inmates and staff was evident in most cases (80%), there seemed to be some confusion at times about the degree of follow up required by institutions, to make sure everyone had an opportunity to receive counseling. The committee did not find many problems with appropriate use of best practices (16%) but we did use a narrow definition of this term. We did find considerable evidence of good correctional practice, of dynamic security, of excellent follow-up on inmate problems, of courageous and active medical response.

Rather than using a traditional organizational policy, training, staff counseling/discipline approach to managing deaths in custody, the IRC encourages CSC to consider alternative methods from other disciplines to improve organizational performance. To this end, we present findings from our application of the Hierarchy of Effectiveness scale.

Yes – Problem(s) identified.
No – No significant problems identified.
N/A - Not Applicable.

*There is disagreement between BOI staff and the Regional staff on this issue.

Assessing CSC Responses by the Hierarchy of Effectiveness Scale

The CSC Board of Investigation conducts and reports on a thorough inquiry into the circumstances and outcomes related to each inmate death. The results of the investigations are separated into findings (compliance and non-compliance with policy) and recommendations. The findings and recommendations are then supported, supported in part, or not supported by the institutions involved in the incident, and leadership of related services, sectors, programs or policy holders. Then, action plans to address the supported findings and recommendations are developed and overseen by the executive committee. The responses are summarized in an internal document known by the acronym "EXCOM" report.

The recommendations and findings made by the BOIs on deaths by overdose, suicide, deaths unknown cause, murder and staff intervention were compiled and then evaluated for their effectiveness to stop similar error from recurring in the future (Tables 7 - 11). The findings and recommendations were separated into pre-incident, incident and post-incident categories, and are summarized in Table 16.

The levels of effectiveness for each of these categories were scored according to the hierarchy of effectiveness introduced in our methodology chapter. In evaluating the responses and the likelihood of preventing a similar event in the future, the committee used the coding scheme introduced in the methodology section. We present the table again below for the reader’s reference. Recall that using the hierarchy of effectiveness scale, the higher the score, the lower the likelihood of success. The gold standard for efficacy are recommendations that involve constraining potential human error through forcing functions, and just next to this is automation of individual functions (i.e., almost eliminates human error). Ranked lower are standardizing local practice or processes, issuing policy, reminders, or memos. As we noted in the methods chapter, policy and education have an important place in ongoing organizational improvement, but these alone should not be relied on to prevent deaths in custody.

Raw numbers are presented in our table. The percentages of recommendations and findings scored at each level of effectiveness are presented in Table 15.

Effectiveness Findings by Type of Deaths

Overdose and Suspected Overdose

It is not possible to analyze the appropriateness and adequacy of the response to case #25 because it was a local investigation, and thus not submitted to EXCOM. For the remaining three BOI reports related to overdose deaths, there were six recommendations, one of which was supported by the organization. There were fifteen findings across the BOI reports on overdose deaths, many of which dealt with compliance issues.

Pre-Incident Responses: There were five recommendations and twelve findings related to pre-incident indicators within the overdose death reports. The five recommendations were all from the investigation into case #13, and only one of the five was supported. The supported recommendation was that range and unit vestibule cameras (with time marks) are installed so that the quality of rounds can be evaluated. Since this recommendation lead to an automated and computerized system change, it is rated 2, or highly effective. Of the four recommendations that were not supported, three were not supported due to lack of feasibility (the post system was not compatible with a satellite clock system), redundancy with existing policy, and redundancy with another recommendation.

One other recommendation from case #13 was not supported by the organization: That the wooden panels covering cell windows on the ranges at the Institution be removed to allow for easier visual checking of inmate cells. The BOI believed that the wooden panels inhibited the informal observation of inmates, because COs must move a vertical slider in order to see inside the window, and requires the face to be within inches of the opening. The CSC rejected this recommendation on the basis that there was no evidence that the COs view of the inmates was impeded. From the IRC’s perspective, the BOI was not suggesting that the COs could not view the inmates; they rightly noted that the panels were a barrier to casual observation and made the rounds and counts a greater burden on the staff. Unfortunately, this was a missed opportunity for the organization to support COs in their rounds and counts by making the process simpler. As we’ve seen, when an organization simplifies a process, they reduce the chance of human error and thus improve safety.

Of the twelve findings, all but one was supported. The responses to these findings were primarily rated 5 or 6 (for education and policy development). One finding was ranked 1, or highly effective: The storage of methadone was removed from the site.^{Footnote 9} The unsupported finding in case #24 was that the search plan was not being consistently utilized despite Commissionaire's concerns about drugs in the Centre and the inmate also expressing frustration with other residents using drugs. The institution responded that search plans are being conducted and are aligned with best practices.

One other finding from case #24 was supported by the CSC; however the finding and the response seem at odds with each other. The BOI finding was: The CCC has Post Orders for the Commissionaires, but it was determined that they are rarely referred to due to the high number of duties for which the Commissionaires are responsible. CSC’s response was: Both the Sergeant and Head Office have guaranteed that Commissionaires will review and sign Post Orders, and this task is being integrated into orientation. An independent review of Commissionaire staff performance was initiated to ensure similar incidents do not occur in the future. The BOI’s finding was one of time resources, and the CSC response only focused on staff performance. In fact, the time resource issue was not acknowledged or addressed by the CSC. The IRC acknowledges that staff performance may be an issue in some cases, but the CSC missed an opportunity to ensure that staffing levels for this CCC are sufficient to adequately perform duties, and the number of duties required of each staff member does not exceed reasonable limits.

Incident Responses: There was one recommendation and two findings related to the incident. The recommendation (case #24) that CPR should not be required when the body is in rigor mortis was not supported. As noted in the Overdose chapter, CPR is still required in these circumstances in case staff mistakenly believe that the person is beyond therapeutic intervention. By starting CPR, the staff can ensure they are doing all they can to preserve life. Both findings related to the incident were supported by the CSC and were rated 4 and 6 in effectiveness.

Post-Incident Responses: There were two findings related to post-incident issues, both emerged in the BOI for case #8. Both findings were related to compliance and were supported through education and memos by the CSC, thus rated 6. There were no recommendations in any of the BOIs related to post-incident issues.

Suicide

There were a total of four recommendations and thirty-seven findings across all six deaths by suicide. Of the three recommendations that were supported, two were policy-based and both were rated ‘five,’ or low in effectiveness.

Pre-Incident Responses: There were twenty seven findings and recommendations targeting pre-incident indicators. While the majority were rated lower in effectiveness, it is promising to see a few remedies higher in effectiveness. For example, (case #4) the segregation clock should not automatically reset when a transfer between facilities takes longer than twenty-four hours. This type of automated change to the system demonstrates a systems approach to safety, and makes it much more likely that a similar event will be prevented in the future. This recommendation was rated 'two,' or highly effective.

Incident Responses: There were four findings related to the incident itself, three of which were rated six. One response appropriately addressed a communication problem between staff by increasing the number of available radios. The one recommendation that was not supported in this section was, that CD 800 Health Services be changed so that the AED is deployed even when it reads, "No shock advised." The Assistant Commissioner, Health Services argued that according to the directive, the AED in fact should have been applied during the incident. From the documents provided to the IRC, it appears that remedial education was provided to nursing staff on the appropriate deployment of the AED. A more effective organizational response to this incident would be to determine how to simplify the instructions on the deployment of the AED during a crisis. It is clear to the IRC that the staff involved believed they were following the procedures correctly; remedial education about the policy does little to address a knowledge gap (indeed, reminders and memos are least likely to lead to effective change). Simplification of procedures and instructions, if possible in that case, would have been a much more effective organizational response.

Post-Incident Responses: All five findings related to post-incident factors were rated six, or lower in effectiveness. These responses were as a result of non-compliance to policy, and staff involved was counselled about the policy requirements.

Deaths Cause Unknown

Pre-Incident Responses: Of the 39 responses, the majority were either education (6) or policy based, and involved having staff comply more carefully with policy. Most errors were not critical to the deaths in question, and recommendations were supported at regional and local levels. A strong recommendation for case #14 involved a physical change to a range to improve staff monitoring, ranked a 2 (automation) Notable recommendations for case #2 included the development of a formal training, orientation and unit for those who chronically self-injure; both of these recommendations ranked a 3 for standardization/differentiation.

Incident Responses: The 14 recommendations and findings around the incidents were focused more on compliance and hence on staff accountability. Many findings involved small questions around policy and procedure and did not impact the deaths. Education and staff counselling, ranked a '6' was the general response to the incidents. One response was ranked 3, because it involved moving a camera to standardize viewing.

Post-Incident Responses: Among 6 recommendations and findings, three involved staff education (rank 6), case #2 had a policy recommendation (rank 5), case #25 pushed for a memorandum of agreement with CRF to standardize practice (rank 3). Finally, in case #2, a vicarious trauma workshop was recommended, which is an excellent suggestion for innovative support of CSC staff who work with those who self-harm (rank of 2).

Homicide

Pre-Incident Responses: The committee noted 39 pre-incident factors that were identified by the BOI as significant enough to be a finding, analysis issue or recommendation that merited a response from CSC. There were no pre-incident factor responses that ranked 1 or 2. Only about a third of BOI recommendations or suggestions were ranked at a 3, the rest were rated low in efficacy on the hierarchy of effectiveness scale. In other words, most recommendations were unlikely to produce long range effectiveness.

For case #7, the BOI suggested that the facility better integrate corrections and treatment staff at this mental health oriented facility, improve documentation by nursing staff, and organize systems that promote better documentation and communication between staff. The recommendations for this involved setting up reporting systems and reorganizing the correctional officer staffing to ensure consistency, and as well, that the institution develop better systems of communication. These improvements were considered by the committee to be moderately likely to be successful and they numbered five of the 12 responses, meeting the standardize level of effectiveness (3). Two findings were around the realm of policy, were rated a 5, and met the rules level of effectiveness. Four findings/analysis were ranked lowest at 6, education level, and were reminders to staff to perform duties properly, usually related to documentation.

In case #7 the BOI felt the perpetrator had been tapered off his medication too soon, while the institution pointed out that the reduction was within national guidelines and did not support their finding. The committee observes that this defensive reaction was unfortunate, as this presents a learning opportunity for the CSC. Rather than the dosage, it is likely more important that the inmate was closely monitored following the change in medication to see if he was decompensating.

In case #17, three recommendations rated a 3, including have a Manager with responsibility for the units, hiring an additional SIO, and developing a more comprehensive gang strategy, all worthwhile strategies that were supported by the institution. Lesser concerns were voiced and responded to about institutional routine, and we ranked them at a 4 or 6.

Case #18 had a recommendation to modify the physical plan due to problems in seeing the unit, which was ranked at a 3. Provision of a local breach kit in case #7 will ensure that, in the future, jammed cell doors will be open promptly in the event of a medical emergency. This recommendation was ranked a 2.

Incident Responses: Over half of the 7 responses to incident findings were ranked 5 or 6 (66.6%), which are low in efficacy. There were four recommendations ranked at 1 or 2 (17%), while the rest were rated at levels 3 or 4 (37%). Incident factors in institutional deaths were often health care responder issues, and findings tended to be more compliance based, leading to responses that are remedial (education, reminders) to improve staff performance.

Post-Incident Responses: Thirteen BOI recommendations and findings were provided. Most were compliance based and involved talking to or training staff , which warranted a 6 ranking. About 14% were efforts to standardize (3) and one was rated as a 2, automating response.

Higher level recommendations of standardization or differentiating (3) were noted in case #10. The incorporation of Elders in gang strategies, segregation of gang members, and assignment of a programming manager to work with Correctional Managers are all more significant moves that can produce change. Also in case #10, a technical move that will improve supervision is the use of a camera in the recreation area (ranked a 2).

Death by Staff Intervention

For the single case of death by staff intervention, most responses were compliance based, such as reporting compliance and handling of weapons. Remedies were educational in nature and involved talking to or formally counseling staff. These remedies were ranked six for efficacy, as they provide no assurance that another staff in another facility will respond differently in the future.

Rated at a 1 (highly effective because it constrains behaviour) was the recommendation in case #19 to amend the Scale of Issue for weapons. This essentially forces CSC staff to use a weapon that might allow for better deterrent effect prior to having to use lethal force. A multipurpose weapon that can dispense non-lethal projectiles (e.g., bean bags), fire non-lethal munitions (rubber bullets) and very loud warning shots certainly provides staff more options to preserve life without having to go swiftly to lethal force.

Rated a 2 (automation) was the provision of radios and loud hailers through findings in this case , which involved staff trying to discourage a large group of inmates from assaulting other inmates.

Summary – Effectiveness of Findings and Recommendations

Figure 7: Percentage of recommendations and findings at each level of effectiveness

In previous reports, the OCI raised concerns that similar events recur and similar organizational gaps reappear across the CSC. Addressing the OCI’s concerns requires a systematic methodology to evaluate and monitor the findings and recommendations coming out of BOI reports, and the response of the CSC in the EXCOM grids. The IRC evaluated the effectiveness of recommendations and findings by ranking them according to the likelihood it will prevent a similar event from happening again in the future. We define effectiveness here as the likelihood that a recommendation will bring about a meaningful reduction in deaths in custody.

As seen in Figure 8 above, over half of all recommendations and findings are ranked 6. While there are some recommendations and findings that are ranked higher in effectiveness, we suggest that BOIs explore ways to develop recommendations so that, as much as possible, the remedies constrain human error through forcing functions, automation, and standardization.

The primary reason for the large number of 5s and 6s is that a large number of findings and recommendations are related to policy development (rated 'five') and reminders to staff about existing policy or other job requirements (rated 'six'). Policy and education are an essential component of a well-functioning organization, and ensures standardized procedures across geographically diverse facilities. While adherence to existing policy, fixing policy gaps, and education critical and important first steps during an investigation; the second is to explore why compliance issues occur, or why human error occurred, which can expose the organizational gap and risk that led to the error.

The IRC suggests that the CSC continue to explore alternatives to corrective measures when there are compliance issues. It was encouraging to see coaching put forward as an alternative to disciplinary measures for non-adherence to policy (Recommendation #5 in the CSC’s Corrective Measures and Management Action Plan into the 2010 Independent Review Committee into Deaths in Custody). An audit of uptake of and adherence to its use would provide the Service with an understanding of its success. The coaching conversations can also assist with investigations by exploring the context in which the oversight or error occurred. It is by understanding that context that organizational gaps can be identified, and any gaps should be addressed through the most effective recommendations possible.

Chapter 10 - Conclusions & Recommendations

Summary of major findings and issues

In this section the committee seeks to summarize our major findings and identify systemic problems and ways in which to improve CSC performance. While we look at specific problems and trends, a recurrent theme is to draw on best practices where we can, and identify strategies that will mostly likely have a system wide impact. Below, we review the terms of reference guiding our committee, examine areas for further research, and make some suggestions on the future functioning of the independent committee.

Terms of Reference Review

1. The appropriateness and adequacy of the corrective measures and management action plans in response to those investigations;

In 78% of cases, the responses of the CSC were satisfactory. The BOI reports were comprehensive and well written summaries of the event, and included in-depth analysis of compliance with policy. As we’ve learned through our exploration of effectiveness of recommendations, those that are policy and education-based are necessary first steps in any investigation. Policy and education are an essential component of a well-functioning organization, and ensures standardized procedures across geographically diverse facilities. However, the BOI should explore more fully the "why" behind compliance issues and, in cases where there is human error, what systems or environmental remedies could prevent another person from making the same error in the future? Answering these questions can expose the organizational gap and risk that led to the human error, and recommendations will be more effective in preventing similar events in the future.

Once compliance to policy and practice is understood and achieved, the investigation should challenge the status quo by questioning the effectiveness of existing procedures, policies and Commissioner Directives. If an inmate dies by suicide and staff were compliant with policy, the investigation should begin under the assumption that his or her mental health needs were not being met. Similarly, if an inmate is murdered while in custody, his or her security and safety needs were not being met. While it is not possible to predict and prevent all suicides (Jacobs, Brewer & Klein-Benheim, 1999; APA, 2003), starting with that assumption provides the lens through which to explore how the organization can better prevent deaths in custody.

We encourage CSC to couch all findings and recommendations in systems-based and non-punitive language if they are to be seen as opportunities for improvements and learning. This can be achieved by maintaining a systems approach to human error, and not accepting compliance to policy as the end point of the investigative process. Reports should also acknowledge strong performance and good practice.

We note that a similarly themed recommendation was made by last year’s committee (R.5). Where we disagree is with the notion of punitive measures as a means to promote stronger performance. Here we likely disagree with the Correctional Investigator as well. As other organizations have found, working with staff in a problem-solving, systems-oriented manner will lead to stronger outcomes. Again, we acknowledge that outrageous conduct or malfeasance should still be subject to disciplinary action.

2. An analysis of trends in contributing or precipitating factors to the deaths;

We found evidence of precipitating factors in 60% of all deaths in custody. In general, the committee was satisfied that in most cases there was no way to predict a lethal medical problem or damaging inmate behaviour, while in other cases prior knowledge of a problem resulted in a reasonable response by CSC staff.

One trend we found was troubling. Four inmates died by suicide in medium and maximum security, three of whom were in segregation at the time. That these three inmates were able to access the means to commit suicide while in segregation represents a serious organizational gap in suicide risk management. A series of research reviews noted that hanging was a common method used to commit suicide within facilities, and restricting access to the means to commit suicide should be an organizational safety priority (Hawton, 2007; Daigle, 2005; Lieberman, Resnik & Holder-Perkins, 2004; Mills, DeRosier, Ballot, Shepherd & Bagian, 2008; Yeager et al., 2005). It is understood that the CSC conducts these types of safety checks as part of their routine operations, but there was no evidence that access to means was explored in any of the BOIs. It is very important that the CSC utilize the investigative process to identify these types of gaps in safety, and develop recommendations that ensure these types of gaps are addressed.

3. An analysis of any trends in mental health care provided to those with mental health needs prior to their deaths;

In 32% of cases, or one in three, inmates had a prior record of mental health problems. Five out of the six inmates who died by suicide (including three in segregation) had psychiatric medications initiated, changed or withdrawn two to six weeks prior to their deaths. One of the perpetrators of an inmate homicide also had his medication changed a few weeks prior to committing the murder. With the exception of case #9, it was unclear to the IRC the extent to which these medications were monitored for effectiveness and side effects according to best practice. As noted in Chapter 5, the offender in case #4 had his medications withdrawn as a consequence for not attending the clinic. This practice should be re-examined in regard to psychotropic medications, especially for those in segregation.

The IRC is confident there was a way for the organization to continue providing psychiatric medications and monitor for symptoms and side effects without requiring the inmate to actively engage health services.

4. An analysis of any trends in case management practices prior to the inmates' deaths;

There were difficulties reported in case management practices in 24% of cases. However, none of these issues was of sufficient concern to warrant a recommendation from the IRC. CSC has considerable policy and oversight in the area of case management, as mentioned earlier, it might be more fruitful to sit down carefully and review situations and circumstances than rely on compliance based measures.

5. An analysis of any trends in security practices such as staff presence and monitoring of inmates activities;

In 32% of cases there were problems observed with security practices. The most egregious of these was an inmate dead for 12 hours without staff detecting him. Yet in the cases we reviewed the majority were satisfactorily monitored and in some cases dynamic security led to quick attention to medical concerns, albeit in vain. We note that last year’s committee made number of recommendations (R,3,4) intended to define and better monitor security patrols. We recognize that CSC has initiated action in response to last year’s IRC (see chapter 1), including clarifying Post Orders, and making clear the responsibilities of staff to perform these duties.

We note the difficulty with detecting live bodies at night. It is somewhat ironic that staff effort to accommodate inmates can lead to poor monitoring. In some cases staff did not wish to wake inmates for stand to counts, in one case the inmate may have been in medical difficulty; in the other he was dead. In another instance, inmates covering their cells for privacy at night made it difficult for staff to detect their overdose. For CSC to accurately ensure live bodies we encourage CSC to continue to investigate new technology aimed at detecting live, breathing bodies (see Chapter 2). Such an initiative must be weighed against the costs and can never substitute for good security practices, but it would be an excellent guard against human error. As per best practice, automating the function of detecting life might result in the saving of lives.

6. An analysis of any trends in the management of and response to those emergencies in response to the inmates' deaths; emergency response trends of concern included correctional staff response time after an inmate was found in distress, and response by correctional officers or health care staff in administration of medical assistance;

There were concerns identified in the medical response in 33% of inmate deaths. The emergency response to case #21A (death by suicide) was not explored in the BOI or by the CSC. It is unclear whether the community residential staff had the means to inject him with emergency glucagon^{Footnote 10} when they found him unconscious but still breathing after an insulin overdose. As well, two out of the four inmates who died by opiate overdose were subject to emergency intervention by facility staff (one other died while Unlawfully at Large (UAL), the other was found in rigor mortis). While CPR was applied to these two inmates, left open is the possibility that life could have been preserved through the administration of naloxone.

These simple medical emergency tools do not pose risks for overdose or abuse. As well, the literature review on naloxone (see Chapter 2) demonstrates that expanding its access is an emerging best practice endorsed by the World Health Organization, professional medical Colleges and health organizations across Canada, and the US Center for Disease Control and Intervention. Facilities will continue to house depressed and potentially suicidal offenders who lack motivation to live, let alone manage chronic health issues. As well, despite the CSC’s best efforts to manage and treat those with substance use problems in its facilities, these disorders can be chronic and recurring, and many will continue to be at risk of overdose. Building the capacity of facilities and non-health care staff to respond to medical emergencies with these types of medical tools may prevent similar deaths in the future.

The literature review on prevention of overdose deaths also highlighted a particularly high-risk and vulnerable time period for those in the criminal justice system. The first 2-4 weeks after release from prison puts offenders with substance use histories at particularly high risk of death by overdose. Given the known risk period, and the effectiveness of naloxone to reverse overdose and prevent deaths, CSC should consider developing programs and access protocols to naloxone for offenders transitioning between custody and the community.

7. An assessment of information sharing among key players during the incident;

There were problems with the sharing of information in 20% of cases, one serious omission that likely resulted in a loss of life. Improvement in mechanisms of information sharing was a recommendation of last year’s committee (R1) and is a recurrent recommendation of the Correctional Investigator. We observe here that miscommunication is exactly the type of problem that benefits from a "systems-based" learning approach to critical incidents that we outlined in recommendation #1. We found most of the suggestions in the BOI’s to be helpful, but again we urge development of systems that have suitable constraints and elements of automation to limit human error.

8. An assessment of support provided to staff members and inmates after the incidents;

In 20% of cases either the inmates (but more often staff) did not receive critical incident stress debriefing or support. The committee found it curious that there were problems in this area as the problems associated with post-traumatic stress disorder are well known. Typically these cases involved only a few of the staff who needed such support. A combination of staff disinterest and lack of formal follow-up appeared to be the usual reasons CISD did not ensue. We do not feel a recommendation is warranted in this case, more diligent follow-up is needed and the BOI’s are quick to address these deficiencies.

9. Any successful and best practices in other international correctional jurisdictions with respect to deaths in custody;

In 16% of cases best practices in the field were not used by CSC, at least as we define them. As noted in chapter two, CSC currently engages in most of the best practices outlined in the literature. How well they do this and how they can improve on these practices is the function of all levels of management and investigative arms such as audit, evaluation and incident investigation. Keeping up on new best practices is the responsibility of research and ad hoc committees such as this year’s independent committee.

Recommendations for Future Research

To assess progress on the precipitating factors that can lead to deaths in custody, the performance system being developed by the Corrections Operations and Programs Branch is laudable. Tracking violence in prison through inmate assaults, riots, disturbances, institutional charges, and drug interdiction efforts through illicit substance finds and drug testing, and inmate risk by self-harm and suicide attempts, are all critical sources of management information. We look forward to their integration with the Incident Investigations Branch. We note that last year’s review committee recommended (R6) consultation with future IRC’s in the development of these data elements, and we support this approach.

In-custody suicides are probably the best studied area in the literature, and CSC’s Research branch is currently conducting good work in providing an annual research report on suicides in custody. However, little is available in the area of drug overdoses, an area where current CSC data is unreliable (see chapter three). A longitudinal study on drug overdoses could better assess Coroner’s reports and provide a more accurate accounting of these incidents. Such a study could involve external investigators, the Incident Investigations Branch and the Addictions Research Centre. Homicide is another area where a long term retrospective (e.g., 20 years) might provide more insight into changes over time, and the influence of prison gangs. CSC would benefit by conducting special studies in these two areas, something suggested more generally by the 2009-10 IRC (R7).

Canada could take a greater hand in the international study of deaths in custody. There is research being conducted outside of CSC on inmate deaths, and to learn more from others and to promote itself as a world leader in developing the best practices possible, a national or an international conference or forum for researchers working in this area would be of significant benefit. This was recommended by last year’s independent committee (R11.7)

Recommendations for Future Research

Independent review committees are one of several ways in which organizations seek to find the truth about their operations outside of any possible personal or organization vested interests. Committees should be structured with a wide array of knowledge and different areas of expertise among its members. Committees should be organized well ahead of the time they commence formal operations, to allow members to familiarize with each other, establish rapport and divide responsibilities. The striking of an independent committee to review deaths and provide advice is a bold move by Correctional Service Canada and indicates a willingness to access outside expertise and explore ways in which to improve services. However, there are some limitations to the current format and there may be other ways in which CSC can use the services and expertise that independent reviewers can provide.

The external review of deaths in custody in the United Kingdom and Australia provide examples of a very strict monitoring system and the other a more general approach to data collection and reporting (AIC 2012, retrieved from http://www.aic.gov.au/en/publications/current%20series/mr/1-20/10.aspx, Fulton, 2008). In the UK, recent recommendations by an Independent Reviewer were for a Ministerial Board consisting of Ministers (in Canada’s case likely the Ministers of Justice and Emergency Preparedness). The Ministerial Board receives reports from an Independent Advisory Panel on Deaths in Custody. The Advisory panel membership would be relatively small and include senior corrections executives and individuals selected for their expertise (i.e., independent). Selection would be a competitive process. A Practitioner and Stakeholder group would support the activity of the Advisory panel (likely John Howard, Elizabeth Fry, victim’s families). The Advisory Panel would have a budget and staff support. This system does not appear to be in place currently in the UK, but is recommended as an ideal type.

In the case of Australia, the Australian Institute of Criminology (AIC) has been monitoring deaths in custody on an ongoing basis for over twenty years. The AIC are provided statistics from criminal justice agencies and maintain a data base from which they provide a report every few years. The reports are fairly general and make data based observations, they tend not to review cases to the level of detail that our IRC has.

The use of either of these methods will rely on a commitment to keeping an independent review committee together for a few years. Hopefully between this year’s IRC and last year’s, Correctional Service of Canada will have a better idea on how such a committee can be most helpful to their organization. We suggest three options below.

Option #1 Three Year Reviews

In this structure, the CSC will keep the current committee, or some members, or appoint a new one and assign them responsibility to conduct a three year review of deaths in custody (2011-12, 2012-13, 2013-14). This provides a better opportunity to chart trends and efficacy of CSC responses, and take into account some Coroner’s reports, which is not possible under the current format. If the committee was given sufficient time they could also collect better data from previous years, again improving trend analysis. Continuous improvements can and should remain a priority across the CSC through the current Investigations process. The current committee strongly supports this option.

Option #2 Reviews with Oversight Responsibilities

Through its BOIs and Incident Investigations Branch, CSC has identified a number of promising initiatives, but it is early to assess their effectiveness (Chapter one). The independent committee could also do oversight on the follow-up on initiatives such as improving the quality of patrols, tracking success through a performance measurement framework, work with SIO’s, and linking Investigations Branch activities with policies and procedures and work by the Audit and Evaluation Branch. This might be linked with a model using three year reviews.

Option #3 Divide Death Reviews into Three (Homicide, Suicide, Overdose, Accidental)

There may be some benefit to dividing up the reviews into cause of death. The causal factors and organizational responses will be different across homicide, suicide and accidental deaths, and thereby provide the review committee with a better focus for recommended prevention strategies. This might be of particular use in the suicide category, from where much of the concern over deaths in custody appears to emanate. Again, this would work better with reports done over the course of three years.

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