Audit of the Framework and Implementation of Situation Management at CSC

Executive Summary

What We Examined

The Audit of the Framework and Implementation of Situation Management at CSC was conducted as part of the Correctional Service Canada (CSC) Internal Audit Sector’s 2016-2019 Risk-Based Audit Plan (RBAP). In CSC’s context, situation management represents the interventions by front line management and staff to prevent, respond to, and resolve situations that may jeopardize the safety and security of an institution and/or a person.

The objectives of this audit were to:

  • Provide assurance that the framework in place to support situation management is effective; and
  • Provide assurance that key activities supporting the situation management framework have been implemented effectively.

For the first objective, the audit examined whether:

  • CSC guidance is clear, up-to-date, and aligns with legislation;
  • Roles and responsibilities are defined, documented, communicated, and understood;
  • CSC provides employees with the necessary training, tools, and resources to effectively manage situations; and
  • Performance monitoring and reporting processes are in place to allow for informed decision making.

For the second objective, the audit examined whether:

  • Intelligence information is used to support and assist with the management of situations;
  • Medical assessments and treatment are provided in compliance with legislation and CSC guidance;
  • Use of force reviews are completed in compliance with CSC guidance; and
  • Mechanisms are in place to resolve non-compliance with the various policies supporting the management of situations.

The audit was national in scope and included the framework and processes in place at the national, regional, and local levels. It also addressed whether the results of the review of the Situation Management Model (SMM) completed in November 2015 by the Correctional Operations and Programs Sector in collaboration with the Health Services Sector and the Canadian Association of Chiefs of Police have been implemented, or are progressing as scheduled in addition to any other key commitments made by CSC as a result of the Coroner’s Inquest Touching the Death of Ashley Smith. For the file review, the audit assessed a sample of use of force incidents that occurred between April 1, 2015 and March 10, 2017.

Of note, CSC is in the process of replacing its SMM with the Engagement and Intervention Model (EIM), to further articulate the role of health services and to reinforce and provide additional clarity around key elements of how situations are to be managed. CSC’s plan to change to the model was taken into consideration during the planning phase, and the criteria for this audit were developed to ensure that resulting audit findings would apply to, and support, the organization’s transition to the EIM.

Why it’s Important

This audit links to CSC’s corporate priority of ensuring the "Safety and security of the public, victims, staff and offenders in institutions and in the community"Footnote 1 and the following corporate risk: "There is a risk that CSC will not be able to maintain required levels of operational safety and security in institutions and in the community."Footnote 2

It is essential that CSC has an adequate and effective framework in place to ensure that situations are managed within the scope of the law, including the Corrections and Conditional Release Act (CCRA), the Corrections and Conditional Release Regulations (CCRR), and that CSC guidance around the use of force is limited to only what is necessary and proportionate.

What We Found

With respect to the first objective, we found that a management framework is generally in place to support situation management. We found that CSC’s policy framework is consistent with law, up-to-date, and reflects current practices. We found that with one exception, roles and responsibilities are clearly defined, documented, communicated, and understood for the key players involved with the implementation of situation management practices. We also found that training, tools, and resources have been developed and provided to staff in accordance with the commitments made by CSC in response to the Coroner’s Inquest Touching the Death of Ashley Smith.

Still, we noted a few areas that require further consideration by management in order to help ensure that the management framework fully supports the effective implementation of situation management practices. Specifically, CSC should:

  • Revise Commissioner's Directive (CD) 567 Management of Security Incidents to clearly articulate responsibility for controlling staff response to a security incident;
  • Develop tools and resources to guide and focus the use of force review process, including the nature and monitoring of corrective action required for different types of non-compliance;
  • Establish mechanisms to help ensure that individuals completing use of force reviews are taking training on the use of force module; and
  • Establish and implement a monitoring and reporting plan for situation management practices that includes, developing key performance indicators and information monitoring and reporting requirements.

For the second objective, we found that institutions have processes in place to share intelligence information, and this information is used to prevent and respond to security incidents. We found that post use of force physical assessments are generally completed with an unobstructed view of the inmate, are usually completed as soon as possible, and treatment is provided when medical issues are identified during the assessment. For our sample, we found that use of force reviews are completed at the institutional level for all use of force incidents, and mechanisms are in place to address non-compliance issues. Still, we noted a few areas that require further consideration by management in order to help ensure that risks are better managed. Specifically, CSC should:

  • Establish formal processes to help ensure that: in the absence of a health care professional on shift, first aid assessments are completed by a staff member currently certified in first aid and cardiopulmonary resuscitation (CPR), following a use of force; the need to complete a post use of force physical assessment is effectively communicated to health services staff; and intervention plans are documented as required by policy.
  • Complete an analysis of the use of force review process to determine the intent of the reviews, and what should be assessed when completing a review to assist local management in taking meaningful and effective corrective action.

Management Response

Management is in agreement with the audit findings and recommendations as presented in the audit report. Management has prepared a detailed Management Action Plan to address the issues raised in the audit and associated recommendations. The Management Action Plan is scheduled for full implementation by October 31, 2018.

Acronyms & Abbreviations

ACCOP:
Assistant Commissioner, Correctional Operations and Programs
ADCCO:
Assistant Deputy Commissioner, Correctional Operations
CCRA:
Corrections and Conditional Release Act
CCRR:
Corrections and Conditional Release Regulations
CD:
Commissioner’s Directive
CPR:
Cardiopulmonary Resuscitation
COPS:
Correctional Operations and Programs Sector
CSC:
Correctional Service Canada
EIM:
Engagement and Intervention Model
GLs:
Guidelines
HSS:
Health Services Sector
NHQ:
National Headquarters
NTS:
National Training Standard
OMS:
Offender Management System
OMSR:
Offender Management System Renewal
RBAP:
Risk-Based Audit Plan
RDHS:
Regional Director, Health Services
RHQ:
Regional Headquarters
SIO:
Security Intelligence Officer
SMM:
Situation Management Model
SOR:
Statement/Observation Report

1.0 Introduction

1.1 Background

The Audit of the Framework and Implementation of Situation Management at CSC was conducted as part of the Correctional Service Canada (CSC) Internal Audit Sector’s 2016-2019 Risk-Based Audit Plan (RBAP). This audit links to CSC’s corporate priority of ensuring the "Safety and security of the public, victims, staff and offenders in institutions and in the community"Footnote 3 and the following corporate risk: "There is a risk that CSC will not be able to maintain required levels of operational safety and security in institutions and in the community."Footnote 4

As evidenced by its corporate priority, CSC is focused on ensuring that federal correctional institutions provide a safe and secure environment that is conducive to inmate rehabilitation, staff and public safety. In order to maintain safety and security within institutions, correctional staff is provided with guidance and training in how to interact with inmates and to manage situations that may arise. While the ultimate goal is to resolve situations at the lowest possible level, there are numerous options available for staff to utilize, which range from dynamic security up to and including the use of force.

It is essential that CSC has an adequate and effective framework in place to ensure that situations are managed within the scope of the law, including the Corrections and Conditional Release Act (CCRA), the Corrections and Conditional Release Regulations (CCRR), and that CSC guidance around the use of force is limited to only what is necessary and proportionate.

CSC Intervention Models

As described in CD 567 Management of Security Incidents, the Situation Management Model (SMM) is a graphic representation used to assist staff in determining the correct response options to be used in managing situations. This SMM is available in Annex A. While it is only one piece of the framework in place, the model is a key tool that provides direction to staff to assess the situation and the subject’s behaviour continuously, and select the most reasonable intervention option, relative to those circumstances as perceived at that point in time. The various response options are shown on the SMM, and they overlap to indicate that one or more can be used at the same time. It is recognized that in dynamic situations, the subject’s behaviour and the staff's perceptions and tactical considerations could change at any moment. The SMM represents the process by which staff assess, plan, and respond to situations that threaten the safety and security of an institution and/or a person.

Underlying the SMM are four key elements in the management of a situation: assessment, selection of management strategy, intervention type, and post intervention. The following graphic provides details of each of these four elements.

CSC Intervention Model

CSC Intervention Model

This graphic is a depiction of the four key elements underlying the management of a situation. It is comprised of five circles; one in the center of the graphic, with the other four evenly distributed around the center. Each of these circles represents a key element of the management of a situation and includes the name of the element as well as some details of the element in a bulleted list. The following is an outline of the information contained in each circle.

The circle in the center of the graphic is titled Situation Management.  The circle directly above the center is titled Assessment and includes the following bulleted list: CAPRA* problem solving model (A model that facilitates the acquisition and analysis of client and situational information, and the consideration, through partners, of response strategies); Inmate's current behaviour; Situational factors; Tactical considerations; Risk; and Ongoing to ensure effectiveness of response.  The circle to the right of the center is titled Management Strategy and includes the following bulleted list: Isolate and contain; Communication; Controlled non-intervention; and Tactical manoeuvring and intervention.  The circle directly below the center is titled Intervention and includes the following bulleted list: Dynamic security; Verbal intervention; Observation and monitoring; First aid/CPR; and use of force.  The circle to the left of the center is titled Post Incident and includes the following bulleted list: Debrief and report; Medical assessment; and use of force review. The four circles around the centre are linked together as each element influences the actions taken to manage a situation.

In 2017, CSC began revising the SMM. While the revised model is based on the same elements as that of the SMM, for example, assessment of the situation, selection of management strategy, etc., it is intended to provide greater clarity for some of these elements as well as expanding on the use of partners during a response, particularly CSC health services. To strengthen this new direction, the revised model will be called the Engagement and Intervention Model (EIM). CSC is planning to replace the current SMM with the EIM before the end of the 2017-2018 fiscal year.

Use of Force Reviews

Given the higher risk associated with interventions where force is utilized, additional oversight mechanisms (use of force reviews) are in place to ensure that legislative and policy requirements were adhered to during the response to a situation. CD 567-1 Use of Force outlines the requirements for post incident reporting, for subsequent reviews of the incident, and defines the timeframes within which the reviews must be completed. Refer to Annex B for details of the review process.

Incident Reporting Module in the Offender Management System (OMS)

When an incident occurs, all parties involved complete a Statement/Observation Report (SOR). The Security Intelligence Officer (SIO) on site then summarizes those SORs into an ‘Incident Report’ in the Offender Management System (OMS). If the SIO indicates that a use of force occurred, OMS automatically triggers this incident’s addition to the module. The module then prompts the necessary parties to input information about the use of force incident and perform the required reviews.

The Use of Force Module (module) was introduced in 2015 to ensure that use of force data was captured in a centralized database to allow for greater monitoring, trend analysis, and facilitate the completion of required reviews.

1.2 Legislative and Policy Framework

Legislation

Criminal Code of Canada

The way in which security incidents are managed at CSC is governed under the criminal code sections: 25 to 27, 34, 35, 37, 67 to 69, 92, 117.07, 494, and 495. Section 26 specifically states, "Everyone who is authorized by law to use force is criminally responsible for any excess thereof according to the nature and quality of the act that constitutes the excess." These sections, while covering different situations, focus on the reasonableness of the force applied and how the force must match the potential outcome of not applying force.

Corrections and Conditional Release Act (CCRA)

The CCRA establishes the purpose of the federal correctional system as contributing to the maintenance of a just, peaceful and safe society with the protection of society as its paramount concern. The following sections of the CCRA directly relate to how incidents are managed at CSC: 3, 3.1, 4, 15.1, 31 to 44, 68, and 97. Section 4 is the most relevant to the management of situations, where it limits the measures CSC may use in carrying out its mandate. Specifically, it states that "the Service uses measures that are consistent with the protection of society, staff members and offenders and that are limited to only what is necessary and proportionate to attain the purposes of this Act."

Corrections and Conditional Release Regulations (CCRR)

The CCRR lays out the regulations to support the CCRA and includes the delegation of authorities to staff members to carry out requirements within the CDs, which would include CD 567 Management of Security Incidents. The following sections of the CCRR directly relate to how incidents are managed at CSC: 3, 4, 19 to 41, and 73.

CSC Directives and Guidelines

There are 15 CDs and guidelines (GLs) that have requirements and processes that are related or applicable to the management of situations. Refer to Annex C for a complete list.

1.3 CSC Organization

National Headquarters (NHQ)

The Assistant Commissioner, Correctional Operations and Programs (ACCOP) is responsible for the development, implementation, maintenance and evaluation of interventions, and to ensure that any issues or deficiencies arising from security policies or procedures are addressed in a timely manner. Additionally, the ACCOP is to ensure that national training and certification standards for staff are developed in collaboration with the Director General, Learning and Development.Footnote 5

The Director General, Security, designated as the senior CSC authority on safety and security is to ensure that security policies and procedures are knowledge and research based and to provide direction and support to regions in relation to policy, safety and security issues. Additionally, the Director General, Security is to inform the ACCOP, of any issues arising from security policies, procedures or implementation.Footnote 6

The Assistant Commissioner, Health Services, and/or Health Services Director Generals are authorized to establish direction that must be adhered to by all health care professionals and other applicable staff.Footnote 7

Regional Headquarters (RHQ)

The Assistant Deputy Commissioner, Correctional Operations (ADCCO), is responsible for communicating policies and providing support to operational units as well as conducting operational reviews of policy implementation on a regular basis. Additionally, the ADCCO is to report any issues or deficiencies arising from security policies/procedures or their implementation to the Director General, Security in a timely manner.Footnote 8

The Regional Director, Health Services (RDHS) will ensure the provision of health services to offenders in CSC institutions and in the community, in accordance with relevant legislation, professionally accepted standards, CSC policies and practice directives; and the implementation of procedures to monitor and evaluate the quality and timeliness of health services and in a manner that promotes patient safety and quality improvement.Footnote 9

Institutions

The Institutional Head is responsible for implementing security policies and procedures, ensuring staff are equipped and trained in their duties, including training on situation management, and ensuring staff follow processes and respond to medical emergencies pursuant to CD 800 Health Services. Additionally, following a security incident, the Institutional Head is to ensure the institution returns to a safe and secure environment as soon as possible, managing any resulting challenges as well as conducting a debriefing with all individuals involved in the incident.Footnote 10

Staff are responsible for ensuring that they know and understand the applicable law, policies and procedures and consider cultural, physical health, mental health and gender issues in their interventions, demonstrate fairness, judgement and professionalism when returning the institution to a safe and secure environment, to not consent to or take part in any cruel, inhumane or degrading treatment or punishment of an inmate and report any such behaviour or treatment if witnessed. Additionally, staff is required to take every reasonable step to return the institution to a safe and secure environment as soon as possible when they become aware of any situation that jeopardizes the security of the institution or safety of the public, staff or inmates and resolve conflicts at the lowest level possible.Footnote 11

1.4 Risk Assessment

The Audit of the Framework and Implementation of Situation Management at CSC was identified as a high audit priority and an area of risk to CSC in the Internal Audit Sector’s 2016-2019 RBAP. An engagement level risk assessment was completed by the audit team using the results of interviews, research, and knowledge obtained through previous audits to assist in determining areas that the audit should cover.

Overall, the assessment identified key risks associated with the framework that is in place to support the management of situations as well as implementation of key controls. These risks have been covered by this audit to assess whether mitigation strategies were sufficient.

2.0 Objectives and Scope

2.1 Audit Objectives

The objectives of this audit were to:

  • Provide assurance that the framework in place to support situation management is effective; and
  • Provide assurance that key activities supporting the situation management framework have been implemented effectively.

Specific criteria have been established to assess these objectives and are included in Annex D.

2.2 Audit Scope

The audit was national in scope and included the framework and processes in place at the national, regional, and local levels. It also addressed whether the results of the review of the SMM completed by the Correctional Operations and Programs Sector (COPS) in collaboration with the Health Services Sector (HSS) and the Canadian Association of Chiefs of Police in November 2015 have been implemented, or are progressing as scheduled in addition to any other key commitments made by CSC as a result of the Coroner’s Inquest Touching the Death of Ashley Smith. For the file review, the audit assessed a sample of use of force incidents that occurred between April 1, 2015 and March 10, 2017.

The audit did not focus on determining if the type of force applied during an incident was correct. Minimum security institutions were excluded from testing as they normally have the lowest number of incidents and are therefore considered by the audit team to be lower risk. Security incidents which occurred in the community were also not included in the audit as CD 567 Management of Security Incidents, where the SMM is defined, pertains exclusively to incidents that occur in an institution.

The Audit of the Management of Security Incidents, which was completed in 2014, previously examined several areas related to this audit, including the reporting of security incidents and whether or not incidents were formally documented with SORs, logbooks, or case work records, as well as the management of equipment and weapons used during an incident response. Although management indicated that the actions it took to address the recommendations from that audit were fully implemented as of August 2015, we found through the current audit that one of these issues is still outstanding today. Refer to section 3.1.3 for details of this issue.

The SMM is the main tool in place to provide guidance to staff when managing situations. This model is in the process of being revised and replaced by the EIM. CSC's plan to change the model was taken into consideration during the planning phase, and the criteria for this audit were developed to ensure that resulting audit findings would apply to, and support the organization’s transition to the EIM.

3.0 Audit Findings and Recommendations

3.1 Management Framework

The first objective for this audit was to provide assurance that the framework in place to support situation management is effective.

The management framework was examined from four perspectives: CSC’s guidance framework; roles and responsibilities; training, tools, and resources; and monitoring and reporting. Annex D provides general results for all audit criteria.

3.1.1 Guidance Framework, and Roles and Responsibilities

We expected to find that CSC guidance is clear, up-to-date, aligns with legislation, and that roles and responsibilities are defined, documented, communicated, and understood.

The following areas met the audit expectations for this criterion:

  • CD 567 Management of Security Incidents and CD 567-1 Use of Force align with the Criminal Code, the CCRA, and the CCRR;
  • Guidance material reviewed is up-to-date and generally reflects current practices;
  • Roles and responsibilities are generally defined and documented in policy and in national generic work descriptions; and
  • Roles and responsibilities are communicated through policy, training activities, day-to-day direction from management, and from interviews seem to be understood by staff.

As described below, there is one area related to the guidance framework that warrants further consideration by management.

CDs related to situation management do not clearly define who is in charge when multiple staff members are responding to a security incident.

CD 567 Management of Security Incidents and CD 567-1 Use of Force are the primary policy instruments that define roles and responsibilities related to situation management. These CDs define roles and responsibilities associated with the procedures to follow when responding to situations; however they are generally assigned to "staff", and do not clearly articulate and delineate roles and responsibilities between the various positions (CX1, CX2, CM, etc.), including who is responsible for controlling the response. While staff indicated that they find their roles and responsibilities are clearly defined, they stated that it is not always clear who is in charge during situations where multiple staff members are responding to a security incident. Further, this issue has been raised as part of inquests, board of investigations, and Office of the Correctional Investigator reports.

There are many risks associated with a lack of clarity around who is in charge of the response to a situation, including a potential lack of ongoing assessment to determine if the team needs to adjust its response, excessive use of force, increased potential for injuries, multiple staff giving verbal orders to the inmate at the same time, and non-compliance with policy requirements such as deployment of a handheld video camera. Given that there are often situations where multiple staff members are responding to a security incident, it is imperative that it is clearly defined who is in charge.

3.1.2 Training, Tools, and Resources

We expected to find that CSC provides employees with the necessary training, tools, and resources to effectively manage situations.

The following areas met the audit expectations for this criterion:

  • National training standard (NTS) activities, specifically oleoresin capsicum (OC) spray and personal safety refresher training, have been revised in accordance with the commitments made by CSC in response to the Coroner’s Inquest Touching the Death of Ashley Smith, and these training activities are provided to staff;
  • Management is monitoring the provision of training and compliance rates are presented and discussed at the Learning and Development Governance Committee;
  • National tools and resources to support management and staff in dealing with situations have been developed and made available to staff;
  • Institutions have developed various tools and resources to support management and staff in dealing with situations, such as checklists to guide use of force reviews, cue cards with procedures for the use of handheld video cameras, and reference documents outlining staff reporting requirements for use of force incidents; and
  • Staff indicated that the new decision-based training approach is a large improvement and supports them in knowing how to better respond to situations.

As described below, there are two areas related to training, tools, and resources that require further consideration by management.

Guidance material is not in place for the use of force reviews.

Use of force review (review) is a key oversight activity and the primary means by which management ensures that staff using force to respond to a situation are doing so in compliance with law and policy. We found that there is no guidance material in place for completing these reviews (refer to 3.2.3 for more detail).

The lack of guidance material can impede the organization’s ability to ensure that reviews are completed effectively, with a consistent focus across the country, and ultimately that the reviews are achieving their intended purpose and improving responses to help ensure that only necessary and proportionate force is being used.

Training on the use of force module is not consistently provided to staff.

We found that while OMS training has been developed for the module, it is not being consistently provided to staff (refer to 3.2.4 for more detail). This lack of training has led to inconsistent and incomplete use of the module, which in turn limits management’s ability to monitor and report on the appropriateness of responses to situations, and follow-up on corrective actions to ensure that CSC staff learn from these reports.

3.1.3 Monitoring and Reporting

We expected to find that performance monitoring and reporting processes are in place to allow for informed decision making.

The following area met the audit expectations for this criterion:

  • Use of force incidents are documented in OMS.

As described below, there are multiple areas related to monitoring and reporting that warrant further consideration by management.

Performance monitoring and reporting is insufficient at the local, regional, and national levels.

Management at all levels, which includes correctional operations and health services, have not established key performance indicators for how CSC measures the appropriate implementation of situation management practices, which could be used to guide monitoring and reporting activities. As a result, performance reporting for both security and health services was inconsistent across all regions, varied in terms of information being reported, and was completed on an ad-hoc and infrequent basis.

Management at all levels indicated that the primary means of monitoring the management of situations is through the reviews (refer to 3.2.3). During these reviews, information related to the incident, staff intervention, medical assessments, as well as noted policy non-compliance is entered into the use of force module within OMS. Although this information is collected, management indicated that the limited reporting capabilities from the module impede their ability to conduct fulsome analysis. For example, management at all levels indicated that they feel staff are not properly assessing and re-assessing situations to inform and adjust their response options; however, we found an absence of data and formal analysis to support this assertion.

To compensate for the lack of reporting capability, three of the five regions maintained spreadsheets to track use of force incidents in addition to documenting information in the use of force module. However, the information maintained on these spreadsheets varied in terms of format and frequency, generally did not include details of policy non-compliance (i.e. deployment of handheld video camera, proper completion of medical assessments, quality and timeliness of staff reporting, etc.), and was not regularly analyzed to identify trends or areas for improvement. Further, the need to maintain spreadsheets outside of the use of force module duplicates work, creates inefficiencies within the review process, and increases the risk of error during data entry.

COPS at NHQ completed an ad-hoc review of all use of force incidents that occurred between April 1, 2015 and December 31, 2016. This review included analysis of various aspects of use of force and a report has been created which identifies areas for improvement and includes recommendations to address these issues. Aside from this review, there is no regular performance monitoring and reporting being completed at the national level by either COPS or HSS.

The lack of performance monitoring and reporting limits CSC’s ability to adequately assess the efficiency and effectiveness of relevant security and health services policies and procedures, including how situations are managed, and whether we learn over time or if systemic issues remain. This in turn increases the risk that management may not have adequate information to properly inform decisions to adjust its expectations and associated policies and procedures if and when required.

Conclusion - Objective 1

With respect to the first objective, we found that CD 567 Management of Security Incidents, and CD 567-1 Use of Force are consistent with legislation, up-to-date and reflect current practices; roles and responsibilities are generally defined, documented, communicated and understood; national training activities have been developed and provided to staff, and compliance with NTS activities are monitored by management; and use of force incidents are documented in OMS.

There are a number of areas where CSC could improve in relation to the management framework, including:

  • Clarifying who is in charge of controlling a response to a security incident;
  • Providing guidance material for use of force reviews;
  • Providing training on the use of force module in OMS to staff; and
  • Monitoring and reporting on performance at the local, regional and national levels.
Recommendation 1

The Assistant Commissioner, Correctional Operations and Programs should:

  • Revise CD 567 to clearly articulate responsibility for controlling staff response to a security incident; and
  • Develop tools and resources to guide and focus the use of force review process, including the nature and monitoring of corrective action required for different types of non-compliance.
Management Response

The policy is nearing promulgation, and work is underway in the drafting of a reviewer guide. There is also a national implementation plan for training to ensure all staff understand the new Engagement and Intervention Model (EIM), and other key components like the role of the Sector Coordinator for on-scene leadership.

Recommendation 2

The Assistant Commissioner, Correctional Operations and Programs, the Deputy Commissioner for Women, and the Regional Deputy Commissioners should establish mechanisms to help ensure that individuals completing use of force reviews are taking training on the use of force module.

Management Response

National

The completion of the OMS training on use of force will ensure each party understands the tool in which the review is completed. More importantly, the reviewer guide that is also being developed will assist reviewers in understanding the framework for incident analysis.

Regional

We fully agree with this recommendation. By March 31, 2018, the RDC will conduct an audit to ensure all users have been properly trained on the module.

Recommendation 3

The Assistant Commissioner, Correctional Operations and Programs and the Assistant Commissioner, Health Services should establish and implement a monitoring and reporting plan for the management of situations that includes developing key performance indicators and information monitoring and reporting requirements.

Management Response

Work is underway with Performance Measurement and Management Reports (PMMR) to develop key performance indicators related to use of force interventions. The indicators will include both security and health related measures. This information will likely reside in the Corporate Reporting System, and will allow all stakeholders to have easy access to relevant information for track trends. This information will be used to support ongoing dialogue between the national and regional headquarters on review of trends and required areas of improvements.

In terms of tracking the status of each reviews for compliance with policy, a tool is being developed that will act as a bring forward (BF) system.

3.2 Implementation of the Situation Management Framework

The second objective for this audit was to provide assurance that key activities supporting the situation management framework have been implemented effectively.

Implementation of the situation management framework was examined from four perspectives: Intelligence information, medical assessment and treatment, use of force reviews, and corrective action. Annex D provides general results for all audit criteria.

3.2.1 Intelligence Information

We expected to find that intelligence information is used to support and assist with the management of situations.

The following areas met the audit expectations for this criterion:

  • Institutions have processes in place to share intelligence information with staff;
  • Inmate physical and mental health information was taken into consideration when developing plans to respond to security incidents in 87% (40/46) of the files reviewed; and
  • Intelligence information is used to prevent and respond to security incidents.

As described below, there is one area related to intelligence information that warrants further consideration by management.

Intervention plans are not always documented as required.

As required by CD 567-1 Use of Force, any planned use of force using line staff must be documented in an SOR and authorized by the Institutional Head or his/her delegate. These plans are designed to outline the strategy to be implemented in response to an incident, and may be developed and communicated simultaneously as the incident unfolds. We found that 24% (4/17) of the planned use of force incidents utilizing line staff that we sampled had a documented intervention plan in place. However, of the files where a plan was not properly documented in writing, it was found that 39% (5/13) of them had a strategy that was developed and captured on video prior to the start of the intervention, thus demonstrating that some form of plan had been established in advance. Interviews with front line staff indicated that they feel it is not always clear when a use of force incident is planned versus spontaneous, which can lead to intervention plans not being documented as required by policy.

When an intervention plan is not documented, there is increased risk that the organization will not be able to demonstrate that a strategy for a planned use of force was appropriately authorized to help ensure the necessary and proportionate response.

3.2.2 Medical Assessment and Treatment

We expected to find that medical assessments and treatment are provided in compliance with legislation and CSC guidance.

The following areas met the audit expectations for this criterion:

  • Post use of force physical assessments were completed by a health care professional in a timely manner in 94% (127/135) of the files reviewed;
  • Post use of force physical assessments were completed by a health care professional with an unobstructed view of the inmate in 95% (121/127) of the files reviewed; and
  • When issues were identified through a first aid assessment completed by a staff member certified in first aid and CPR, or a physical assessment completed by a health care professional, treatment was provided to the inmate(s) in 91% (20/22) of the files reviewed.

As described below, there is one area related to medical assessment and treatment that warrants further consideration by management.

First aid and physical assessments are not always completed following a use of force incident.

CD 567-1 Use of Force requires that "a post use of force physical assessment will be offered by a health care professional, normally at the inmate’s final cell destination, with restraint equipment removed." Further, "in the absence of a health care professional on shift […] a staff member currently certified in first aid and CPR will offer an initial post use of force first aid assessment […] to determine if immediate attention is required." These assessments are to be offered to all inmates involved in a use of force incident.

We reviewed a sample of use of force incidents to determine if post use of force physical and first aid assessments were completed as required. Twenty four percent (42/172) of these incidents occurred in the evening when health care staff was not on shift. We found that first aid assessments were not completed for 50% (21/42) of these incidents. Interviews with front line staff indicated that at times there is a lack of communication following the incident to ensure that a first aid assessment is completed by a staff member currently certified in first aid and CPR as required.

When a health care professional was on site during a use of force incident, we found that physical assessments were offered to inmates and subsequently completed in 90% (135/150) of the files reviewed. Interviews with staff at institutions revealed that various methods for security staff to communicate the need to complete an assessment to health services staff were in place; however, formal processes are generally not in place, and thus the method of communication varied depending on the institution and the correctional manager responsible for communicating this need. For example, some correctional managers will send emails to the chief of health care, while others may call or meet in person the following day. The lack of formal processes has at times led to a breakdown in communication and subsequently, physical assessments not being completed.

3.2.3 Use of Force Reviews

We expected to find that use of force reviews are completed in compliance with CSC guidance.

The following area met the audit expectations for this criterion:

  • Use of force reviews were either in progress or completed by management at institutions for all use of force incidents that we assessed.

As described below, there are two areas related to use of force reviews that warrant further consideration by management.

Use of force reviews are not completed within the required timeframes at the local, regional, and national levels.

A review is to be completed for all use of force incidents to assess compliance with law and policy, including whether or not the use of force was necessary and proportionate. The review is comprised of various stages (local, regional, and national), and includes an assessment of both the use of force response, and the post use of force physical assessment. Depending on the type of force used (i.e. physical handling, use of weapons) incidents are assigned a level (1, 2, or 3) which dictates the number of required stages and the associated timeframes for completing the reviews. The requirements for completing reviews, the various levels of review, and associated timeframes are outlined in CD 567-1 Use of Force (refer to Annex B for details of the review process).

We conducted an analysis of the completion dates of reviews (as captured in the module) for all use of force incidents that occurred between April 1, 2015 and March 10, 2017 to determine if they were completed within the required timeframes at each stage of review. In total, there was 2,841 use of force incidents reported in OMS during this period. The following tables outline the level of compliance with review timeframes at the institutional, regional, and national levels.

Table 1: RHQ and Institutional Compliance with Review TimeframesFootnote 12
Review Completed By Region
Atlantic Quebec Ontario Prairie Pacific National Total
Institution 10%
(31/319)
12%
(74/607)
25%
(144/567)
43%
(424/984)
35%
(128/364)
28%
(801/2841)
RHQ 36%
(51/142)
45%
(105/235)
49%
(148/303)
33%
(156/471)
46%
(46/101)
40%
(506/1252)
Table 2: NHQ Compliance with Review TimeframesFootnote 13
Review Completed By National Total
NHQ Correctional Operations and Programs Sector 81%
(302/372)
NHQ Women Offender Sector 58%
(54/93)

It should be noted that when a review is completed and signed off (locked) in OMS, the system automatically assigns a completion date. When a completed review is subsequently unlocked and relocked a new completion date is assigned which replaces the original one. The result is that the actual completion date of the review may not be accurately reflected in OMS, which ultimately may have a negative impact on the compliance rates presented in table 1 and table 2 above.

During interviews with staff, we were informed of various issues that lead to delays in completing reviews, but the most significant were the volume of reviews that need to be completed, resourcing issues including key positions not being backfilled when the incumbent is on leave, and quality and timeliness of staff reporting through an SOR. While management at all levels indicated that they feel they are made aware of serious violations of policy in a timely manner, the delays in completing reviews can weaken oversight of use of force incidents, and increase the risk that compliance issues including inappropriate responses are not identified and addressed in a timely manner.

The focus of use of force reviews is not consistent across the country.

As indicated above, reviews are completed to assess compliance with law and policy, including whether or not the use of force was necessary and proportionate. Interviews with staff and managers revealed that there is a lack of clarity around what should be considered when completing a review. For example, management at all levels indicated that they feel staff are not properly assessing and re-assessing situations to inform and adjust their response options accordingly; however, we found that this was generally not reflected in the reviews, as only 3% (5/167) of the files we reviewed highlighted this as an area of non-compliance. Further, while staff completing reviews indicated that their primary focus was to ensure that the amount of force used was necessary and proportionate to the situation, we found that the specific policy requirements being considered varied across the country, and in some circumstances included requirements that were not related to use of force. For example, one region included non-compliance with dress and deportment requirements. Ultimately, the results of the reviews seem to indicate that more focus is placed on assessing compliance with policy and procedures (i.e. proper use of handheld video camera) rather than a fulsome and critical analysis of the use of force response.

Individuals completing reviews indicated that they are not provided with any training or guidance material, which has led to some uncertainty as to what the focus of the review should be. This lack of guidance increases the risk of inconsistency in the focus of the reviews, creates inefficiencies throughout the review process, and ultimately impedes management’s ability to effectively monitor how well CSC manages use of force incidents overall.

3.2.4 Corrective Action

We expected to find that mechanisms are in place to resolve non-compliance with the various policies supporting the management of situations.

The following areas met the audit expectations for this criterion:

  • Compliance issues are documented in the module; and
  • Corrective actions for compliance issues are identified.

As described below, there are two areas related to corrective action that warrant further consideration by management.

Corrective action is not always taken as required, nor is it effective.

As indicated above, reviews are meant to be completed to ensure compliance with law and policy, which ultimately means to ensure that the force used was necessary and proportionate to the situation. When non-compliance is identified, these issues are documented in the module, along with required corrective actions. We found that 77% (129/167) of the files reviewed included some form of policy non-compliance, and of these, 96% (124/129) outlined corrective action to be taken. The majority of the non-compliance related to issues associated with the quality and timeliness of staff reporting through SORs, deployment and use of handheld video cameras, and reviews not being completed on time.

The corrective action that was taken for these issues was generally limited to management sending emails to the staff member(s) involved, or providing an in-person reminder of policy requirements. Further, we found that this same type of corrective action was utilized regardless of the significance of the policy non-compliance; for example, issues with first aid assessments not being completed were dealt with the same way as staff not stating their name and date prior to turning off the handheld video camera. Management indicated that while corrective action is taken, it is not very effective in improving compliance or changing behaviours and responses, which was evident during our file review as we found that the same issues of non-compliance kept re-occurring over time. Moreover, as per the "Hierarchy of Effectiveness Theory", ‘education and information’ is identified as the least effective type of corrective action. CSC’s Incident Investigations Branch has determined that this was typically the action taken to address issues around documentation that were identified through incident investigations.

At the institutional level, we were informed by staff and management that the individual who completed the review was typically responsible for taking corrective action and that this action is usually taken prior to the review being finalized. We found evidence in the module stating that corrective action was taken in 91% (113/124) of the files reviewed, which included attestations from management that staff had received verbal reminders and copies of emails sent to staff.

In 5% (9/167) of the files, the reviews identified that the force used was not necessary and proportionate to the situation. These issues varied from a lack of proper and ongoing assessment of the situation to determine the appropriate response, to disproportionate force being used. We found that corrective action was either not identified or taken for two of the nine files, which demonstrated a lack of accountability for critical and potentially criminal non-compliance with legislation and policy requirements.

Management at the local level indicated that they try to take corrective action that is geared towards educating staff rather than disciplining them. However, we found that this action does not appear to escalate to disciplinary action if the same issues persist, and is generally not integrated with the specific employee Performance Management Program as part of an action plan. Further, management at all levels indicated that the nature of corrective action to be taken for various degrees of non-compliance has not been formally defined. Ultimately, the lack of effective corrective action has led to many of the same issues of policy non-compliance occurring over and over again.

Compliance issues and corrective action information are inconsistently documented in the use of force module.

As indicated above, when compliance issues are identified during the reviews, they are documented in the module in OMS. The module includes text boxes to enable reviewers to input their review comments, including identified policy non-compliance, for each of the various stages of the process. Further, the module also has an "actions tab" where reviewers at the regional and national level should document the corrective action required and management at the local level would indicate the corrective action taken. During audit testing we found that compliance issues as well as corrective action were documented in an inconsistent manner within the module.

While training on the module has been developed at NHQ, individuals completing the reviews generally indicated that they are not receiving this training, which has ultimately led to its inconsistent use. When information around compliance issues and corrective action is not documented in a consistent manner within the module, it can lead to inefficiencies and further impede management’s ability to monitor trends and determine if corrective action taken is leading to improvements in performance.

Conclusion - Objective 2

With respect to the second objective, we found that intelligence information is shared, considered, and used to support and assist with the management of situations; when physical assessments are completed they are generally done so in a timely manner, with an unobstructed view of the inmate, and when issues are identified treatment is provided to inmates; use of force reviews are completed; and policy non-compliance and associated corrective action is generally identified and documented in the module.

There are a number of areas where CSC could improve in relation to the management of situations. These include:

  • Intervention plans are not always documented as required by policy;
  • Post use of force first aid and physical assessments are not always completed;
  • Use of force reviews are not being completed within the required timeframes;
  • The focus of use of force reviews is inconsistent;
  • Corrective action is not always taken nor effective; and
  • Compliance issues and corrective action are not consistently documented within the module.
Recommendation 4

The Regional Deputy Commissioners should direct the institutional heads in their regions to establish formal processes to help ensure that:

  • In the absence of a health care professional on shift, first aid assessments are completed by a staff member, currently certified in first aid and CPR, following a use of force;
  • The need to complete a post use of force physical assessment is effectively communicated to health services staff; and
  • Intervention plans are documented as required by policy.
Management Response

We agree with this recommendation. By March 31, 2018, the RDC to clarify procedures and responsibilities related to use of force incidents.

Recommendation 5

The Assistant Commissioner, Correctional Operations and Programs, and the Assistant Commissioner, Health Services should complete an analysis of the use of force review process to strengthen the reviews, and determine what should be assessed when completing a review to assist local management in taking meaningful and effective corrective action.

Management Response

It has been observed that there needs to be a consistent understanding key element of the legal framework, like "necessary and proportionate", and how this applies to use of force interventions using the SMM or the new EIM as a guide to interventions. Policy and training have now become more focused on assessing situational factors and associated risk level, which is expected to result in better articulation of risk factors and the need to align mitigation measure through appropriate selection of intervention strategies. Similarly, the reviewer guide for use of force will allow management to effectively analyze incidents with a more consistent focus of key elements. This guide will also provide some guidance on managing change through corrective measures, which will also lend to better consistency in this process.

4.0 Conclusion

For the first objective, we found that a framework is generally in place to support situation management. However, the following areas require further consideration by management in order to help ensure that the management framework fully supports the effective implementation of situation management at CSC:

  • Clarifying who is in charge of controlling a response to a security incident;
  • Providing guidance material for use of force reviews;
  • Providing training on the use of force module in OMS to staff; and
  • Monitoring and reporting on performance at the local, regional and national levels.

With respect to the second objective, we found that key activities including the sharing and consideration of intelligence information, completion of medical assessments and provision of treatment, completion of use of force reviews, and implementation of corrective action are in place and support the effective management of situations. However, the following areas require further consideration by management in order to help ensure that key activities supporting the management of situations are implemented effectively:

  • Ensuring that intervention plans are documented as required by policy;
  • Ensuring that post use of force first aid and physical assessments are completed;
  • Ensuring that use of force reviews are completed within the required timeframes;
  • Clarifying the focus and intent of use of force reviews;
  • Ensuring that corrective actions taken are effective; and
  • Ensuring that compliance issues and corrective action are consistently documented within the module.

Recommendations have been issued in the report based on areas where improvements are required.

5.0 Management Response

Management is in agreement with the audit findings and recommendations as presented in the audit report. Management has prepared a detailed Management Action Plan to address the issues raised in the audit and associated recommendations. The Management Action Plan is scheduled for full implementation by October 31, 2018.

6.0 About the Audit

6.1 Approach and Methodology

Audit evidence was gathered through a number of methods:

Interviews
Interviews were conducted with some senior management and staff at NHQ, RHQ, and the local levels. Interviews took place in person, by teleconference, and by videoconference.
Review of Documentation
Documentation that was reviewed included: applicable legislation, CSC policy instruments, corporate documents such as guidelines, work descriptions, tools, training manuals, institutional and staff reports, intervention plans, e-mails, inmate health care records, and institutional briefing materials.
File Review
A sample of use of force incidents was selected and associated documentation and video footage was reviewed in relation to the criteria on intelligence information, medical intervention, use of force reviews, and corrective action.
Observation
Observations of operational morning meetings and shift briefings were completed at the majority of sites visited during the conduct phase to determine the type of intelligence information being shared and discussed with staff.
Analytical Review
Analytical review was completed in relation to the criteria on guidance framework, training, tools and resources, use of force reviews, and corrective action.
Sampling Strategy
A non-statistical sample of 172 use of force incidents were selected for testing to ensure adequate coverage of:
  • Planned and spontaneous use of force;
  • Incidents involving both the emergency response team and line staff;
  • Incident type (i.e. inmate fight, self injurious behaviour, provision of medical treatment, etc.); and
  • Incidents that occurred at men’s medium and maximum security institutions, women’s institutions, and regional treatment centers.
The population was stratified by planned versus spontaneous use of force, then by the type of incident. Random samples were then selected from the stratified populations for each institution included in the audit.

6.2 Past Audits, Internal Reviews, and External Reviews

Internal Audits

Specific engagements that were used in planning the work for this audit include:

Audit of the Management of Security Incidents

The audit found that:

  • Monitoring and reporting of security incidents was not occurring in all situations;
  • Log books contained records of security incidents which were never formally reported; and
  • Trend analysis was not being completed to try and predict, or alleviate potential security incidents before they occurred.

Areas where significant testing was completed for the Audit of the Management of Security Incidents were scoped out of this current audit. The following actions were taken by management to address the recommendations from the audit:

  • COPS created a monitoring report that was distributed to regions for review and input;
  • Developed a template for shift briefings that was distributed to all regions;
  • Issued a security bulletin to all regions addressing observation reports and log books;
  • Received attestations from all regions that sites were utilizing log books as required by policy;
  • Took measures to ensure that OMS and Reports of Automated Data Applied to Reintegration (RADAR) accounts were created for all Correctional Officers-ll (CO-ll);
  • Revised and promulgated CD 570;
  • NHQ Security Branch received attestations that sites have updated local policy and practices pursuant to CD 570;
  • A new national equipment inventory system was implemented in February 2014 requiring sites to migrate equipment information to the new tool, this was subsequently completed by all sites; and
  • Revised and promulgated CD 568-1.

Internal Reviews

Use of Force Review

The Security Branch conducted a review of use of force incidents that occurred between April 1, 2015 and December 31, 2016. The review was completed in April 2017; however, the final report is still in draft form. The report will provide the results of analysis around various metrics (i.e. rates of use of force incidents per region, age of inmates involved in incidents, location of incidents, types of incidents, use of force types, etc.).

The audit team reviewed the draft report to identify how the results of the review will be used to inform decisions around policy and procedures related to the management of situations.

Board of Investigation Into the Incident Involving an Inmate at Dorchester Penitentiary on May 26, 2015, and his Subsequent Death at Outside Hospital on May 27, 2015

The Board of Investigation into the death of Matthew Hines was reviewed as part of the planning phase of this current audit. Many issues were noted, including the health care assessment and health care involvement, the type of force applied and how it was applied, the lack of reassessment based on the situational factors, and a lack of managerial oversight.

External Reviews

Annual Report of the Office of the Correctional Investigator (2015-2016)

The 2015-2016 Annual Report of the Office of the Correctional Investigator examined the use of force within CSC, as well as the SMM. The report found that:

  • There is a trend in the reliance on and the significant escalation in the number of use of force incidents involving inflammatory agents; and
  • More than half of the post use of force health care assessments reviewed included deficiencies.

The audit team considered the results of actions taken by CSC to address recommendations during the planning phase of the current audit.

Coroner’s Inquest Touching the Death of Ashley Smith

The Coroner’s Inquest Touching the Death of Ashley Smith made a number of recommendations related to the SMM. CSC subsequently responded to the recommendations by making a multitude of commitments. To provide assurance that those commitments are being met, the CSC Internal Audit group conducted an auditability assessment of the CSC commitments and ranked them based on their risk. The following recommendations directly relate to the SMM and were considered in the planning of the current audit.Footnote 14

Recommendation 50: CSC develops a new, separate and distinct model, from the existing SMM, to address medical emergencies and incidents of self-injurious behaviour.

Recommendation 51: That the SMM not be resorted to in any perceived medical emergency.

Recommendation 52: That, when reporting a Use of Force intervention to preserve the life of an inmate who has self-harmed an expedited reporting system will apply. Further, all such incidents should be reviewed, within 48 hours, by:

  1. The Warden;
  2. The Chief of Health Care;
  3. The Chief Psychologist;
  4. Women Offender Sector (for female inmates);
  5. Office of the Correctional Investigator;
  6. RHQ - Members of the Regional Complex Mental Health Committee; and
  7. NHQ - Members of the National Complex Mental Health Committee.

The review will focus on the mental health needs of the inmate, their behaviour and its lethality, as well as the response of frontline staff, including its appropriateness. It will assist and support the well-being of the inmate, in addition to the efforts of the institution and frontline staff. It will also include strategies to manage the inmate in a safe manner, and encourage staff to exercise good judgment.

Recommendation 55: That, to reduce institutional or criminal charges laid against an inmate, CSC adopts the methods of the St. Lawrence Valley Correctional and Treatment Centre model of care for disruptive or self-injurious behaviours symptomatic of a mental health disorder.

The following commitments were made by CSC in response to the recommendations:Footnote 15

"Correctional Operations and Programs Sector, in collaboration with Health Services and the Canadian Association of Chiefs of Police, will revisit the application of the SMM to medical emergencies, incidents of self-injurious behaviour, and offenders with mental health disorders in order to ensure its continued suitability."

"In June 2014, an updated Use of Force Review module was added to the Offender Management System for use at five institutions across Canada, and by those responsible for Use of Force review at the regional level. The changes to the module resulted from an Executive Committee (EXCOM) decision and aim to increase efficiencies for the review of use of force incidents. These changes created a streamlined, triage process, including a clear explanation for review and decision-making. The module is to provide a more user-friendly structure to allow users to capture and distribute use of force related information for timely review, when required. The revised OMS modules are to be rolled out nationally in tandem with the updated Commissioner's Directive 567-1: Use of Force."

6.3 Statement of Conformance

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with management. The opinion is applicable only to the area examined.

The audit conforms to the Internal Auditing Standards for Government of Canada, as supported by the results of the quality assurance and improvement program. The evidence gathered was sufficient to provide senior management with proof of the opinion derived from the internal audit.

Sylvie Soucy, CIA

Chief Audit Executive

Glossary

CAPRA problem-solving model:
A model that facilitates the acquisition and analysis of client and situational information, and the consideration, through partners, of response strategies.
Dynamic security:
Regular and consistent interaction with inmates and timely analysis of information and sharing through observations and communication (e.g. rapport building, training, networking, intelligence gathering and strategic analysis). Dynamic security is the action that contributes to the development of professional, positive relationships between staff and inmates, and is a key tool to assess an inmate’s adjustment and stability.
Health care professional:
An individual registered or licensed for autonomous practice in the province of practice. Individuals must operate within their scope of practice and competence. Examples include Psychologists, Psychiatrists, Physicians, Mental Health Nurses, and Clinical Social Workers.
Intervention plan:
An intervention strategy designed to respond to an incident when time and/or circumstances allow line staff the opportunity to formulate their response. This plan may be developed and communicated simultaneously as an incident unfolds, and the plan must be documented by the appropriate staff in a Statement/Observation Report, and when time and circumstances permit, captured on a video-recording.
Planned use of force:
The authorized deployment of line staff through an Intervention Plan or deployment of the Emergency Response Team through a SMEAC (Situation, Mission, Execution, Administration and Communication).
Situation management model:
A model/graphic representation used to assist staff in determining the correct response options to be used in managing security situations.
Spontaneous use of force:
An immediate intervention by staff to an incident in which at least one use of force measure, consistent with the Situation Management Model, is required to bring a safe resolution to the situation.
Use of force:
Any action by staff, on or off of institutional property, that is intended to obtain the cooperation and gain control of an inmate, by using one or more of the following measures: non-routine use of restraint equipment; physical handling/control; a chemical or inflammatory agent is intentionally aimed at an individual or dispensed to gain compliance; use of batons or other intermediary weapons; display and/or use of firearms; and any direct intervention by the Emergency Response Team with an inmate.

Annex A: CSC Intervention Models

Situation Management Model

Effective January 2000 to January 2018.

Situation Management Model

Situation Management Model

The situation management model is circular which demonstrates its flexibility. The model may be read like a clock, starting at noon and going clockwise.

The innermost circle represents your assessment of the situation. Each situation is assessed in terms of the CAPRA problem-solving model.

The acronym stands for:

  • client
  • acquiring and analyzing
  • partnership
  • response
  • assessment

The model facilitates the acquisition and analysis of client and situational information, and the considerations, through partners, of response strategies, continual assessment of the effectiveness of the response is an integral aspect of the CAPRA process.

A band of potential inmate behaviours surrounds this circle. The behaviours range from least to most resistive. Starting at noon on the dial they are:

  • cooperative (noon to three o'clock)
  • verbally resistive (three to five o'clock)
  • physically uncooperative (five to seven o'clock)
  • assaultive (seven to nine o'clock)
  • grievous bodily harm and death (nine to twelve o'clock)
  • escape (nine to twelve o'clock)

A ring representing the management strategies available surrounds this band. These strategies are communication, negotiated resolution, controlled non-intervention and/or tactical intervention. This ring is also a visual reminder to isolate and contain when possible.

A band of response options surrounds this ring. Response options are divided into four categories, each with an increasing degree of force. Travelling around the dial, they are:

Component one - requires no use of force, is appropriate for all behaviours and runs from noon around the dial

  • dynamic security
  • staff presence
  • verbal intervention
  • conflict resolution
  • negotiation
  • verbal orders

Component two - introduces use of force and runs from two to twelve o'clock

  • restraint equipment
  • inflammatory agents
  • chemical agents
  • physical handling

Component three - introduces physical weapons and runs from six to twelve o'clock

  • batons
  • other intermediary weapons
  • firearms

The outermost ring of the circle represents responses that you must continually perform throughout the situation:

  • reassess response options
  • reassess situation
  • debrief and report

Each behaviour on the clock corresponds with its appropriate response options.

For example, if the inmate is cooperative, the appropriate response is from component one: dynamic security, staff presence and verbal intervention.

When inmate behavior is verbally resistive, component one responses still apply. However, they may be used in conjunction with appropriate responses from component two.

When the inmate becomes physically uncooperative, the appropriate component one responses continue to apply. You may now also use the corresponding appropriate options from components two or three. These include inflammatory or chemical agents and batons or other intermediary weapons.

Finally, when inmate behavior includes grievous bodily harm, death or escape, the previous actions continue to apply. The option to use component four, firearms, is now also considered.


Engagement and Intervention Model

Effective January 2018 to current.

Engagement and Intervention Model

Engagement and Intervention Model:

a risk-based, person-centred, graphic representation used to assist staff with activating engagement and intervention strategies.

Description of Engagement and Intervention Model Components

Assess Situation Self-Awareness & Perception

Identify Threat/Risk/Problem/Health Status

  • Level of Compliance and Associated Actions
    • Cooperative
    • Verbal resistance
    • Passive resistance
    • Active resistance
    • Assaultive
    • Grievous bodily harm or death
    • Escaping
  • Altered Level of Consciousness/Cues of Distress
  • Appearance
    • Dishevelled - in part or change from normal
    • Blank stare/daze look
    • Red face/pale complexion
    • Signs of blood or trauma
  • Speech
    • Slurred speech
    • Unusually fast/slow speech
    • Delayed response to questions/directions
    • Repetitive/non-sensible statements
    • Speaking incoherently
  • Behaviour
    • Swaying/staggering/unable to sit straight
    • Overly animated/crying
    • Drowsiness/disoriented/unresponsive
    • Excessive perspiration
  • Other Situational Factors
    • Available staff
    • Level of containment
    • Self-injurious or suicidal behaviour (or history of)
    • Offender’s mental state and ability to comprehend direction
    • Offender’s institutional behavior
    • Offender’s characteristics
    • Location
    • Presence of weapons
    • Number of offenders
  • OMS - Flags, alerts, needs
  • OSCAR
  • Staff’s role is essentially defensive (not aggressive or passive)
  • An incident is an emotional and physical event
  • Self control is key - mind and body are one
  • Indicators of hostility, fear and/or aggression:
    • Kinesics (body language)
    • Proxemics (body space)
    • Paraverbal communication (pitch, tone, volume)
Engagement & Intervention Strategies
  • Dynamic security and staff presence
  • Communication
  • Isolate, contain and control
  • Controlled non-intervention
  • First aid/health assessment
  • Health care intervention
  • Tactical intervention and manoeuvring
  • Interdisciplinary team and any person who has a good rapport with the offender
Response to Cues of Distress
  • Treat all persons who present with Cues of Distress as a medical emergency and call for medical assistance; either institutional Health Services or 9-1-1
  • Stay calm and help the person remain calm
  • Try to keep the person conscious, ask them questions to encourage them to keep talking, ask the person to keep their eyes open
  • Monitor, assess and stay with the person until help arrives
  • Do not ignore the person’s complaints or calls for help even if the signs and symptoms are not obvious

Reassess
  • Reassess interventions
  • Reassess situational factors
  • Reassess the person
  • Has the level of risk changed?
Risk Evaluation Debrief, Report & Quality Improvement
  • AIM
    • Ability: physical and mental capacity and opportunity to carry out a threat
    • Intent: shows intent to behave or act in a specific manner (verbal/non-verbal)
    • Means: has the means to carry out specific action or behaviour associated with the threat
  • Need for immediate response?
  • Reasonable perception
  • Risk - low, moderate, high
    • Low: no imminent harm
    • Moderate: potential for harm
    • High: imminent severe harm
  • Debrief Process
    • Assessment/Intervention/Debrief (AID)
    • Why now
    • Legal, moral, ethical
    • Necessary and proportionate
  • Report Writing
    • Most appropriate report(s)
    • Clear, concise, accurate
    • Articulate decisions made

Annex B: Use of Force Review Process and Matrix

Review ProcessFootnote 16

"43. Within two working days of the completion of the incident report in OMSR, the Institutional Head will ensure that a preliminary review of any incident involving the use of force is completed in order to identify any serious concern or deficiency. This review will be completed by a Correctional Manager or above.

44. There are three types of review processes dependent on the type of intervention. The requirements for review and the sample size (if applicable) are identified in Annex B.

45. A Level 1 Use of Force - Compressed Review is a condensed analysis and assessment of incident-related documentation and video-recordings (where applicable) finalised by the Assistant Warden, Operations, at the institutional level to ensure compliance with law and policy. This involves a use of force situation where physical handling (no allegation of excessive use of force or injury), control of offender, inflammatory agents and/or chemical agents intentionally aimed at an individual, displaying/pointing or charging of a firearm, or the non-routine application of handcuffs were sufficient to resolve the situation. The Institutional Head will ensure that all level 1 use of force reviews will be completed within 20 working days of the incident.

46. A Level 2 Use of Force - Full Review is an analysis and assessment of all incident-related documentation and video-recordings (where applicable) finalised by the Deputy Warden to ensure compliance with law and policy. This involves any other use of force situation where force is used to resolve the incident not covered in level 1. The Institutional Head will ensure that all level 2 use of force reviews will be completed within 20 working days of the incident. The Assistant Deputy Commissioner, Integrated Services, will conduct regional level 2 reviews within 25 working days upon notification of the use of force completion at the institutional level. The Director General, Security will identify for the Security Branch, the use of force incidents requiring a full review as outlined in Annex B. The Women Offender Sector will review 100% of the use of force incidents that occur at women sites. National level 2 reviews will be completed within 30 working days upon notification of the use of force completion at the regional level.

47. A Level 3 Use of Force - Expedited Review requires immediate review of a use of force, finalised by the Assistant Deputy Commissioner, Integrated Services, and the Director General, Security. This involves a situation where there may be serious violations of policy. Where the preliminary review indicates possible serious violations of policy, or any other aspects that may cause serious concerns, the Institutional Head will inform, without delay and in writing, the Assistant Deputy Commissioner, Integrated Services, the Director General, Security, and when applicable the Deputy Commissioner for Women, the Assistant Commissioner, Health Services, and the Director General, Aboriginal Initiatives. The Institutional Head will provide a description of the incident and a summary of any concerns.

48. In these cases, the Director General, Security, in consultation with the Assistant Deputy Commissioner, Integrated Services, will decide if an expedited review is necessary, and if so, will notify Regional Headquarters, the Institutional Head, the Office of the Correctional Investigator, and the Director General, Incident Investigations. In such cases, the Institutional Head will ensure that the use of force documentation, including video footage, is made available in OMSR without delay, but no later than two working days from the creation of the incident report, and that the review be completed within five working days upon receipt of the notification from the Director General, Security. The Assistant Deputy Commissioner, Integrated Services, will finalize the review within five working days of receiving notification of use of force completion at the institution. The Director General, Security, will finalize the review within five working days upon receipt of notification of use of force completion at the regional level."

Use of Force Review MatrixFootnote 17
Level of Review CM Responsibility Authority to Finalize Review Percentage to be Reviewed
Preliminary Review First Level Assessment AWO DW IH Inst. RHQ NHQ
Level 1 R R R O O 100% 0 0
Level 2 R R X R O 100% 25% 5%
Level 3 R R X X R 100% 100% 100%
Current Risk of Suicide/Self-Injury - Alerts in OMSR or designated mental health beds in Treatment Centres and/or mainstream institutions or self-injurious or administration of medical treatment Authority to Finalize Review will be determined according to level (1, 2, 3) of use of force incident. 100% 100% 20%*

* If an Emergency Response Team intervention is required due to self-injurious behaviours, 100% of those incidents shall be reviewed at the national level.

R = Required

O = Optional

X = Not applicable

Annex C: CSC Directives and Guidelines

The following CDs and GLs include requirements and processes that are related or applicable to the management of situations.

  • CD 253 Employee Assistance Program
  • GL 253-2 Critical Incident Stress Management
  • CD 560 Dynamic Security and Supervision
  • CD 567 Management of Security Incidents
  • CD 567-1 Use of Force
  • CD 567-2 Use of and Responding to Alarms
  • CD 567-3 Use of Restraint Equipment for Security Purposes
  • CD 567-4 Use of Chemical and Inflammatory Agents
  • CD 567-5 Use of Firearms
  • CD 568-1 Recording and Reporting of Security Incidents
  • CD 600 Management of Emergencies
  • CD 702 Aboriginal Offenders
  • CD 800 Health Services
  • GL 800-4 Response to Medical Emergencies
  • CD 843 Interventions to Preserve Life and Prevent Serious Bodily Harm

Annex D: Audit Criteria

The following table outlines the audit criteria developed to meet the stated audit objectives and audit scope:
Objective Audit Criteria Met/
Met with Exceptions/
Partially Met/
Not Met

1. Management Framework

To provide assurance that the framework in place to support situation management is effective.

1.1 Guidance Framework - CSC guidance is clear, up-to-date, and aligns with legislation. Met with exceptions
1.2 Roles and Responsibilities - Roles and responsibilities are defined, documented, communicated, and understood. Partially met
1.3 Training, Tools and Resources - CSC provides employees with the necessary training, tools, and resources to effectively manage situations. Met with exceptions
1.4 Monitoring and Reporting - Performance monitoring and reporting processes are in place to allow for informed decision making. Not met

2. Implementation of the Situation Management Framework

To provide assurance that key activities supporting the situation management framework have been implemented effectively.

2.1 Intelligence information is used to support and assist with the management of situations. Met with exceptions
2.2 Medical assessments and treatment are provided in compliance with legislation and CSC guidance. Partially met
2.3 Use of force reviews are completed in compliance with CSC guidance. Not met
2.4 Mechanisms are in place to resolve non-compliance with the various policies supporting the management of situations. Partially met

Annex E: Site Selection

The following sites were selected based on security level, number of incidents, number of incidents where a chemical agent was used, whether a violation of CSC guidance was noted during an incident review, and whether an institution has open, closed, or mixed concept ranges.

Region Sites
Atlantic
  • Atlantic Institution
  • Springhill Institution
  • Nova Institution for Women
  • Regional Headquarters
Quebec
  • Regional Mental Health Centre - Archambault Institution
  • Special Handling Unit - Regional Reception Centre
  • Regional Headquarters
Ontario
  • Collins Bay Institution
  • Millhaven Institution
  • Regional Treatment Centre - Millhaven Institution
  • Regional Headquarters
Prairies
  • Edmonton Institution
  • Edmonton Institution for Women
  • Regional Psychiatric Centre
  • Regional Headquarters
Pacific
  • Kent Institution
  • Mountain Institution
  • Regional Treatment Centre - Pacific Institution
  • Regional Headquarters
NHQ
  • Various Sectors

Annex F: Statement/Observation Report

Statement/Observation Report

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