The Final Report of the Independent Review Committee into Deaths in Custody: 2009-2010

Abridged Version

Submitted to Correctional Service Canada
February 15, 2011

Ross Hastings, Chair
Greg Forestell
Greg Graceffo

The first Independent Review Committee (IRC) was mandated to review all non-natural deaths in custody in Fiscal Year 2009/2010 as well as the appropriateness and adequacy of the corrective measures initiated by CSC. The IRC reviewed and reported on the incidents and the offenders involved, the Boards of Investigation reports, and the corrective measures grids. In order to publish this report to the Internet alongside the second and third IRC reports, due to the sensitive nature of the content, this current version of the IRC's report is abridged in the interest of protecting all personal identifying information. For publishing purposes, sections 2.2 and 2.4 of the overview and sections 3.1 and 3.2 of the analysis have been redacted, and the appendices have been wholly exempt from disclosure as these sections outline private individual case matter.

Introduction and Overview

1.1 The work of the Office of the Correctional Investigator - key areas of concern

The issue of deaths in custody was brought front and centre by Howard Sapers, the Correctional Investigator, in his annual report for 2005-2006. At that time, Mr. Sapers expressed his concern that, time and again, similar recommendations were made by CSC's National Boards of Investigation, and by provincial coroners and medical examiners, but that CSC did not seem to be able to implement these recommendations at a national level (Gabor, 2007:4).

To address this issue, the Office of the Correctional Investigator (OCI) sponsored a comprehensive review of reports and recommendations dealing with the issue of deaths in custody. The report was produced by Professor Thomas Gabor of the Department of Criminology of the University of Ottawa. Its primary focus was on "the identification of systemic issues that have compromised the prevention of, or the response to, fatal assaults and self-injury" (Gabor, 2007:5), and "the goal was to move from an analysis of incidents, on a case by case basis, to an overall assessment of trends and patterns" (Gabor, 2007:4).

Gabor's report covered a total of 82 deaths in custody during the period between 2001 and 2005. His work resulted in five major findings (Gabor, 2007:9-20):

  1. Several concerns are raised repeatedly in investigations of deaths in custody. These include problems with post-incident medical or emergency care, the failure to keep adequate medical records or to assure that necessary information is shared within and amongst institutions and staff; concerns about the adequacy of the collection and preservation of evidence (including security videos); repeated problems with patrols, counts and live body verification; issues related to mental health programming and suicide prevention; the availability of contraband; and the failure to offer post-incident stress management.
  2. There are indications that, between 2001 and 2005, CSC did not appear to improve its overall capacity to prevent deaths in custody or to respond to critical incidents.
  3. There were indications that CSC tended to act on the findings and recommendations of its Boards of Investigation, but often disagreed with, or took no action on, recommendations from Coroners.
  4. A significant period of time elapsed between an incident of a death in custody and the formal approval by CSC of action plans in response to the incident (Gabor estimates an average of 475 days).
  5. There is a likelihood that at least some deaths in custody could have been prevented through improved risk assessments, more vigorous preventive measures and more competent and timely responses by institutional staff.

Gabor's conclusion was that "overall, Correctional Services Canada is not incorporating into current practices, the lessons that can be learned from previous incidents" (Gabor, 2007:21).

Since that time, the Office of the Correctional Investigator (OCI) has continued to devote a considerable amount of attention to this issue (OCI, 2010c). These activities include two reports on individual incidents of a death in custody: A failure to respond (May, 2008), which dealt with the suicide of an Aboriginal inmate, and A Preventable Death (June 2008) which dealt with the death of Ashley Smith. In both cases, it was argued that these deaths could perhaps have been prevented if the findings and recommendations of previous reports had been better addressed by the CSC. In addition, between September 2009 and September 2010, the OCI has issued a series of four assessments of CSC's response to the issues raised around the problem of deaths in custody.

The final assessment in September of 2010 (OCI, 2010d) acknowledges that CSC is making a concerted effort to address some of the issues and concerns that have been repeatedly raised in their own investigations and reports and by the OCI. Nevertheless, the OCI argued that the latest numbers do not indicate a reduction in the rate of offender deaths by other than natural causes (OCI, 2010c:3), and that measurable progress is not yet where it should be (OCI, 2010b:1). The OCI concluded that:

…overall, lessons learned were not consistently applied and that the Service has failed to address systemic deficiencies related to accountability and governance issues in federal corrections.

The OCI identifies six ongoing areas of concern, all of which have been raised time and again over the years. They are (OCI, 2010c and 2010d):

  1. Inadequate or inappropriate responses to medical emergencies;
  2. Critical information-sharing failures between clinical and front line staff;
  3. Deficiencies in monitoring suicide pre-indicators;
  4. Compliance issues related to the frequency and quality of patrols, rounds and counts;
  5. The management of mentally ill offenders is too often driven by security-oriented responses rather than by appropriate health care and treatment; and
  6. The need for improvements to CSC investigative reports and processes.

1.2 The response of the CSC and the creation of the Independent Review Committee

The Commissioner of the CSC, Mr. Don Head, formally responded to the Correctional Investigator in a letter dated February 10, 2009 (that is, before the OCI released any of the four assessments of the response of the CSC to the concerns raised in its earlier work). In his letter, Commissioner Head details a number of initiatives and commitments undertaken by the CSC to help improve its capacity to anticipate and respond to the types of incidents that can lead to a death in custody.

Among the commitments listed, Commissioner Head undertook to implement an Independent Review Committee (IRC) to assess on an annual basis CSC's actions and responses to various deaths in custody reports (Head, 2009:6). The idea behind the IRC is to benefit from the experience of independent experts and observers who might be able to identify ideas and options for improvement that may not be apparent to those within the organization.

As stated in the Terms of Reference of the IRC, our mandate is:

to review all non-natural deaths that occurred in CSC institutions during the 2009-2010 year and the appropriateness and adequacy of the corrective measures initiated by CSC.

1.3 The organization of this report

In order to accomplish this task, the members of the IRC were given access to 20 reports of the Boards of Investigation (BOI) into incidents of deaths in custody (N = 20, 17 of which involved deaths by non-natural causes). We also received the Executive Summaries of these reports, the grids of corrective measures and the closure memos. In addition, we were also given executive summaries of BOI reports into non-natural deaths in custody for the three previous fiscal years (2006-2007, 2007-2008, and 2008-2009) in order to gain a sense of some of the trends in this area.

However, it should also be noted that, because of constraints in terms of both time and resources faced by the IRC, we did not attempt to access other reports (including those by the police, Medical Examiners or Coroners), nor did we pursue other avenues of information such as interviews or site visits.

The three members of the IRC worked in the following manner:

2. Deaths in Custody, 2009-2010: A Descriptive Overview

2.1 Description of the sample

According to the statistics provided by CSC, there were a total of 51 deaths in custody during the 2009-2010 fiscal year. This figure covers all types of death; it includes homicides, suicides, drug-related deaths, accidents and deaths by natural causes.

The process followed in all such cases is clearly outlined in Commissioner's Directive (CD) 041: Incident Investigations Process Chart (CSC, 2010). For the purposes of this report, the following elements of CD 041 are relevant:

  1. All deaths in custody are reported to regional and national headquarters.
  2. The Incident Investigations Branch reviews and summarizes the information available on the incident, and presents it to the Senior Deputy Commissioner (SDC).
  3. The SDC then determines under which authority the investigation into the incident will be convened.

The sample covered in this report covers 20 BOI reports into deaths in custody during 2009-2010. The distribution of the cases is described in Table 2.1 (see below); it includes 17 deaths by non natural causes and 3 deaths that were attributed to natural causes but where concerns were raised about the rapidity, quality or appropriateness of the care received by the individual in question.

Table 2.1: The sample covered in this report
Type of Death CSC:
Non-natural causes 17 17
Natural causes - concerns raised 9 3
Natural causes - no concerns raised 25 0
Total 51 20

2.2 Types of death

The sample provided to the Independent Review Committee included a total of 20 incidents: this includes 2 deaths attributed to natural causes and 18 deaths by non-natural causes. Our analysis of the reports of the BOIs indicates that these cases were distributed in the following manner:

A quick review was undertaken to see if there was any pattern in the incidents in terms of days of the week or time of the day, especially in the case of the 10 suicides. The findings do not illuminate very much. The only element of interest is the pattern of the suicides. In four of the 10 incidents, the inmate was found around mid-day. The other six cases were all either relatively late in the evening or during the night. It is also interesting that in six of the incidents (two at mid-day and four of the evening/night cases), concerns were raised about either the timing or the quality of the patrols or rounds. At least seven of the suicide victims had made previous attempts to end their lives, and another had a history of self-injury.

Finally, only four of the incidents involve inmates who were in segregation, either for their own protection or because of concerns related to care or discipline. These cases include two suicides, both of whom had been in segregation for over three weeks (23 days in one case and 25 in the other). There was also one death by natural causes (3 days) and one drug overdose (2 days).

As indicated in Table 2.2 (see below), the 17 deaths by non-natural causes is slightly above the average of 15 such deaths per year over the last four fiscal years. The data for the last four years are similar to the average of 16.4 deaths by non-natural causes per year reported by Gabor for 2001 to 2005 ((Gabor, 2007:13).

Table 2.2: Deaths by non-natural causes - 2006 to 2010
Suicide Homicide Drug-related Total
2009-2010 10 2 5 17
2009-2009 9 2 4 15
2007-2008 6 0 3 9
2006-2007 11 2 6 19
Total 36 6 18 60

We are confident that the data reported in last column for the total number of deaths per year are reliable, but there is more ambiguity about the classification of the type or the causes of death (the three middle columns). For example, there is one case (#10) in which an inmate was ruled by the Coroner to have died of a drug overdose. However, the report of the BOI concluded that his death was a suicide resulting from an intentional overdose. We have accepted the conclusion of the BOI and classified this as a suicide. However, CSC has accepted the Coroner's more limited verdict and classified this as a drug-related death. In another case (from 2007-2008), CSC classifies one of the deaths that we have listed as a suicide as being a death by causes unknown and are waiting for the results of the Coroner's inquest before making a final decision on the cause of death in this incident.

A similar ambiguity exists in the case of some of the drug-related deaths. In these cases, it is clear that the overdose was the cause of the death, but it is very difficult to assess with certainty whether the suicide was accidental or intentional unless the victim has left a suicide note or some other form of clear indication of their intentions.

In any case, it is clear that the data on the type of death can only reflect the best information available at the time, and they may be subject to reclassification in the future on the basis of new information. Given the delays in some of the investigations by the police or by coroners, this can sometimes happen well after the actual incident has taken place.

2.3 Distribution of incidents by region

A description of the distribution of the different types of deaths-in-custody by CSC region is included in Table 2.3 (see below). It would be interesting to compare these figures to the distribution of inmates by region in order to assess whether this distribution is proportional. However, we did not have the data required to do this at this point.

Table 2.3: Type of death by region
Type of death Natural causes - no concerns Natural causes - concerns Non-natural causes Total
Atlantic 0 1 3 4
Québec 3 3 5 11
Ontario 13 2 5 20
Prairie 6 1 4 11
Pacific 3 1 1 5
Total 25 8 18 51

2.4 The characteristics of the inmates involved in the incidents

The inmates involved ranged in age from 24 to 58 years old, and had an average age of 41.4 years. The average age in the three cases of death by natural causes was 49.3 years of age. The average age of the 10 suicide incidents was 42.7 years old.

All 20 of the BOI reports we analyzed involved male inmates. Finally, one inmate was identified as Black, and three were identified as Aboriginals.

2.5 The characteristics of the sentences being served

This information covers the number of federal sentences received, the length of the sentence, the percentage of sentence served at the time of the incident, the amount of time served in the current institution, and whether the individual in question has passed his date of eligibility for day parole, full parole or statutory release.

It would be inappropriate to draw any significant conclusion from the limited number of cases under review. However, there were a few elements that struck us as perhaps worthy of further attention. These include the following:

  1. In 12 of the 20 cases, the individual was serving his first federal sentence - two were serving their second, four their third, two their fourth and one his seventh.
  2. In the cases of the suicides, six persons were serving their first federal sentence, three their third, and one his seventh.
  3. Four of the five cases of a drug-related death involved individuals serving their first federal sentence - the other individual was serving his second such sentence.
  4. 11 of the incidents involved individuals serving a sentence of five years or less, and six involved individuals serving life sentences or an indeterminate sentence.
  5. Four of the suicide victims were serving sentences of either two or three years, while another four were serving either a life sentence or an indeterminate sentence.
  6. Most of the individuals involved could be said to have "prison experience"; only four had served less than a quarter of their sentence, and 10 had served at least half.
  7. The data on the time served at the current institution was thought provoking. For instance, three of the suicide victims were individuals serving a life sentence who had served significant time; in one case, the individual had served 25.5 months, and in the other two, 11 years and 14.5 years. The other seven suicide victims had all served 19 months or less, and four of them had been at their current institution for less than 7 months (the briefest period was 14 days, and the next briefest was 48 days).
  8. The pattern in the five cases classified as drug-related is similar; one individual had served 12 years, another 8 years, a third 21 months and a fourth 113 days. The briefest time served was one day in the case of an individual who was returned to custody post-suspension.

One final issue deserves further consideration. In a number of cases, there was some indication of an inmate expressing frustration or concerns over either the handling of a transfer request or over a parole hearing and its possible outcomes. These types of events are recognized as being stressful and as potential risk or precipitating factors. This suggests that an inmate's history in these areas, especially in recent years, should perhaps receive more attention in CSC investigations.

3. An Analysis of the Incidents

3.1 Pre-incident factors

This section will cover relevant factors up to the discovery of the incident by CSC staff - the basic issue is whether an incident could have been anticipated and, perhaps, prevented. In this regard, the question is whether staff had the information they required to make appropriate decisions, and whether they were compliant with CSC policies and practices in responding to the information that was available.

This section will focus on the following areas: issues related to the physical health of the inmate; issues related to mental health; indicators of a risk of suicide; proximal causes or indicators, and the issue of patrols, rounds and counts.

  1. Physical health: in general, the responses of CSC staff to health related issues were assessed as satisfactory in the majority of BOI reports - in general staff members were seen as having responded appropriately in light of the information that was available. There were however two areas of concern. The first is that there were a few cases where information that was available to some was not effectively shared with others. In a few other cases, files did not follow an individual upon transfer, leading to missed opportunities to respond more effectively. On the other hand, there were also at least three cases where the refusal of the inmate to disclose accurate information, or his refusal or failure to cooperate with treatment seems to have been a contributing factor of some significance (cases #3, 10 and 14).
  2. Mental health: it is striking that all 10 of the suicide victims seem to have had difficulties in relation to mental health. In most of the cases, the responses of CSC staff were assessed as satisfactory by the BOIs, at least in light of the information that was available to staff members. There were, however, two cases where responses raised concerns and were assessed as unsatisfactory; in the first (#10) communication problems between mental health workers and staff contributed to a failure to appreciate the patient's recent decline, and in another (#19) there was a failure to complete some aspects of the intake assessment and treatment was compromised by the absence of mental health professionals at key times for the individual in question. The larger question in this area continues to be whether carceral institutions have the resources they require to respond effectively to the needs of individuals experiencing serious psychological difficulties.
  3. Indicators of suicide risk: all ten of the victims of suicide had a previous history of self harm and of attempts to take their life. In eight of these cases, the responses of CSC staff were assessed as satisfactory. In the two other cases, the current level of risk was not known to staff. There is a sense in a few of the files that the consequences of asking for help can be perceived by the individual as having punitive consequences. It would seem that this issue is worthy of further study.
  4. Proximate causes/indicators: In general, it is difficult to discern a clear pattern in this regard. It is noteworthy that seven of the 10 suicides were preceded by a situation or an event that caused the individual a significant level of stress. However, in four of these cases, the nature or the extent of the stress was not known to CSC staff, largely because the individual successfully masked the situation (even though others appear to have been aware of the problem), or repeatedly denied having suicidal ideation or any intent to self-harm. This raises some interesting questions about the nature of dynamic security, and about what it is possible and realistic to expect CSC staff to be able to accomplish in this sphere given the nature of a prison environment and the desire of some to maintain their privacy even if the potential consequences are significant. The CSC should give some consideration to exploring other avenues for systematically obtaining the type of information that is currently sought primarily through staff-based initiatives.
  5. Rounds, counts and patrols: This area continues to draw a great deal of attention in the reports of the BOI. It would seem that some progress has been made in recent years in this area, at least in regards to the frequency and predictability of the patrols. For the most part, the BOIs found that staff was compliant with CSC policy in this regard. There was, however, at least one case where the BOI members were not given access to video records to confirm the versions of incidents presented to them (case # 1), and another where they simply stated that the staff members in question were not credible (case # 14). Concerns were also raised in at least seven cases about the quality of the patrols and the failure to verify a live body during the patrol (cases # 3, 5, 7, 8, 10, 15 and 16 - five of these were suicides). In some cases, the difficulties seem related to the speed at which the patrol or round was executed and the consequent inability to properly assess a situation where there might be difficulties. In other cases, especially at night, the CO was unable to properly assess the situation because the night light was out or covered (cases # 3 and 8) or the cell opening was covered. Staff are caught in a particularly difficult conundrum, especially at night where they have to balance the live body verification against the need to let inmates sleep without being overly disturbed. This clearly is an issue that requires study and collaboration if improvements are to be made.

3.2 Incident-related factors

The focus in this section is on the rapidity and the quality of the responses by CSC staff after an incident has been discovered, and up to the point where there has either been a determination of death or the inmate involved has left the detention centre in order to be treated outside the CSC institution.

This section will focus on the following areas: issues related to patrols, rounds and counts (especially as related to the question of response time); issues related to compliance with requirements in first-aid, CPR and use of defibrillators; and ambulance escort policies.

  1. Patrols, rounds and counts (response time): To some extent, this issue has already been covered in the previous section - we return to it here because of the implication in some reports that the incident could and even should have been discovered earlier. The BOIs almost always assessed the frequency of patrols as being compliant with directives (although, there were indications patrols were at least a few minutes late in at least three cases - # 11, 14 and 18). However, concerns were often raised about the speed of the patrols and the subsequent impact on their quality (cases # 7, 10, 14, 16, and 19). There were also cases in which the absence of a radio (#1, 7, 8 and 18) or apparent confusion about the location of keys (#13) caused some delay - however, these were not identified by the BOIs in question as compliance issues nor as having a significant impact on the outcome of the incident.
  2. First-aid: In general, there seems to have been considerable improvement in this regard in recent years. Gabor had listed this as an area of concern in his original report (2007). However, the BOI reports for 2009-2010 indicate that there was almost complete compliance in terms of training and equipment use in this area. The only minor exceptions were an incident in which only one CO wore medical gloves (# 2), another in which institutional medical kits were not adequately stocked, and another in which the CO escorting an inmate in an ambulance was not currently certified (#18). There was no indication in any of these cases that this had an impact on the final outcome.
  3. CPR/defibrillators: This also seems to be an area of improvement since the Gabor report (2007). In general, the BOIs found both staff and institutions compliant in terms of both training and of the availability and use of equipment. There were a few minor exceptions. In one case, a CO was not wearing a CPR mask (this seems to have been a systemic problem in the institution in question and has now been rectified at that level), and in others there was either a delay in starting CPR (#8), confusion about the use of the defibrillator (#14), or a CO whose certification was not current (#18).
  4. Ambulance escorts: There were at least four cases where there were delays in an ambulance leaving an institution, either because there was confusion about the ambulance escort policy (#17 and 19) or recalcitrance on the part of the staff to complying with policy (#16 and 18). Given the importance of rapid response in emergency situations, these findings suggest this issue requires further clarification, both in terms of the content of the policy directives in this regard (there have been recent changes) and of the need to inform staff of current policy requirements and to hold them accountable for compliance.

3.3 Post-incident factors

The focus of this section is the performance of CSC staff and others involved (especially health care specialists) in the aftermath of an incident.

It will focus on the following areas: emergency response and the quality of care provided after the incident, the provision of post-incident supports to staff and to inmates, and compliance with reporting requirements (by CSC staff).

  1. Emergency response/medical care: In general, the BOIs assessed the quality of emergency response and the medical care provided as being compliant. The only areas of concern revolved around delays responding (#14) or in ambulances leaving the institution (see previous section).
  2. Post-incident supports: In general, Critical Incident Stress Management (CISM) was offered to all staff directly involved in an incident. The only area of confusion here appears to lie in the focus of CISM on those directly involved and the directive for those not directly involved to access help through their Employee Assistance Plan (EAP). Some clarification of this distinction would help clarify this confusion. The BOIs also indicated that support was generally available to inmates who requested it, but not in the form of CISM - it might be useful to consider developing a clearer policy statement in regard to the needs and rights of inmates in this regard.
  3. Reporting requirements: There were at least eight cases where post-incident reporting was not compliant. However, the concerns here were usually relatively minor - for the most part, they were either corrected after the fact or through clearer direction to the employee about expectations in the future.

4. The Response of the Correctional Service of Canada

4.1 Time elapsed in reporting phases

The Gabor report was very critical of the amount of time taken by CSC between the date of an incident and the completion of a report by a BOI, and between the submission of a report by a BOI and the response by CSC (and the subsequent closure of the file on an incident). The data available to us for 2009-2010 indicate that there has been significant progress in this regard.

Table 4 indicates that, between 2001-2005 (Gabor's time frame) and 2009-10 (the focus of this report), the BOIs are producing their reports in a much shorter time frame and the CSC is responding much faster to these reports. Overall, the time elapsed has dropped from an average of 475 days (Gabor, 2007) to an average of 231 days.

Table 4: Time elapsed in reporting phases
Time elapsed
(in days)
Cases from
From incident to BOI Report 165 104.7
From BOI Report to EXCOM response 310 127.2
Total 475 231.4

4.2 BOI findings and recommendations and the response of the CSC

One of the main purposes of the CSC's BOIs is to make suggestions and recommendations about how incidents could be prevented in the future or dealt with more effectively when they do occur. In that context, it is interesting to note that only half of the BOI reports under consideration included recommendations to the CSC.

The data on individual reports indicates that:

  1. Recommendations were included in ten of the 20 reports under consideration.
  2. A total of 38 recommendations were identified. The vast majority of these (N = 33) were aimed at contributing to an improved capacity to anticipate incidents or to intervene more effectively before a crisis occurs.
  3. For the most part, the recommendations were supported in whole or in part (N = 28), and indications from the EXCOM grids are that the necessary steps were taken (or were in process) to address the concerns or issues that were raised. These usually involved a clarification of policy requirements or a reminder of expectations rather than any significant change in policy or practice.
  4. A similar pattern was found in our overview of BOI findings, especially those identified as findings of non-compliance. We were not able to undertake a detailed analysis in this regard. However, our sense is that most of the findings of non-compliance that were supported resulted in corrective measures at the local level. This usually took the form of a reminder to all of the expectations and requirements of a policy, or of a specific training-type intervention with an employee. There were a few cases of responses being identified as "accountability measures", which suggests some form of disciplinary intervention. However, there is no indication in the BOI reports of how these were handled or of what the results might have been.
  5. When recommendations were not supported, it was usually either because EXCOM did not support the findings upon which the recommendations were based, or because the changes required were not physically or financially possible at that point in time or the implementation of the changes would take some time. There also appeared to be a number of situations where CSC executives at the local, regional or national level felt that the current policies and practices already covered the suggestions made in the recommendations.
  6. In many cases, most of the recommendations that were supported have already been implemented before EXCOM provides its formal response to the BOI report. This appears to be the result of two factors: local management seems willing and able to "get ahead" of issues and to respond, and the effectiveness of the debriefing provided by the BOIs before they leave the sites of the investigations.

One the face of it, all of this appears to be good news. However, there is also a possibility that the paucity of recommendations may also be a by-product of the nature of the investigation process and of how it has evolved in recent years.

It was explained to us that the focus of BOIs is primarily on the basic question of "whether staff did what they are trained to do?" This is obviously an important question, but there is a concern that it may direct too much attention to issues of compliance, and not enough to the wider issue of the effectiveness of the policies and procedures currently in place. There is a risk that, in relying on a compliance-oriented investigations process, opportunities to use investigations to nourish a "learning organization" approach to self-assessment and organizational change and to identify areas of research and innovation may be lost.

5. Conclusions and Recommendations

On the basis of our review, we feel there are a number of areas where further work on issues related to deaths in custody is warranted. The members of the Independent Review Committee on Deaths in Custody (2009-2010) respectfully submit the following recommendations for the consideration of CSC.

The sharing of health-related information on inmates: The key issue here is to assure that all staff members in decision-making positions have the most complete information possible at their disposal before making a decision in the case of an inmate. In our view:

Patrols, rounds and counts: There has been significant improvement in the frequency and unpredictability of patrols and rounds (though one must appreciate the limits of the notion of unpredictability when these activities must always occur within a one hour time frame). The issues of assuring the quality of patrols, rounds and counts, especially as these relate to live-body counts, and of maintaining a visible staff presence and ongoing interaction with inmates continue to pose challenges. In our view:

The consequences of non-compliance/poor performance: There are a number of occasions where the findings of the BOIs indicate poor or non-compliant performance, but there is no indication in the reports of the consequences of these findings for either the employee or the institution. While we appreciate the need to respect the privacy of individuals, and the limited value of "making an example" of individual employees, we do think that opportunities for progress and improvements are being lost. In our view:

The failure to define, measure and communicate success in an effective manner: CSC's current reliance on reacting to deaths in custody only after the fact in the form of BOIs may have the unanticipated consequence of putting too much emphasis on cases when the system fails, and thereby of skewing the perception of the organization. In simple terms, we have little or no data on "success stories" or on the proportion of incidents in which timely and effective interventions helped to avoid a tragedy. In our view:

The issue of dynamic security: Our review of the various reports of the BOIs provided by CSC indicates that, in a number of cases, family, acquaintances or other inmates were in possession of information that might have helped prevent an incident. In other words, information about such things as drug debts, personal crises, gang involvement or a desire for revenge was "there" (at least for some), but it was not available to CSC staff. That said, it also seems to us that there are real limits to the ability and capacity of CSC staff to make rapid and significant progress in the area of dynamic security within the constraints of a short term time frame. In that context, perhaps the most promising avenue is to explore the possibility of collaborative efforts. In our view:

The nature and format of the investigation process: The current investigative process (especially the reliance on BOIs) seems to us to be an effective way to assess compliance with policy and expectations. However, we are much less convinced that the BOIs, with their focus on a relatively rapid response to individual incidents, are an effective mechanism for policy evaluation or for performing the type of functions that are at the core of a learning organization (especially as this relates to the prediction and prevention of future incidents). We feel much could be gained from having more systematic linkages between the current BOI process and other approaches to assessing the relevance, efficiency and effectiveness of policies and practices. In our view:

The future of the Independent Review Committee: The purpose behind the creation of the IRC was to allow for an independent review of all non-natural deaths in CSC institutions in 2009-2010 and an assessment of CSC's responses to these incidents. This first year of the work of the IRC has been a learning experience, both for CSC and for the members of the IRC. Part of the challenge was the volume of work involved in the process, and part was related to the "learning curve" for the members of the IRC. Hopefully, this year's experience will provide a base upon which to build a more efficient and effective process for the years to come. In our view:

The above is an accurate account of the findings and recommendations of the Independent Review Committee on Deaths in Custody (2009-2010).

Original signed by
______________________________      February 15, 2011
Ross Hastings

Original signed by
______________________________      February 15, 2011
Greg Forestell

Original signed by
______________________________      February 15, 2011
Greg Graceffo


Correctional Service Canada (2010a). Terms of Reference of the Independent Review Committee.
(2010b). Commissioner's Directive 041: Incident Investigations Process Chart. Ottawa: Correctional Service of Canada.

Gabor, Thomas (2007). Deaths in Custody: Final Report. Ottawa: Office of the Correctional Investigator.

Head, Don (2009). Letter to Howard Sapers (Correctional Investigator). February 10, 2009.

Office of the Correctional Investigator (2010a). Final Assessment of the Correctional Service of Canada's Response to Deaths in Custody. Ottawa: Office of the Correctional Investigator.

(2010b). Press release: Correctional Service of Canada Challenged to Apply Lessons Learned and Prevent deaths in Custody. Ottawa: Office of the Correctional Investigator. Downloaded on October 9, 2010 from:

(2010c). Backgrounder: Correctional Investigator's Assessment of the Correctional Service of Canada's Progress in Responding to Deaths in Custody. Ottawa: Office of the Correctional Investigator. Downloaded on October 9. 2010 from:

(2010d). Final Assessment of the Correctional Service of Canada's Response to Deaths in Custody. Ottawa: Office of the Correctional Investigator. Downloaded from: Downloaded on October 9, 2010 from:

Terms of Reference
Independent Review Committee

June 2010


In response to the Office of the Correctional Investigator's June 2007 report on Deaths in Custody, CSC's Commissioner, Don Head, wrote a letter dated February 10, 2009 in which he made the following key commitment: "implement an independent review group to assess on an annual basis CSC's actions and responses to various deaths in custody reports".

Objective of the Review

CSC has been searching for ways to improve its performance in relation to the prevention and reduction of deaths within our correctional facilities. Our own investigative processes are effectively bringing the issues to our attention in a timely manner but we need to look for solutions that may not be as apparent to us from within our organization.

This is an opportunity to benefit from the members of Independent Review Committee's experience and seek out their suggestions and advice on the approaches and techniques that CSC could introduce that would enhance its capacity to respond more effectively to these types of incidents in our correctional institutions.


Ross Hastings, Professor of Criminology, Ottawa University - Chairperson
Greg Forestell, Chief Coroner, Province of New Brunswick - Member
Greg Graceffo, Assistant Deputy Minister, Manitoba Corrections - Member


The members of the Independent Review Committee will review all non-natural deaths that occurred in CSC institutions during the 2009-2010 year and the appropriateness and adequacy of the corrective measures initiated by CSC.

The Incident Investigations Branch will send the members the reports, as well as the executive summaries, grid of corrective measures and closure memos for the 18 investigations involving non-natural deaths that occurred between April 1, 2009 and March 31, 2010.

To gain a broader picture of the trends in regard to Deaths in Custody, the Committee will also receive the executive summaries of the investigation reports that were completed for the 51 non-natural deaths that occurred in CSC custody between April 1, 2006 and March 31, 2009 as well as a five-year statistical summary of non-natural deaths in custody from 2005-06 to 2009-10.


The start date start for the project is May 2010. The Review consists of:

Original Signed by
Marc-Arthur Hyppolite
Senior Deputy Commissioner
Correctional Service of Canada

Amendment Terms of Reference

Independent Review Committee

Whereas in June 2010, I mandated the Independent Review Committee to review all non-natural deaths that occurred in CSC institutions during the 2009-2010 year and the appropriateness and adequacy of the corrective measures initiated by CSC.

Now Therefore I, Marc-Arthur Hyppolite, Senior Deputy Commissioner of Corrections, do hereby direct the Independent Review Committee to respect the following:

Given under my hand in the City of Ottawa, in the Province of Ontario, this 17th day of November 2010.

Original signed by
Marc-Arthur Hyppolite
Senior Deputy Commissioner of Corrections
Correctional Service of Canada

Independent Review Committee on Deaths in Custody 2009-2010
Final Report - February 15, 2011


*All appendices are exempt from disclosure.

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