Response of the Correctional Service of Canada to the Correctional Investigator’s Final Report: An Investigation of the Correctional Service of Canada’s Mortality Review Process


The Mortality Review Process is a formal process to review deaths in custody due to natural causes that is convened under section 19 of the Corrections and Conditional Release Act (CCRA).

Death by natural causes includes deaths that occur as a result of a naturally occurring disease process. It excludes deaths such as those related to accidents, assault by another inmate(s), or self-injury including overdose. If during the mortality review the health expert raises questions regarding the cause of the death, the case is referred to the Incident Investigations Branch.

The process that is currently in place was reviewed by CSC’s Health Care Advisory Committee and presented to Coroners/Medical Examiners across the country; and both groups considered the mortality reviews to be comprehensive.

Consistent with the principle for continuous quality improvement of an accredited health organization, over the past year, CSC’s Senior Medical Advisor has been leading work to improve the review process. Quality improvement efforts include how the organization reviews natural deaths in custody as well as examining the quality of health services delivered to offenders. CSC will continue to implement health services that minimize the impact of chronic diseases and other illness to prevent, where possible, deaths in custody.

Recommendation 1:

As per Section 19 of the Corrections and Conditional Release Act, the Correctional Service of Canada (CSC) should “forthwith” convene an investigation as soon as practical after the death of an inmate, regardless of the cause of that fatality or whether or not other outside agencies (e.g. police or Coroner’s Offices) are concurrently involved. The convening of a board of investigation should normally be within 15 working days of the fatality.

As required by section 19 of the CCRA, upon the death or serious bodily injury of an inmate, CSC convenes an investigation of the matter, and reports on its findings to the Commissioner or his delegate. Every investigation is convened as soon as is feasible in the circumstances. CSC is committed to the investigation process and, as such, has proposed a 6-month pilot project to further examine the process for reviewing deaths by natural causes in order to expedite the mortality review. Timeframe: October 2014.

Recommendation 2:

Section 19 reports into fatalities in CSC facilities should be shared with Coroner/Medical Examiner’s Offices as soon as practical.

Coroner’s/Medical Examiner’s Offices perform independent reviews. CSC provides copies of Mortality Review Reports when requested and as appropriate.

Recommendation 3:

“Sudden” or “unexpected” fatalities, regardless of preliminary cause(s), should be subject to a National Board of Investigation.

The Incident Investigations Branch in collaboration with Health Services determines on a case-by-case basis, whether a National Board of Investigation is convened when concerns and/or questions may exist with respect to the medical care, prior to and/or at the time of the incident.

Recommendation 4:

The Senior Deputy Commissioner’s recommendation to convene a mortality review should be informed by the opinion of an independent medical practitioner.

CSC’s National Senior Medical Advisor is currently involved throughout various stages of the Mortality Review Process. Following the referral of a death in custody for investigation using the Mortality Review Process, Health Services prepares the Convening Order in consultation with the National Senior Medical Advisor.

Recommendation 5:

All mortality reviews, regardless of cause of death, should be chaired by a physician.

The expertise of the National Senior Medical Advisor is used during the Mortality Review Process at different stages: a) confirming that the death in custody, from a medical perspective, is suitable for the Mortality Review Process; b) providing direction and consultation to the Nurse Reviewer at the beginning of the medical chart review; c) providing expert consultation to the Nurse Reviewer throughout the process; d) participating in the debrief conference and commenting on findings and responding to medical questions.

Recommendation 6:

At a minimum, the mortality review board should consist of at least three individuals – a registered nurse, the National Medical Advisor and the relevant Regional Manager of Clinical Services.

The National Senior Medical Advisor, a registered nurse and the relevant Regional Manager Clinical Services currently participate in the process. A representative from the Incident Investigations Branch is also involved in reviewing findings and recommendations. CSC will make more explicit the roles and responsibilities of all participants. Timeframe: May 2014.

Recommendation 7:

Medical record reviews should become a standard component of section 19 investigations to assess quality of health care provided.

In all cases of death by natural or unknown cause, medical records are reviewed to assess the quality of health care provided in accordance with relevant legislation, policies, procedures and guidelines.

Recommendation 8:

CSC should modify the general template for mortality reviews into expected deaths to include criteria followed by the Prisons and Probation Ombudsman for the United Kingdom.

CSC will review the process followed by the Prisons and Probation Ombudsman for the United Kingdom with respect to expected deaths with a view to considering best practices. Timeframe: May 2014.

Recommendation 9:

When relevant, the Convening Order for mortality reviews should include a specific mandate to: interview any involved staff members; visit institutions and; verify the accuracy and thoroughness of information contained in the documentary file.

As mentioned in response to recommendation 1, CSC is committed to the investigation process and, as such, has proposed a 6-month pilot project to further examine the process for reviewing deaths by natural causes in order to expedite the mortality review. Timeframe: October 2014.

Recommendation 10:

CSC should conduct a comprehensive lessons learned exercise with a view to identifying best practices for reducing natural cause deaths and implementing measures to prevent or reduce fatalities.

CSC Health Services is accredited by Accreditation Canada. Accreditation Canada provides national and international health care organizations with an external review process to assess and improve the quality of care provided to patients according to professional standards. An important component of the accreditation process is a quality improvement culture. CSC has a number of specific initiatives designed to improve health care outcomes. For example, CSC has a comprehensive early identification, testing, treatment, education and disease prevention approaches to addressing infectious diseases. In terms of addressing chronic disease, CSC is currently reviewing 900 randomly selected medical charts led by the National Senior Medical Advisor. The results of this review will inform chronic disease management strategies. Timeframe: June 2014.

Recommendation 11:

To promote best practices, individual mortality reports containing significant findings should be shared widely and completely as possible within CSC.

Mortality Reports are shared at the institutional, regional, and national levels. Responses to findings that require corrective measures are developed by the Chief Health Services and reviewed by the Regional Manager Clinical Services, the relevant Institutional Head and the Regional Director Health Services. Key findings and issues are also brought to Health Services Executive Team for discussion and action as required. In addition, the findings, recommendations and/or issues with national implications are reviewed by the National Investigation Board.

Recommendation 12:

In the interests of transparency and openness, upon request mortality reports in their entirety should be shared, in a timely manner, with the designated family member(s).

CSC works with the designated family member to assist the family following a death in custody. Mortality Review Reports are shared with the family upon the family’s request and in accordance with privacy and other legislation.

Recommendation 13:

The investigative responsibility and function for reviewing natural cause fatalities should be separate and distinct from CSC’s Health Services Sector.

Mortality Reviews are conducted under the authority of the Senior Deputy Commissioner. Final decisions about the method of investigation, the level of involvement of the Incident Investigations Branch, response to compliance findings, and closure of the file rest with Senior Deputy Commissioner.

Recommendation 14:

On a priority basis, the mortality review exercise should be subject to a quality control audit chaired by an outside medical examiner.

Mortality reviews are subject to internal review procedures and processes including review by the National Investigations Board.