Recommendations Of The Coroner's Inquest Into The Death Of Robert Gentles

Table of Contents

1. All alternatives be considered before a cell extraction is ordered.

2. All cell extractions be videotaped.

3. All cell extractions of non-compliant inmates, except for those in the most extreme situations, such as where actual risk of bodily harm or death may be imminent to any staff or inmate, be conducted by properly trained and equipped IERTs.

4. A fully qualified nurse, doctor, or paramedic be present during all IERT and non-IERT cell extractions for non-compliant inmates. The attending Health Care professional must be adequately equipped to handle possible medical emergencies and must perform a health check of the inmate immediately following the restraint, and prior to removal.

5. CSC maintain an IERT on 24-hour standby in all medium and maximum security institutions. During lockdowns, the IERT should be on site.

6. CSC continue to follow RI 605 dated June 23, 1995 on cell extractions for all non-IERT cell extractions. The role of each member of the extraction team for non-IERT extractions must be determined by the Correctional Supervisor or his/her delegate before the cell is entered.

7. It is recommended that as soon as an inmate is securely restrained that he be placed in a sitting position provided that it can be done without risk or injury to inmate or staff.

8. It is recommended that a standard kit of equipment be assembled for non-IERT cell extractions. This kit should include leg irons, handcuffs, a chemical agent and a video camera and be made available to the team prior to the commencement of any extraction.

9. It is recommended that CSC only authorize for use those chemical agents, inflammatory sprays and their constituents, which meet Health Canada and Environment Canada standards. All chemical agents and inflammatory sprays in use by CSC must be re-authorized annually.

10. It is recommended that for each incident for which chemical agents/inflammatory sprays are to be used they be used only upon the specific authority of the person who is in charge of the institution at that time. This will be done in accordance with the Commissioner's Directives and Standard Operating Procedures. The person in charge must make himself/herself aware of the reason for the request for chemical agent/inflammatory spray before authorizing its use.

11. It is recommended that, when time and circumstances permit, before a chemical agent/inflammatory spray is administered to an inmate that the medical authority at the institution be called to check the inmate's medical file for possible adverse effects to the chemical agent/inflammatory spray. If that is not possible, and when time and circumstances permit, a continually updated list of inmates with medical conditions that might be adversely affected by chemical agents/inflammatory sprays shall be available on each living unit and must be checked.

12. It is recommended that chemical agents/inflammatory sprays continue to be used only by properly trained staff.

13. It is recommended that after a chemical agent/inflammatory spray has been applied that officers wait the recommended time before a second application and/or before entering the cell.

14. It is recommended that all written procedures concerning chemical agents and inflammatory sprays include the name commonly used in the workplace as well as the proper technical name.

15. It is recommended that a communications policy be implemented to ensure that all inmates are aware of the procedures to be followed during a lockdown, especially as they relate to meals and movement.

16. It is recommended that the communications of information during a lockdown should not rely exclusively on the communication of information by inmate representatives, as it is not possible to be certain what information is passed.

17. It is recommended that CSC investigate alternative ways of more efficiently providing meals to inmates during a lockdown at Kingston Penitentiary.

18. It is recommended that during a lockdown adequate meals be served at reasonable intervals. The first meal of the day should be served to all inmates no later than 11:00 am.

19. It is recommended that when administrative segregation is used, it be administered in compliance with institutional procedures and the law and adequately monitored by senior management.

20. It is recommended that all correctional officers be re-certified in CPR every year and in first aid every three years.

21. It is recommended that all correctional officers receive refresher training every three years in the following areas:

• CSC and the Law
• Use of Force Management Model
• Cell Extraction Procedures
• Restraint Equipment
• Arrest and Control
• Use of Force, and
• Chemical Agents

22. It is recommended that all employees of the Correctional Service of Canada continue to receive training in anti-racism, cultural awareness and harassment.

23. It is recommended that, for the safety of correctional officers and inmates, all correctional officers receive training in cell extractions of non-compliant inmates.

24. It is recommended that new officers, after initial in-class training, be on-the-job trained on an ongoing basis during their first year of work. They should be brought back frequently for training during their first year with respect to ethical dilemmas experienced on the job.

25. It is recommended that the Commissioner appoint a consultant to study the effectiveness and recommend improvements regarding the course "CSC and the Law".

26. Recognizing the potential negative impact on correctional officers working in an institutional setting, CSC must continue to train new recruits and existing staff in accordance with the values expressed in the Mission of the Correctional Service of Canada.

27. It is recommended that the orientation program for all new officers include a module on "Officer Norms", outlining its beneficial and detrimental aspects.

28. It is recommended that the Standing Operating Procedures (replacing the Security Manual) and the training in those procedures have been provided to all Correctional Officers within a year.

29. It is recommended that training be provided in how to lift and carry an un-cooperative inmate.

30. It is recommended that training be provided in how to determine whether or not an inmate is "playing possum" or is in medical distress.

31. It is recommended that CSC evaluate psychological screening as a component of its officer recruitment process.

32. It is recommended that any officer who has inmate contact and who is out on stress leave go for a psychological evaluation prior to returning to work.

33. It is recommended that CSC provide a Stress Management course for staff with an option of professional counseling as needed.

34. It is recommended that CSC provide a 1-800 number to access counseling for staff who are reluctant to self identify to local management when they are suffering the effects of job related stress.

35. It is recommended that the amount of overtime be reviewed on a monthly basis. Corrective action should be taken where an excessive number of hours are being worked by individual correctional officers. This will ensure that the stresses of the job are not made worse by lengthy exposure to the prison environment.

36. It is recommended that any record of stress related counselling should not be kept on employees' personnel files. This should encourage employees to feel comfortable to come forward and ask for help or stress counselling without reprisal.

37. It is recommended that the Correctional Service review all Commissioner's Directives, Regional Instructions, Standing Orders and Standard Operating Procedures to ensure they are clear and in compliance with the law and policy to avoid any duplication and conflicting information.

38. It is recommended that the Union of Solicitor General Employees, with the support of CSC, encourage its members to report any illegal acts or harassment, as their obligations as peace officers should take priority over labour solidarity.

39. It is recommended that all log book entries be read daily by unit managers and the I.P.S.O. so that action plans and necessary follow-up can be established when required. There must be feedback to the reporting officer.

40. It is recommended that staff conduct in breach of the CCRA, Commissioner's Directives, Regional Instructions, Standing Orders, Standard Operating Procedures or the CSC Code of Conduct be dealt with by management expeditiously, suitably and openly by any one or more of the following measures:

• Counseling
• Re-training; and/or
• Discipline

41. It is recommended that all Standard Operating Procedures, Commissioner's Directives, Regional Instructions and Standing Orders contain a definition to ensure that terminology used within is clearly understood by staff.

42. It is recommended that CSC continue to investigate the most appropriate device for transporting uncooperative inmates. (ie. Chair used by ambulances)

43. It is recommended that CSC, with cooperation from the USGE, investigate the possibility of rotating staff among institutions on a regular basis in order to have a turnover of the majority of staff at Kingston Penitentiary.

44. It is recommended that there be formal steps to notify families of a death in the institution. Notification must be made in person.

45. It is recommended that there always be a staff member trained in crisis negotiation in the institution.

46. It is recommended that all directives concerning report writing be strictly adhered to.

47. It is recommended that reports (i.e. Use of Force and Situation Reports) be filled out immediately following an incident. Appropriate disciplinary action should be taken if this is not done.

48. It is recommended that the Situation Report contain an attention box with a warning that officers fill out reports independently.

49. It is recommended that a room be made available at the time of an incident within every institution (i.e. cafeteria, chapel, etc.) for the preparation of reports concerning serious incidents. This room must be supervised during the preparation of those reports by the institutional head or his designate. It is further recommended that a record be kept of those preparing and invigilating the reports.

50. It is recommended that CSC continue with the current audit of its filing and information systems with the objective of improving that system.

51. It is recommended that all persons in the CSC with specific authority who are empowered or required to dispose of complaints, grievances or investigations be able to admit error on the part of, and on behalf of the Correctional Service.

52. It is recommended that CSC initiate a national program of statistical collection, analysis and reporting that will reflect trends in the use of force, segregation, inmate discipline, inmate grievances, officer discipline and officer grievances. This would provide indicators to the management team of the performance of their institution.

53. It is recommended that press releases be accurate, precise and clear with no possibility of a misinterpretation of information. (i.e. gilding the lily)

54. It is recommended that there be a top down commitment where management sets the appropriate example for staff in accordance with the Mission Statement and the five core values.

55. It is recommended that the Warden and Deputy Warden at Kingston Penitentiary be left in place for a minimum of a three year term. CSC should consider instituting a system of financial incentives for Warden's and Deputy Wardens to stay in their jobs at difficult posts like Kingston Penitentiary.

56. >It is recommended that the salary classification of a Warden of a maximum security institution reflect the responsibilities of the position and be such that it will allow for his/her transfer back to the line operation after the completion of a staff assignment (Regional or National Headquarters) without a financial penalty.

57. It is recommended that special assignments that take the Warden away from the institution be limited.

58. It is recommended that all levels of management be held accountable for their actions or lack of same. Senior managers who are found to be ineffective should be provided with additional training, retrained, demoted or dismissed.

59. It is recommended that because of the nature of work performed by CSC peace officers, that CSC take forward to treasury Board a proposal that the Master Agreement between the Public Service Alliance of Canada and the Treasury Board be amended to provide an exception to the general "sunset clause" which provides for the removal of any disciplinary action from a public service employee's file after two years. This exception to the "sunset clause" should be applied only in circumstances where a CSC peace officer has received discipline relating to the use of force against an inmate.

60. It is recommended that when allegations of excessive force used against an inmate are proven, the staff member involved be dismissed from the Public Service.

61. It is recommended that any agreement with the applicable union concerning the appropriateness of discipline or the conduct of investigations should be in writing and should be permanently preserved by both parties.

62. It is recommended that the CSC take forward the proposal to Treasury Board that its current legislative and/or policy position be amended to provide for suspension with pay in certain circumstances. This would give CSC the option to suspend and employee with or without pay.

63. It is recommended that the Code of Discipline (CD 60) be amended to include procedures that must be followed whenever a staff member has committed an alleged infraction.

64. It is recommended that an officer who uses an unauthorized control hold be disciplined.

65. The public accountability of each Citizen Advisory Committee (CAC) should be strengthened. To achieve this it is recommended that the Regional Deputy Commissioner, at the beginning of each year, take steps to ensure that each CAC in the Region is at optimum levels of strength and performance. Each committee shall be comprised of at least three persons and no more than seven who are reasonably representative of a cross-section of the community. Newspaper advertisements should be used as necessary to recruit new members. A selection committee made up of the head of the institution, the local union president and chair of the local CAC shall select new members. The participation of the correctional officers is considered essential in the success of the committee's mandate.

66. It is recommended that each CAC prepare an annual report containing a review of the past year's activities, an assessment of the effectiveness of the committee's monitoring of crisis situations where the safety of staff and/or inmates was clearly at risk and a statement of the needs of the committee in order to carry out their duties in the coming year. The report would be submitted to the Regional Deputy Commissioner, the Correctional investigator, the head of the institution and to the community agencies and individuals involved in public policy relating to community safety and prisoner rehabilitation.

67. It is recommended that in situations involving the application of chemical agents/inflammatory sprays prior to death, blood and tissue samples be screened for concentrations of chemical agent constituents. In cases where the samples are being forwarded to the Centre of Forensic Sciences, it is recommended that they be provided in the amounts and containers specified by the Centre.

68. It is recommended that the post-mortem report and, if possible, the police report, be provided to the Centre for Forensic Sciences along with the Case Submission form (form CFS 69) when the samples are submitted.

69. It is recommended that a review of Kingston Penitentiary be conducted with respect to its appropriate use within the context of the Corrections and Conditional Release Act. This review should be conducted by a committee consisting of representatives from CSC, the Ministry of the Solicitor General and independent persons from the community.

70. It is recommended that with the issue of accountability a concern, that increased civilian oversight of CSC is required. An independent oversight committee shall be formed by the Ministry of the Solicitor General to conduct a study and report within 12 months to the Justice Committee of the Parliament of Canada. This committee shall determine what type of civilian oversight body should be established and the scope of its powers.

71. It is recommended that CSC through the I.P.S.O.s conduct an annual review of stock in the armories to ensure that security equipment meets the current standards and that any items not meeting the standards are removed.

72. It is recommended that CSC investigate the possibility of requiring inmates in certain cell settings (i.e. open-faced cells) to use headphones for their stereos and televisions.

73. It is recommended that the Chief Coroner receive written reports from the Commissioner of Corrections and any other recipient of these recommendations with respect to their implementation. These reports shall include the status of this jury's recommendations as to why certain, if any, recommendations were not implemented. These reports are due to the Chief Coroner within twelve months and will be made public.

74. It is recommended that the Chief Coroner receive a written report from the Solicitor General with respect to implementation of these recommendations also within twelve months. This report will also be made public.