Annual Report on Deaths in Custody 2016-2017

Research Report

SR-19-01

December 2019

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Executive Summary

The Correctional Service of Canada (CSC) acknowledges, accepts, and takes seriously its obligation to ensure the safety and security of all offenders in its custody. Deaths in custody, particularly non-natural deaths, remain a complex and difficult issue. Providing the appropriate treatment for offenders with life-threatening, non-curable illnesses and the prevention of non-natural deaths remain a fundamental priority of the organization. The current report builds on the previous in-depth review of all deaths in custody across a 16-year period by extending analysis to the 2016/2017 fiscal year. The annual reports will continue to contribute to the organization's ability to quickly identify trends, areas for opportunity, and initiatives to reduce deaths in custody, particularly non-natural deaths.

In 2016/2017, the majority of deaths were the result of natural causes (81%). There were also three deaths by suicide, four by overdose, and two by homicide. There were no accidental deaths or deaths where staff were involved during this fiscal year. In general, this makeup of deaths in custody is consistent with trends over the last 16 years.

Offenders who died in custody varied considerably, but tended to be White, serving sentences for a homicide related offence, and serving indeterminate sentences. Those who died from natural causes tended to be older (M = 59.83). More specifically, 71% of offenders who died from natural causes were over the age of 55 years, while those who died of non-natural causes were younger (M = 41.46 years; 81% were between 18 and 54 years of age).

Deaths in the 2009/2010 to 2016/2017 period Footnote 1 were examined more closely. Among natural deaths, cancer was the leading cause, followed by cardiovascular-related conditions. Chronic health issues were common among offenders who died by natural cause, with at least one chronic health condition unrelated to the cause of death identified in 96% of cases. Mental health issues were also quite prevalent, identified in 51% of cases. Other common elements in natural deaths included the presence of cigarette smoking as a contributing factor (identified in 48% of cases) and offender non-compliance with medication (34% of cases).

Suicide was the most common type of non-natural death, accounting for 70 deaths. Most suicide deaths occurred by hanging. Those who died by suicide tended to have life-histories marked by substance misuse (89%) and mental health concerns (i.e., 89% had at least one mental health condition, and nearly 60% had at least one prior suicide attempt). Changes in mental health medication regimens appeared in 38% of cases and in nearly 70% of such cases, the change occurred within three weeks of the incident. Over the 8-year period analyzed, 35 offenders died in custody from an overdose, with fentanyl being identified in 37% of the cases (i.e., either as a standalone substance or in combination with others).

CSC has prioritized learning from all deaths that occur in custody in an effort to prevent future non-natural deaths and improve on the treatment of offenders with life-threatening, non-curable illnesses. The investigations and reviews conducted following deaths in custody allow for the identification of areas of need in the service. CSC works proactively to implement recommendations and consider policy and practice in light of findings, thereby contributing to the safety and well-being of offenders, as well as staff and the public.

Introduction

The Correctional Service of Canada (CSC) takes seriously all offender deaths that occur while in custody. In an effort to enhance transparency, understand the nature of and circumstances leading to deaths in custody, and to inform policy, its 2015/2016 Annual Report on Deaths in Custody provided an in-depth review of all deaths in custody that occurred between 2009/2010 and 2015/2016. This detailed report was conducted in response to recommendations of the Third Independent Review Committee on Deaths in Custody and other inquiries. The current report builds on the previous report by extending analysis to the 2016/2017 fiscal year.

This year’s report examines all deaths in custody that occurred in 2016/2017 and explores trends since 2000/2001, with a more detailed analysis for the 2009/2010 - 2016/2017 period. Both natural deaths (i.e., where the cause of death is the result of an illness or internal breakdown of the body) and non-natural deaths (i.e., all deaths that do not qualify as a natural death or where the cause is initially undetermined) are explored in detail, with consideration paid to the manner of death, the circumstances surrounding the death, and the profile of offenders who died. Regional and yearly variation is analyzed where appropriate. For non-natural deaths, suicide and overdose deaths are also examined more closely. It is important to note that due to low base numbers, yearly fluctuations, variations, or trend analysis should be interpreted with caution; this is particularly so in the case of sub-categories of non-natural deaths.

All deaths in custody are subject to review and investigation under CSC policy. As per Commissioner’s Directive (CD) 041, Incident Investigations Footnote 2, CSC’s Incident Investigation Branch investigates all non-natural deaths Footnote 3 and CSC’s Health Services Sector conducts a Mortality Review for all natural deaths, except in the rare instances where the circumstances warrant no further investigation. This report examines investigations thematically in an effort to discern trends and identify areas for improvement.

The underlying goal of the Annual Report on Deaths in Custody is to help inform organizational policy and practices in an effort to reduce and prevent all non-natural offender deaths and provide appropriate person-centered and compassionate health care to offenders with life-threatening, non-curable illnesses Footnote 4. This report also promotes accountability and transparency by providing detailed information on all deaths in custody. The CSC Research Branch (Policy Sector) will continue to track all deaths that occur in custody to advance these goals.

Data Source and Methodology

The information used to conduct the analysis presented in this report was gathered from a variety of sources. Coroner’s reports, toxicology reports and Warden’s situation reports (where available) were systematically examined for relevant information pertaining to each death. For all deaths from fiscal year 2009/2010 onwardsFootnote 5, either a Mortality Review (for natural cause deaths) or Board of Investigation (for non-natural deaths) was obtained and systematically coded to extract relevant information. In order to ensure the quality and consistency of the information gathered, each death was audited by a different coder and any discrepancies were reconciled. The Offender Management System (OMS) was used to gather demographic and other information about the deceased offender, as well as to retrieve incident reports on the death.

Previously developed and tested coding forms were used by multiple coders in order to capture information from Board of Investigation reports and Mortality Reviews in a reliable mannerFootnote 6. Once coded, each death was entered into a database maintained using survey software and subsequently extracted to statistical software for analysis. The database that was previously developed will continue to be maintained to track all deaths in custody and used for analysis in subsequent annual reports and research projects.

The information extracted from these reports was broad-based and wide-reaching, and there were some types of information that were not consistently found. It was impossible to ascertain whether the information had simply not been recorded, or non-reporting indicated that the term was irrelevant or non-applicable. In these cases, the item was coded as not indicated. When information was not available for 25% or more of cases, items were not included in the analyses. For example, in coding for the item ‘Primary source of support in year prior to death,’ information was not available in 54% of non-natural deaths; hence, this item was not included in the report for non-natural deaths. An overview is provided for the entire 17-year period, while a more in-depth analysis is presented for an 8-year period (2009/2010 - 2016/2017).

Looking at trends over low base-rate phenomenon, such as deaths in custody, can be challenging. To overcome the natural fluctuations that can occur year-to-year, comparisons were normally carried out by comparing 2016/2017 to an amalgamation of previous 7-years. In some cases, the full 8-year period was analyzed as a whole in order to preserve anonymity due to small numbers. Not all percentage totals in the tables will add to 100% due to rounding and this is more pronounced due to the small numbers in some tables.

Changes to the Annual Report

This annual report provides greater definitional clarity regarding the types of deaths that occur in federal custody (i.e., the originating incident occurred within a federal institution or at a hospital while in CSC’s custody). Natural cause reflects incidents where the cause of death is the result of an illness or internal breakdown of the body. All other types of deaths that occur in custody that do not meet this definition would fall into the category of non-natural deaths. There are a number of types of non-natural deaths that fall within this category:

  1. Suicide reflects incidents where the offender intentionally ended their own life (e.g., hanging/ligature, cutting, blunt force trauma, overdose, and other manners).
  2. Overdose reflects incidents where the offender died as a result of ingesting licit or illicit drug(s); overdoses will only be classified as a suicide if there is evidence of intent (e.g. a suicide note).
  3. Homicide reflects incidents where an offender dies as a result of harm caused by another offender.
  4. Accidental reflects incidents that are non-natural in nature but are the result of an accident (e.g., slip/fall).
  5. Staff Involved reflects incidents where staff were directly involved in an incident that lead to the death of an offender (regardless of intent; e.g., use of force during a security incident such as an attempted escape). Please note that there has been a change in terminology from ‘Staff Intervention’ to ‘Staff Involved’ in order to remove ambiguity and be more inclusive of the variety of incidents involving staff.
  6. Undetermined reflects incidents where the specific cause of death could not be determined, as well as deaths where the investigation process is ongoing at the time of this report.

The format and presentation have also been updated in this report. Text boxes are used to provide definitions and contextual information, as well as to highlight notable findings, throughout the report. Graphical representation of data is also presented through the report to complement the text. Finally, the majority of the tables referred to within this document have been included as appendices in order to make this document more accessible to readers, while still providing the level of detail as the previous annual report.

The Research Branch gratefully acknowledges the assistance of the Incident Investigation Branch, Health Services and the Parole Board of Canada in gathering and assisting with the interpretation of the varied documents and reports used in the analysis. This report would not have been possible without their assistance and co-operation.

Overview of Deaths in Federal Custody

Deaths in Custody over a 17-year period: Manner of Death and Regional Differences

In 2016/2017 there were 38 natural cause deaths, accounting for 81% of all deaths during this fiscal year. There were also three deaths by suicide, four by overdose, and two by homicide. There were no accidental deaths or deaths where staff were involved during this fiscal year. The overall rate of deaths in custody in 2016/2017 was 3.32 per 1000 offenders. The rate of natural deaths in 2016/2017 was 2.68 per 1000 offenders, while the rate of non-natural deaths in 2016/2017 was 0.64 per 1000 offenders.

Across 17-year period (2000/2001 and 2016/2017), there were a total of 904 deaths in federal custody. Of these deaths, 67% were natural cause deaths (see Table 1). Non-natural deaths account for 33%; however, this percentage has fluctuated over this 17-year period, ranging from a high of 44% in 2002/2003 to a low of 19% in 2016/2017. It is important to note that the proportion of natural versus non-natural deaths in custody can fluctuate greatly, producing a magnified effect on percentages due to low base numbers.

Table 1
Deaths in Custody by Manner of Death Over a 17-year Period (2000/2001 - 2016/2017).
Fiscal Year Manner of Death Total
Natural Non-natural
Suicide Overdose Homicide Accident Staff involved Undetermined
2000/2001 25 8 7 - - - 1 41
2001/2002 33 13 3 1 1 - 2 53
2002/2003 27 12 7 2 - - - 48
2003/2004 40 10 3 8 1 - 3 65
2004/2005 33 9 2 3 - - 1 48
2005/2006 33 10 2 3 1 - - 49
2006/2007 42 11 5 3 - - - 61
2007/2008 30 5 3 2 - - - 40
2008/2009 48 9 2 2 - - 4 65
2009/2010 30 10 4 2 1 - 2 49
2010/2011 35 4 4 5 - 1a 1 50
2011/2012 35 8 5 3 1 - 1 53
2012/2013 34 14 2 1 2 - 3 56
2013/2014 33 9 2 2 1 - - 47
2014/2015 45 13 6 1 2 - - 67
2015/2016 42 9 8b 3 2 1a - 65
2016/2017 38b 3 4 2b - - - 47
Total 603 157 69 43 12 2 18 904

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a This death is excluded from subsequent detailed analysis due to small numbers.
b The investigation for one death is still ongoing and this may result in changes to numbers in future reports.

In 2016/2017, the Quebec region recorded the highest number of natural deaths in terms of raw numbers (12), followed by the Ontario region (10). The Atlantic region had the lowest number (1). Non-natural deaths were highest in raw numbers in the Prairie region (i.e., 5 compared to 2 in both the Quebec and Ontario regions). Regional breakdowns were not examined within the single fiscal year given the small numbers.

Likewise, the Quebec and Ontario regions had the highest number of natural deaths across the 17-year period examined (2000/2001-2016/2017; 176 in both cases), while the Atlantic region had the lowest (48; see Table 2). Over this period, the Ontario region had the highest number of non-natural deaths in custody (80), followed by the Prairie region (76) and the Quebec region (63). An examination of the breakdowns within each region indicate that the Quebec and Ontario regions had the largest percentage of natural deaths (i.e., 73% and 68%, respectively). In terms of non-natural deaths, the Atlantic region had the largest percentage of suicide deaths (27%) and the smallest percentage of overdose deaths (4%). The Prairie region had the largest percentage of homicide deaths (11%) and the second largest percentage of both overdose deaths (9%) and suicide deaths (21%). The Ontario region had the largest percentage of overdose deaths (10%) and the smallest percentage of suicide deaths (14%).

Table 2
Regional Distribution of Deaths in Custody by Manner of Death Over a 17-year Period (2000/2001 - 2016/2017).
Manner of Death Region Total
Atlantic Quebec Ontario Prairie Pacific
Natural 48 176 176 99 104 603
Non-natural
Suicide 22 36 35 37 27 157
Overdose 3 14 25 16 11 69
Homicide 5 5 8 19 6 43
Accident 1 2 5 1 3 12
Staff Involved 1 - 1 - - 2
Undetermineda 2 6 6 3 1 18
Total 82 239 256 175 152 904
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a These deaths are currently under investigation and are thus not included in subsequent analyses.

Profiles of Offenders Who Died in Federal Custody

Offenders who died in custody varied considerably, but tended to be White, 55 years of age or older, serving a sentence for a homicide related offence, and serving indeterminate sentences. Women accounted for two of the deaths that occurred in 2016/2017 and nine of the deaths that occurred in the previous seven years. Results by gender were not presented due to low numbers and the possibility of revealing identifying information about individual offenders.

Characteristics of offenders who died of natural causes in 2016/2017

  • 76% were White
  • 79% were 55 years of age or older
  • 61% were serving an indeterminate sentence
  • 61% were convicted of a homicide related offence
  • 89% were classified as medium or minimum security

Offenders who died of natural causes in 2016/2017 were more likely to be White, 55 years of age or older, and were typically serving an indeterminate sentence (see Table 3 in appendix). These offenders tended to be serving time for a homicide related offence and classified as either medium or minimum security. At the time of death, offenders who died of natural causes had typically served either a relatively short amount of time (less than five years) or a considerable amount of time (20+ years).

Offenders who died of non-natural causes tended to be White (67%, n = 6), under the age of 44 (67%, n = 6), serving time for a homicide related offence (44%, n = 4), and classified as medium security (67%, n = 6; see Table 3 in appendix). At the time of death, they had typically served a relatively short amount of time (less than five years of their sentence; 67%, n = 6). The most common index offence among both natural and non-natural deaths was homicide, in both 2016/2017 (61% and 44%).

When considering the 8-year period (2009/2010 - 2016/2017), differences were observed between the offenders who died of natural causes and those who died by non-natural manner. For example, those who died from natural causes were more likely to be White (71% versus 29% for non-natural causes), serving an indeterminate sentence (55% versus 39% for non-natural causes), be classified as minimum security (30% versus 9% for non-natural causes), and be older (M = 59.83). More specifically, 71% of offenders who died from natural causes were over the age of 55 years. Those who died of non-natural causes were more likely to be classified as maximum security (28% versus 10% for natural causes) security and were more likely to be younger (M = 41.46 years). Over three quarters of offenders who died of non-natural causes were between the ages of 18 and 54 years (81%). Among Indigenous offenders in 2016/2017, a greater number of deaths were natural (56%) compared to non-natural (44%).

Natural Deaths in Federal Custody

Manner of Death and Regional Differences

In 2016/2017, there were 38 natural cause deaths in custody, accounting for 81% of all deaths during this fiscal year. The three most common subtypes of natural cause deaths in 2016/2017 were cancer, cardiovascular related, and other (24% each; see Table 5 in appendix). Given the relatively low number of deaths overall in this fiscal year, comparisons with the previous 7-year period should be made with caution. Therefore, while this report will describe natural cause deaths for 2016/2017, the full 8-year period (2009/2010 - 2016/2017) will also be discussed. When natural cause deaths are examined across this time period, the two most common subtypes of natural cause death remained both cancer (34%) and cardiovascular related (28%; see Figure 1).

Figure 1. Subtype of Natural Cause Deaths, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Figure 1. Subtype of Natural Cause Deaths, 2009/2010 - 2016/2017
Subtype of Natural Cause Deaths 2009/2010-2016/2017
Cancer 34%
Infection 9%
Cardiovascular-related 28%
Respiratory-related 10%
Liver-related 9%
Neurological-related 4%
Other 5%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Given the small numbers in the current fiscal year, regional variation was examined across the 8-year period (2009/2010 - 2016/2017). Cancer related natural deaths were highest in raw numbers in the Ontario (37) and Quebec (26) regions, and lowest in the Atlantic (6) region across this time period (see Table 6 in appendix). Cardiovascular related deaths were highest in the Quebec region (30).

When the percentages within each region were examined, cardiovascular related deaths were the most common in the Atlantic, Quebec and Prairie regions (i.e., 37%, 38%, and 33%, respectively), with cancer related deaths being the next most common subtype in these regions (i.e., 32%. 33%, and 24%; see Figure 2). In the Ontario and Pacific regions, cancer related deaths were the most common subtype of natural cause death (i.e., 41% and 38%), with cardiovascular related deaths the next most common subtype in these regions (i.e., 14% and 30%). Liver related deaths were the most common in the Prairie (20%) and Ontario (11%) regions.

Figure 2. Subtype of Natural Cause Deaths by Region, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Figure 2. Subtype of Natural Cause Deaths by Region, 2009/2010 - 2016/2017
Subtype of Natural Cause Deaths Region
Atlantic Quebec Ontario Prairie Pacific
Cancer 32% 33% 41% 24% 38%
Infection 11% 8% 10% 6% 10%
Cardiovascular-related 37% 38% 14% 33% 30%
Respiratory-related 5% 9% 13% 12% 8%
Liver-related 5% 6% 11% 20% 2%
Neurological-related 5% 1% 7% 4% 6%
Other 5% 6% 4% 2% 6%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Further Examination of Natural Deaths

Events Surrounding Natural Cause Deaths in 2016/2017

  • 65%1 had a DNR on file
  • 87%1 were receiving palliative care
  • 48%1 had next-of-kin involved 2
  • 95% had at least one chronic health condition identified
  • 62% had at least one mental health condition identified
  • 35% were noncompliant with their medication

1 These proportions exclude unexpected natural deaths and one whose investigation is currently in progress
2 Includes contact, visits, decision-making and/or consent

In 2016/2017, 15 (65%) offenders who died of natural causes had a Do not Resuscitate order (DNR) on file and 20 (87%) were receiving palliative careFootnote 7 (see Table 7 in appendix). Nearly half of offenders had their next-of-kin involved (i.e., contact, visits, decision-making, and/or consent). These proportions exclude the 14 offenders who died unexpectedly from natural causes and one whose investigation is ongoing. In 2016/2017, the final cause of death was related to substance misuse in 19% of natural deaths and to cigarette smoking in 27% of natural deaths. During this fiscal year, 95% of offenders who died of natural causes had at least one chronic health conditionFootnote 8 identified, 62% had at least one mental health condition identified, and 35% had noncompliance issues with their medication.

When the full 8-year period was examined, 136 (81%) offenders who died of natural causes had a DNR on file and 147 (88%) were receiving palliative care (see Table 7 in appendix). Fifty-five percent had their next-of-kin involved (i.e., contact, visits, decision-making, and/or consent). Again, these proportions exclude offenders who died unexpectedly from natural causes. During this time period, 96% of offenders who died of natural causes had at least one chronic health condition identified, 51% had at least one mental health condition identified, and 34% were noncompliant with their medication. In 24% of cases, the final cause of death was related to substance misuse and in 48% of cases the final cause of death was related to cigarette smoking.

Events Surrounding Natural Cause Deaths, 2009/2010 - 2015/2016

  • 76%1 had a DNR on file
  • 80%1 were receiving palliative care
  • 56%1 had next-of-kin involved2
  • 96% had at least one chronic health condition identified
  • 49% had at least one mental health condition identified
  • 34% were noncompliant with their medication

1 These proportions exclude unexpected natural deaths and one whose investigation is currently in progress
2 Includes contact, visits, decision-making and/or consent

There was minimal regional variation when it came to the presence of health conditions and palliative care receipt. Over the 8-year period, over 90% of individuals who died of natural causes had at least one chronic health condition identified, regardless of the region (see Table 8 in appendix). Between 70% and 84% of individuals who died expectedly of natural cause deaths were receiving palliative care across the regions. Those in the Prairie region were the most likely to have a DNR on file (94%), though the percentage was over 60% in all regions. The Pacific region had the smallest percentage of individuals who had their next of kin involved (37%), compared to over 50% of individuals in the remaining regions. The Quebec region had the smallest percentage of individuals who had noncompliance issues with their medication (23%), compared to 34-37% in all other regions. They also had the smallest percentage of individuals who had at least one mental health condition identified (30%), compared to 54-70% in all other regions. The Atlantic region had the largest percentage of individuals who had noncompliance issues with their medication (47%), compared to 23-42% in all other regions. The Pacific region had the largest percentage of individuals who had at least one mental health condition identified (70%), compared to 30-58% in all other regions.

Regional Variation of Natural Deaths in Custody, 2009/2010 - 2016/2017

Atlantic

  • 80%1 had a DNR on file
  • 58%1 had next-of-kin involved2
  • 58% had at least one mental health condition
  • 47% were noncompliant with their medication

Quebec

  • 62%1 had a DNR on file
  • 52%1 had next-of-kin involved 2
  • 30% had at least one mental health condition
  • 23% were noncompliant with their medication

Ontario

  • 79%1 had a DNR on file
  • 52%1 had next-of-kin involved2
  • 54% had at least one mental health condition
  • 34% were noncompliant with their medication

Prairie

  • 94%1 had a DNR on file
  • 58%1 had next-of-kin involved2
  • 55% had at least one mental health condition
  • 41% were noncompliant with their medication

Pacific

  • 69%1 had a DNR on file
  • 37%1 had next-of-kin involved2
  • 70% had at least one mental health condition
  • 42% were noncompliant with their medication

1 These proportions exclude unexpected natural deaths and one whose investigation is currently in progress
2 Includes contact, visits, decision-making and/or consent

In 2016/2017, in terms of chronic health conditions identified in offenders who died by natural cause, cardiovascular conditions were the most common, noted in 76% of offenders (i.e., at least one condition was identified; see Table 9 in appendix). Other common issues included chronic gastrointestinal conditions (i.e., 65% of offenders had at least one condition identified), blood-borne viruses/infections, and endocrine conditions (within each category, 49% of offenders had at least one condition identified). When the full 8-year period was examined (2009/2010 - 2016/2017), cardiovascular conditions remained the most common type of chronic health conditions identified (71%; see Figure 3). However, respiratory conditions (46%) and gastrointestinal conditions (43%) were the next most common types of chronic health conditions. Reproductive conditions were the least commonly identified conditions for both 2016/2017 and the full 8-year period (i.e., 8% and 10%, respectively).

Figure 3. Types of Chronic Health Conditions, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure. These totals will not add to the total number of natural deaths as offenders may have multiple types of chronic health conditions.

Figure 3. Types of Chronic Health Conditions, 2009/2010 - 2016/2017
Types of Chronic Health Conditions 2009/2010-2016/2017
Central Nervous System 23%
Musculoskeletal 37%
Respiratory 46%
Cardiovascular 71%
Blood-borne virus/Infection 38%
Endocrine 35%
Gastrointestinal 43%
Reproductive 10%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure. These totals will not add to the total number of natural deaths as offenders may have multiple types of chronic health conditions.

There was minimal regional variation when it came to the most common types of health conditions identified across the 8-year period (2009/2010 - 2016/2017). Cardiovascular conditions were the most commonly identified and reproductive conditions were the least commonly identified type of chronic health conditions, regardless of region (see Figure 4 and Table 10 in appendix). However, there was some regional variation in the prevalence of conditions. For example, while there was no regional variation in the most common and least common type of chronic conditions identified, the percentages of offenders with these conditions did vary. The percentage of offenders with at least one chronic cardiovascular condition identified ranged from 65% in the Ontario region to 83% in the Quebec region and ranged from 5% in the Atlantic region and 12% in the Pacific region for chronic reproductive conditions. In the Atlantic and Ontario regions, chronic gastrointestinal conditions were the second most common type of condition identified (i.e., 58% and 50% respectively), while respiratory conditions were more common in the Quebec, Pacific and Prairie regions (i.e., 54%, 52%, and 47%).

Figure 4. Types of Chronic Health Conditions Identified by Region, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure. These totals will not add to the total number of natural deaths as offenders may have multiple types of chronic health conditions.

Figure 4. Types of Chronic Health Conditions Identified by Region, 2009/2010 – 2016/2017
Types of Chronic Health Conditions Region
Atlantic Quebec Ontario Prairie Pacific
Central Nervous System 16% 14% 29% 26% 30%
Musculoskeletal 53% 25% 41% 37% 46%
Respiratory 26% 54% 39% 47% 52%
Cardiovascular 74% 53% 65% 71% 66%
Blood-borne virus/Infection 37% 29% 41% 45% 40%
Endocrine 32% 40% 31% 39% 34%
Gastrointestinal 58% 31% 50% 45% 40%
Reproductive 5% 10% 10% 8% 12%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure. These totals will not add to the total number of natural deaths as offenders may have multiple types of chronic health conditions.

In 2016/2017, only 5% of offenders who died of natural causes had no chronic health conditions identified, which is consistent across the full 8-year period (see Figure 5 and Table 11 in appendix). In 2016/2017, 76% of offenders had between two and eight chronic health conditions identified, while 16% had nine or more identified. Similarly, 79% of offenders in the full 8-year period had between two and eight chronic health conditions identified and 10% had nine or more identified.

Figure 5. Number of Chronic Health Conditions Identified, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Figure 5. Number of Chronic Health Conditions Identified, 2009/2010 - 2016/2017
Number of Chronic Health Conditions Identified 2009/2010-2016/2017
None 5%
One 5%
Two 13%
Three 15%
Four 16%
Five 13%
Six 10%
Seven 7%
Eight 5%
Nine 5%
Ten or more 5%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

In 2016/2017, natural cause deaths most commonly occurred on Wednesday (27%) and were less likely to occur on Monday and Saturday (8% each; see Figure 6 and Table 12 in appendix). Across the full 8-year period, natural cause deaths most commonly occurred on Sunday (19%) and were less likely to occur on Tuesday (11%). In comparison to the full 8-year period, where 29% of natural cause deaths occurred in the morning (i.e., between 6am and 12pm), natural cause deaths were least likely to occur during this time in 2016/2017 (16%; (see Figure 7 and Table 13 in Appendix).

Figure 6. Natural Deaths by Day of the Week, 2009/2010 -2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure+.

Figure 6. Natural Deaths by Day of the Week, 2009/2010 -2016/2017
Natural Deaths by Day of the Week 2009/2010-2016/2017
Monday 19%
Tuesday 13%
Wednesday 11%
Thursday 18%
Friday 13%
Saturday 13%
Sunday 14%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure+.

Figure 7. Natural Deaths by Time of Day, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Figure 7. Natural Deaths by Time of Day, 2009/2010 - 2016/2017
Natural Deaths by Time of Day 2009/2010-2016/2017
Morning 29%
Afternoon 27%
Evening 25%
Overnight 19%
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Special Topic: Parole by Exception

Parole by exception, as stated in the Correctional and Conditional Release Act (CCRA, section 121), may be granted to an offender in CSC custody not yet eligible for day and/or full parole. When parole by exception is proposed due to health concerns, the institutional Parole Officer will initiate the pre-release process and the rationale must be clearly supported by medical evidence. If the Parole Board of Canada (PBC) determines that the criteria outlined in the CCRA1 has not been met, the review will be terminated. If these criteria are determined to have been met, the PBC will proceed with a consideration of granting parole by exception. In the instance of an offender who has a life-threatening in-curable illness whose parole eligibility dates have passed, they would apply for similar release through the regular parole process.

This would explain the somewhat low numbers of offenders who died in custody who had applied for parole by exception, as many offenders would not qualify and would apply for release through the regular parole process instead. More specifically, out of the 292 natural cause deaths that occurred in federal custody between 2009/2010 and 2016/2017, only 20 (7%) applied to the PBC for parole by exception and were denied. The other individuals either: a) did not submit an application through the regular parole process, b) submitted an application through the regular parole process and had their application denied, or c) cancelled/waived/withdrew their application.

However, it is important to note that the current report only examines offenders who have died in federal custody. This report does not examine offenders who were granted either parole by exception or parole and were subsequently released into the community (e.g., for palliative or hospice care). In other words, this report reflects only a portion of the decisions made surrounding compassionate release.

1 121 (1) Subject to section 102 — and despite sections 119 to 120.3 of this Act, sections 746.1 and 761 of the Criminal Code, subsection 226.1(2) of the National Defence Act and subsection 15(2) of the Crimes Against Humanity and War Crimes Act and any order made under section 743.6 of the Criminal Code or section 226.2 of the National Defence Act — Parole may be granted at any time to an offender (a) who is terminally ill; (b) whose physical or mental health is likely to suffer serious damage if the offender continues to be held in confinement; (c) for whom continued confinement would constitute an excessive hardship that was not reasonably foreseeable at the time the offender was sentenced; or (d) who is the subject of an order of surrender under the Extradition Act and who is to be detained until surrendered.

Compliance Issues in Relation to Natural Deaths

Reports produced by the Incident Investigation and Health Services branches in response to deaths outline if and where compliance issues with policy were discovered. In 2016/2017, the most common compliance issue identified in Mortality Reviews for natural cause deaths related to reporting requirements according to policy (24%), which is similar to the previous 7-year period (29%). Examples of such compliance issues identified over the 8-year period (2009/2010 - 2016/20017) include:

Across the 8-year period (2009/2010-2016/2017), the majority of compliance issues were similar across regions, with a few exceptions. The Quebec region had the highest percentage of compliance issues noted regarding exposure protocols (23%). The Atlantic region had the highest percentage of compliance issues around reporting requirements as per policy (37%), and the Quebec region had the lowest (20%). The Ontario region had the highest percentage of non-compliance when it came to providing support (Critical Incident Stress Management) to staff (32%) and offenders (33%) noted.

Special Topic: Offenders who are Aging and/or Dying in Custody

A significant amount of research has been conducted with offenders who are aging and/or dying in custody (e.g., Aday, 2006; Morton & Anderson, 1991). This research suggests variation in offenders’ perspectives on end of life (EOL). While much of the literature suggests that the thought of dying in custody is distressing for many offenders (e.g., Aday, 2006; Crawley & Sparks, 2006), some research suggests that this is not the case for all. For some, leaving the institution to enter palliative care/hospice may create significant stress for those who have spent a significant period of their life in custody and who may have outlived their friends and family members (e.g., Morton & Anderson, 1991; also see Aday & Wahidin, 2016 for a discussion on the current literature). In certain cases, hospice and palliative care opportunities within the institution may be the most humane option. CSC’s person-centred approach to care would allow offenders to communicate their treatment preferences and may also have a positive effect on their experiences with care, even in an institutional setting (e.g., Sanders & Stensland, 2018).

Non-Natural Deaths in Federal Custody

Manner of Death and Regional Differences

In 2016/2017, there were nine non-natural deaths in custody, including three suicide deaths, four overdose deaths, and two homicide deaths (see Table 14 in appendix). Overall, non-natural deaths were lowest in raw numbers in 2016/2017 compared to the seven fiscal years prior. Given low base numbers, fluctuations are likely to occur and should be interpreted with caution.

Over the 8-year period analyzed (2009/2010 - 2016/2017), suicide deaths were the most common cause of non-natural death (49%, n = 70), followed by overdose deaths (25%, n = 35), and homicide deaths (13%, n = 19; see Table 14 in appendix). Other types of non-natural deaths were relatively uncommon. As a percentage of non-natural deaths, suicide deaths have been decreasing, from 64% (9) in 2014/2015 to 33% (3) in 2016/2017. At the same time, the percentage of overdose deaths has been increasing, from 9% (2) in 2012/2013, to 44% (4) in 2016/2017.

Figure 8. Non-Natural Deaths in Custody Over an 8-year Period, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Figure 8. Non-Natural Deaths in Custody Over an 8-year Period, 2009/2010 - 2016/2017
Fiscal Year Non-Natural Deaths
Suicide Overdose Homicide Other
2009/2010 10 4 2 3
2010/2011 4 4 5 2
2011/2012 8 5 3 2
2012/2013 14 2 1 5
2013/2014 9 2 2 1
2014/2015 13 6 1 2
2015/2016 9 8 3 3
2016/2017 3 4 2 0
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

In terms of raw numbers, non-natural deaths over the 8-year period were highest in the Ontario region (37) followed by the Prairie region (36), and lowest in the Atlantic region (18; see Figure 9). In terms of the sub-types of non-natural deaths, suicide deaths were highest in the Prairie region (17), while overdose deaths were highest in the Ontario region (12; see Table 15 in appendix). As a percentage of non-natural deaths, suicide deaths were most common in the Atlantic region (61%), while overdose deaths were most common in Ontario (32%) and Quebec (30%).

Figure 9. Number of Non-Natural Deaths in Custody by Region, 2009/2010 - 2016/2017

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Figure 9. Number of Non-Natural Deaths in Custody by Region, 2009/2010 - 2016/2017
Region Non-Natural Deaths in Custody
Atlantic 18
Quebec 30
Ontario 37
Prairie 36
Pacific 21
Total 142
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this figure.

Characteristics of offenders who died from non-natural causes between 2009/2010 - 2016/2017

  • 76% had histories of substance misuse
  • 71% had at least one mental health condition
  • 66% had prior drug-related offences
  • 22% were in segregation at the time of death

Compliance Issues in Relation to Non-Natural Deaths

Over the 8-year period examined, the most common compliance issues noted in investigations pertaining to non-natural deaths related to reporting requirements (45%), exposure protocol (25%) and search logs/documentation of items found (22%; see Table 18 in appendix).

Recommendations from Board of Investigation (BOI) Reports

Investigations into non-natural deaths contain recommendations in cases where a need for a policy or other type of change has been identified. A thematic analysis of BOI recommendations was previously conducted for non-natural deaths that occurred between 2009/2010 and 2015/2016 and was continued for the 2016/2017 fiscal year. The recommendations put forth in the BOI reports were previously organized into eight general themes:

  1. Review a current process or implement a new process,
  2. Change or merge reports/forms,
  3. Review or change the guidelines, roles, responsibilities, and/or training of staff,
  4. Change the type of equipment used in medical emergencies,
  5. Changes to improve communication and sharing of information between services and departments,
  6. Review current policy or implement policy change to prevent a similar situation,
  7. Change institutional infrastructure, and
  8. Best practices.

In 2016/2017, the most common recommendations related to improving the communication and sharing of information between services and departments, and reviewing/changing the guidelines, roles, responsibilities, and/or training of staff.

As with the previous 7-year period, many of these recommendations were to clarify particular aspects of a staff member’s position or policies/procedures. Such recommendations were intended to eliminate confusion during medical emergencies or improve the training of all staff members who come into contact with offenders, especially contract employees. Overall, the recommendations across each category aimed to improve the Services’ overall care of individuals with mental health or substance misuse issues in order to prevent similar situations (i.e., non-natural deaths) from occurring, whether through policy changes, more effective training for staff or improved communication between services and departments.

Suicide Deaths in Federal Custody

Profile of Offenders who Died by Suicide

Profile of offenders who died by suicide in custody, 2009/2010 -2016/2017

  • 27% were Indigenous
  • 50% were classified as medium security
  • Average age was 41 years
  • 41% were convicted of a homicide-related offence
  • 80% had a history of substance misuse
  • 89% had at least one mental health condition identified

The three offenders who died by suicide in custody in 2016/2017 between the ages of 25 and 44, were classified as either medium security or maximum security, and all were serving indeterminate sentences for homicide-related offences (see Table 19 in appendix). This profile is consistent with that of offenders who died by suicide in custody in the 7-year period prior (2009/2010 - 2015/2016). In the previous 7-year period, the 67 offenders who died by suicide in custody tended to be White (64%) or Indigenous (27%), with an average age of 41. They tended to be medium security (49%) or maximum security (30%) offenders. Many were serving indeterminate sentences (42%), and serving time for homicide-related offences (39%).

Across the full 8-year period examined (2009/2010 - 2016/2017), those who died by suicide tended to have life-histories marked by substance misuse and mental health concerns. For example, 80% had a history of substance misuse, 89% had at least one mental health condition, and nearly 60% had at least one prior suicide attempt (see Table 23 in appendix). It was also common for those who died by suicide to have had previous mental health interventions; for example, 60% were on medication for mental illness at the time of death, 87% had regularly accessed mental health services, and 31% had been previously placed in a regional treatment centre (see Table 25 in appendix). Of note, 38% had a medication change prior to the suicide; in nearly 70% of such cases, the change occurred within three weeks of the incident.

Details Surrounding Suicide Deaths in Custody and Compliance Issues Identified

Over the last 8 years, 39% (n = 27) of suicide deaths have occurred in segregation (see Table 23 in appendix). The percentage was highest in the Atlantic and Pacific regions (46%, n = 5 in both cases), and lowest in the Ontario region (25%, n = 4; see Table 24 in appendix). Hanging was the primary method utilised in suicide deaths (see Table 20 appendix). Suicide deaths were most common in the middle of the week (between Tuesday and Thursday), peaking on Wednesdays (21%), and in the afternoon period (40%; see Table 21 in appendix).

Over the 8-year period analyzed, the most common compliance issue in relation to suicide deaths related to reporting requirements (46%, n = 32; see Table 27 in appendix). Other common compliance issues related to exposure protocol (noted in 23% of cases, n = 16) and search logs/documentation of items found (noted in 19% of cases, n = 13).

Overdose Deaths in Federal Custody

Profile of Offenders who died by Overdose

Profile of offenders who died by overdose in custody, 2009/2010 -2016/2017

  • 11% were Indigenous
  • 71% were classified as medium security
  • Average age was 39 years
  • 26% were convicted of a homicide related offence
  • 86% had a history of substance misuse
  • 54% had at least one mental health condition identified

Over the 8-year period analyzed, 35 offenders died in custody from an overdose, with four deaths occurring in 2016/2017. Offenders involved in overdose deaths tended to be White (86%), medium security (71%), serving an indeterminate sentence (26%) or short (less than four year) sentence (23%) for a homicide-related offence (26%) or robbery (23%; see Table 28 in appendix). The average age of offenders who died by overdose was 39. Those who died by overdose tended to have documented histories of substance misuse (86%; see Table 34 in appendix).

Details Surrounding and Compliance Issues Related to Overdose Deaths

Of the four overdose deaths that occurred in 2016/2017, two involved prescription medications and two involved illegal substances (see Table 29 in appendix). All four cases involved opioids as a standalone or contributing substance. Across the 8-year period examined, illegal substances were most common, evident in 74% (n = 26) of cases, with opioids being present as a standalone or contributing substance in 89% (n = 31) of cases. In terms of specific substances, fentanyl was involved in 37% (n = 13) of cases, heroin was involved in 20% (n = 7), and morphine was involved in 23% (n = 8; see Tables 30 and 31 in appendix). Overdose incidents were most common between Wednesday and Saturday and in the morning period (see Tables 32 and 33 in appendix).

Over the 8-year period analyzed, the most common compliance issues in relation to overdose deaths related to reporting requirements, noted in 43% (n = 15) of cases. Other common compliance issues related to search logs/documentation of items found (31%, n = 11) and exposure protocol (29%, n = 10; see Table 36 in appendix)

CSC Research on Overdose Incidents in Federal Custody

Findings indicate that opioid-related incidents are increasing, but life-saving measures are likely preventing fatalities.

In response to the growing number of opioid-related overdose incidents in custody, CSC has recently conducted an in-depth review of all fatal and non-fatal overdose incidents in custody over a five-year period (2012/2013 - 2016/2017; McKendy, Biro, & Keown, 20191). This review found that 330 overdose-related incidents occurred during this period, most of which were unintentional and non-fatal. Opioids were the most common substance involved in overdose incidents over the 5-year period, while those involving fentanyl and its analogues have increased. This report also indicated the importance of harm reduction measures, such as the new initiative in which non-health services staff are trained to administer naloxone (as of Fall 2016), a substance that can temporarily reverse opioid overdose. Use of Naloxone has substantially increased following the introduction of the nasal spray version of naloxone (Narcan™) for use by correctional officers.

1 McKendy, L., Biro, S., & Keown, L. A. (2019). Overdose Incidents in Federal Custody, 2012/2013 - 2016/2017 (Special Report SR-18-02). Ottawa, ON: Correctional Service of Canada

Non-Natural Deaths in Federal Custody by Other Manner

Profile of Offenders who Died by Other Manner and Compliance Issues Identified

Profile of offenders who died by homicide, 2009/2010 - 2016/2017

  • 32% were Indigenous
  • 58% were classified as medium security
  • Average age was 41 years
  • 42% were convicted of a homicide-related offence
  • 44% had a history of substance misuse
  • 39% had at least one mental health condition identified

Homicides, accidental deaths, and undetermined cause deaths tend to occur less frequently than other non-natural deaths. In 2016/2017, deaths by other non-natural manner included two homicide deaths (see Table 38 in appendix). Over the 8-year period analyzed, 3 5 other types of deaths occurred (i.e., nine accidental deaths, 19 homicide deaths, and seven deaths that were undetermined).Footnote 9 Offenders who died by other non-natural manner in the 8-year period tended to be White (63%) or Indigenous (26%), medium (57%) or maximum security (29%), serving an indeterminate sentence (46%), and serving time for a homicide-related offence (40%). The average age of these offenders was 41 years.

Offenders who died by other non-natural manner over the 8-year periodFootnote 10 often had histories involving substance misuse, health issues, or mental health issues (see Table 41 in appendix). For example, 56% (n = 18) had histories of substance abuse, 44% (n = 14) had prior drug-related offences/incidents, 47% (n = 15) had at least one chronic health issue, and 50% (n = 16) had at least one mental health issue. The most common compliance issue in relation to non-natural death by other manner related to reporting requirements (44%, n = 14; see Table 42 in appendix). Other common compliance issues related to exposure protocols, search protocols, and search logs/documentation of items found.

Conclusion

Deaths in custody, particularly non-natural deaths, remain a complex and difficult issue for all correctional jurisdictions. CSC recognizes that it is vital to continuously work to enhance relevant prevention and intervention strategies. CSC has prioritized learning from all deaths that occur in custody in an effort to improve treatment for offenders with a life-threatening, non-curable illness and prevent future non-natural deaths in custody.

As previously mentioned, CSC strives to provide compassionate, innovative, patient- and family-centered hospice palliative care (HPC)Footnote 11 to offenders with a life-threatening, non-curable illnessFootnote 12. The Hospice Palliative Care Guidelines for Correctional Service Canada (2009) is informed by the principles and standards of the Canadian Hospice Palliative Care Association (Canadian Hospice Palliative Care Association, 2013; Ferris et al., 2002). HPC aims to provide self-directed care by an Interdisciplinary HPC Team, who are both knowledgeable and skilled in all aspects of the caring process related to their discipline of practice, in order to meet each offender’s unique health and social care needs. HPC is available across a continuum of care, from diagnosis to end-of-life and may be provided in different environments, such as an offender’s parent institution, at a CSC Regional Hospital where 24-hour nursing care is available, or in community agencies and facilities such as Haley House.

CSC also continues to expand strategies in place to prevent non-natural deaths in custody. Current measures in place to combat overdose deaths, for example, include drug prevention and detection strategies (e.g., use of ion scanners, urinalysis testing, intelligence gathering to lead searches, and drug detection dogs; Correctional Service Canada, 2017; Johnson, Cheverie, & Moser 2010), harm reduction measures, including opiate agonist therapy (Cheverie 2014) and the availability of naloxone to both medical and non-medical staff working in CSC institutions, as well as the availability of correctional programming targeting substance misuse (Ternes, Doherty & Matheson 2014; Doherty, Ternes & Matheson, 2014; Kunic & Varis 2009). To reduce the likelihood of suicide deaths, CSC utilizes tools to screen individuals for mental illness and suicide risk (Mills and Kroner 2010; Archambault et al. 2010; Stewart et al. 2009), and has procedures in place for enhanced observation and care of individuals at risk (Correctional Service Canada, 2012).

Though the presentation of information may differ across each annual report as the number of deaths that occur each fiscal year can fluctuate greatly, the goal of these reports remains the same. This annual report, and future reports, will continue to contribute to the organization's ability to quickly identify trends, areas for opportunity, and initiatives to reduce deaths in custody. Furthermore, this report contributes to transparency and open communication regarding both natural and non-natural deaths, thereby facilitating the continual collaboration with stakeholders and experts who may contribute to the important goal of preventing non-natural deaths and improving the health care of offenders with life-threatening, non-curable illnesses while in federal custody.

This report also highlights the need for CSC to maintain its efforts for the reduction of deaths in custody, particularly non-natural deaths. These efforts must include the acquisition of knowledge, the development of capacity, and the introduction of measures, protocols, and initiatives to increase our efficiencies. CSC must also self-reflect on how it manages its in-custody population to assist offenders in their own path to reintegration, in a safe and secure environment. Finally, CSC must support its professional workforce, without which CSC will not be able to fulfil its mission. Training, collaboration, and better communication must be maintained or increased in order to build cohesion and expertise in managing potentially tragic situations that can result in a loss of life.

References

Aday, R. (2006). Aging prisoners’ concerns toward dying in prison. OMEGA: Journal of Death and Dying, 52(3), 199-216.

Aday, R. & Wahidin, A. (2016). Older prisoners’ experiences of death, dying, and grief behind bars. The Howard Journal of Crime and Justice, 55(3), 312-327. doi: 10.1111/hojo.12172

Archambault, K., Stewart, L., Wilton, G., & Cousineau, C. (2010). Initial results of the Computerized Mental Health Intake Screening System (CoMHISS) for Federally Sentenced Women. Research Report R-230. Ottawa, ON: Correctional Service Canada.

Canadian Hospice Palliative Care Association (2013). A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice (Revised and Condensed Edition). Ottawa, ON: Canadian Hospice Palliative Care Association. Retrieved from http://www.chpca.net/media/319547/norms-of-practice-eng-web.pdf

Cheverie, M., MacSwain, M., Farrell MacDonald, S., & Johnson, S. (2014). Institutional Adjustment of Methadone Maintenance Treatment Program (MMTP) Participants. Research Report R-323. Ottawa, ON: Correctional Service Canada.

Correctional Service Canada (2009). Hospice Palliative Care Guidelines for Correctional Services Canada. July 2009.

Correctional Service Canada (2010). Commissioner’s Directive (CD) Number 041: Incident Investigations.

Correctional Service Canada (2012). Commissioner’s Directive (CD) Number 843: Interventions to Preserve Life and Prevent Serious Bodily Harm.

Correctional Service Canada (2017). Commissioner’s Directive (CD) Number 566-8-1: Use of Non-Intrusive Search Tools.

Corrections and Conditional Release Act (S.C 1992, c. 20), section 121.

Crawley, E. & Sparks, R. (2006). Is there life after imprisonment? How elderly men talk about imprisonment and release. Criminology and Criminal Justice, 6(1), 63-82. doi: 10.1177/1748895806060667

Doherty, S., Ternes, M., & Matheson, F.I. (2014). An Examination of the Effectiveness of the National Substance Abuse Program High Intensity (NSAP-H) on Institutional Adjustment and Post-Release Outcomes. Research Report R-290. Ottawa, ON: Correctional Service of Canada.

Ferris, F. D., Balfour, H. M., Bowen, K., Farley, J., Hardwick, M., Lamontagne, C., Lundy, M., Syme, A., & West, P. (2002). A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice. Ottawa, ON: Canadian Hospice Palliative Care Association.

Johnson, S., Cheverie, M., & Moser, A. (2010). Assessing the Impact of Enhanced Drug Interdiction Activities at Kingston Penitentiary: A Pilot Study. Research Report R-232. Ottawa: Correctional Service Canada.

McKendy, L., Biro, S., & Keown, L.A. (2019). Overdose Incidents in Federal Custody, 2012/2013 - 2016/2017. Special Report SR-18-02. Ottawa, ON: Correctional Service of Canada

Mills, J. and Kroner, D. (2010). Concurrent Validity and Normative Data of the Depression Hopelessness and Suicide Screening Form with Women Offenders. Research Brief B-47. Ottawa, ON: Correctional Service Canada.

Morton, J. B. & Anderson, J. C. (1991). Elderly offenders: the forgotten minority. Corrections Today, 44(7), 14-17.

Sanders, M. & Stensland, S. (2018). Living a life full of pain: Older pain clinic patients’ experience of living with chronic low back pain. Qualitative Health research, 28(9), 1434-1448. doi: 10.1177/1049732318765712

Stewart, L. A., Harris, A., Wilton, G., Archambault, K.Y. Cousineau, C., Varrette, S., & Power, J. (2009). An Initial Report on the Results of the Pilot of the Computerized Mental Health Intake Screening System (CoMHISS). Research Report R-218. Ottawa, ON: Correctional Service Canada.

Stewart, L. A., Nolan, A., Sapers, J., Power, J., Panaro, L., & Smith, J. (2015). Chronic health conditions reported by male inmates newly admitted to Canadian federal penitentiaries. Canadian Medical Association Journal Open, 3(1), E97-E102. doi: 10.9778/cmajo.20140025

Ternes, M., Doherty, S., & Matheson, F.I. (2014) An Examination of the Effectiveness of the National Substance Abuse Program Moderate Intensity (NSAP-M) on Institutional Adjustment and Post-Release Outcomes. Research Report R-291. Ottawa, ON: Correctional Service Canada.

Appendix A - Tables

Table 3
Characteristics of Death for Fiscal Year 2016/2017
Characteristics Manner of Death Total
Natural Non-natural
Ethnicity
White 29 6 35
Indigenous 7 3 10
Black - - -
Other 2 - 2
Age
18 - 24 - 1 1
25 - 34 1 2 3
35 - 44 4 3 7
45 - 54 3 1 4
55 - 64 12 2 14
65 - 74 16 - 16
75 - 79 1 - 1
80+ 1 - 1
Sentence length
Less than 4 years 4 3 7
4 to 6 years 1 1 2
6 to 10 years 7 - 7
More than 10 years 3 1 4
Indeterminate 23 4 27
Index offence
Homicide related 23 4 27
Sexual 7 - 7
Assault - 1 1
Robbery 5 - 5
Other violent - - -
Property 1 1 2
Drug 1 2 3
Other non-violent 1 1 2
Offender security level
Maximum 4 2 6
Medium 18 6 24
Minimum 15 1 16
Not yet determined 1 - 1
Time served on sentence
Less than three months - - -
Three months to less than five years 14 6 20
Five years to less than 10 years 5 - 5
10 years to less than 20 years 6 2 8
20+ years 13 1 14
Total 38 9 47
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 4
Characteristics of Offenders who Died in Custody by Natural and Non-natural Deaths over a 7-year Period (2009/2010 - 2015/2016).
Characteristics Manner of Death Total
Natural Non-natural
Ethnicity
White 208 92 300
Indigenous 35 30 65
Black 5 5 10
Other 6 6 12
Age
18 - 24 1 9 10
25 - 34 3 46 49
35 - 44 20 25 45
45 - 54 54 28 82
55 - 64 88 19 107
65 - 74 63 5 68
75 - 79 16 - 16
80+ 9 1 10
Sentence length
Less than 4 years 51 29 80
4 to 6 years 21 23 44
6 to 10 years 25 17 42
More than 10 years 20 12 32
Indeterminate 137 52 189
Index offence
Homicide related 111 48 159
Sexual 60 17 47
Assault 16 12 28
Robbery 31 29 60
Other violent 6 7 13
Property 8 7 15
Drug 6 4 10
Other non-violent 16 9 25
Offender security level
Maximum 25 37 62
Medium 149 75 224
Minimum 71 12 83
Not yet determined 9 9 18
Time served on sentence
Less than three months 14 10 24
Three months to less than five years 90 72 162
Five years to less than 10 years 28 17 45
10 years to less than 20 years 40 20 60
20+ years 82 14 96
Total 254 133 387
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 5
Offenders who died in Custody by Natural Death Sub-type, 2009/2010 - 2015/2016 and 2016/2017.
Natural Sub-types Fiscal Year Total
2009/2010 - 2015/2016 2016/2017
Cancer 91 9 100
Cardiovascular related 73 9 82
Infection 22 3 25
Liver related 24 3 27
Neurological related 12 1 13
Othera 5 9 14
Respiratory related 27 3 30
Total 254 37b 291b

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aAlso includes individuals where a specific natural sub-type was unable to be determined.
bOne investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 6
Regional Distribution of Natural Deaths in Custody by Subtype Over an 8-year Period (2009/2010 - 2016/2017).
Natural Sub-types Region Total
Atlantic Quebec Ontario Prairie Pacific
Cancer 6 26 37 12 19 100
Cardiovascular related 7 30 13 17 15 82
Infection 2 6 9 3 5 25
Liver related 1 5 10 10 1 27
Neurological related 1 1 6 2 3 13
Other a 1 5 4 1 3 14
Respiratory related 1 7 12 6 4 30
Total 19 80 91 51 50 291b

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aAlso includes individuals where a specific natural sub-type was unable to be determined.
b One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year

Table 7
Events Surrounding Natural Deaths, 2009/2010 - 2015-2016 and 2016-2017.
Factors/Events Fiscal Year Total
2009/2010 -2015/2016 2016/2017
DNR on fileb 121 15 136
Received palliative careb 127 20 147
Next-of-kin involvementb
Yesa 81 11 92
Notified by CSC, not involved 30 6 36
Notified by non-CSC, not involved 7 - 7
No next of kin noted 18 6 24
Unclear 20 - 20
Final cause is related to
Substance misuse 62 7 69
Cigarette Smoking 130 10 140
Primary source of social support
Family/friends outside the institution 73 9 82
Other offenders 4 3 7
CSC staff 10 1 11
Medical personnel 81 4 85
Not indicated 86 20 106
Any chronic health condition identified 243 35 278
Any mental health condition identified 124 23 147
Noncompliance with medication
Yes 87 13 100
No 79 5 84
Not indicated 71 19 90
Not applicable 17 - 17
Total number of natural deaths 254 37c 291c

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Includes contact, visits, decision-making and/or consent.
b These categories exclude unexpected deaths.
c One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 8
Events Surrounding Natural Deaths for an 8-year Period (2009/2010 - 2016/2017) by Region.
Factors/Events Region Total
Atlantic Quebec Ontario Prairie Pacific
DNR on fileb 8 28 50 30 20 136
Received palliative careb 7 37 54 28 21 147
Next-of-kin involvement
Yesa 7 22 34 19 10 92
Notified by CSC, not involved 4 6 11 6 9 36
Notified by non-CSC, not involved - 3 3 - 1 7
No next of kin noted - 7 7 4 6 24
Unclear 1 4 10 4 1 20
Final cause is related to
Substance misuse 7 9 22 18 13 69
Cigarette Smoking 12 35 36 25 32 140
Primary source of social support
Family/friends outside the institution 6 13 29 18 16 82
Other offenders - 1 2 - 4 7
CSC staff 2 - 5 2 2 11
Medical personnel 4 27 28 13 13 85
Not indicated 7 39 27 18 15 106
Any chronic health condition identified 17 78 87 47 49 278
Any mental health condition identified 11 24 49 28 35 147
Noncompliance with medication
Yes 9 18 31 21 21 100
No 4 14 37 14 15 84
Not indicated 6 39 19 14 12 90
Not applicable - 9 4 2 2 17
Total number of natural deaths 19 80 91 51 50 291c

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Includes contact, visits, decision-making and/or consent.
b These categories exclude unexpected deaths.
c One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 9
Types of Chronic Health Conditions for Natural Deaths, 2009/2010 - 2015/2016 and 2016/2017.
Chronic Health Condition Types Fiscal Year Totala
2009/2010 -2015/2016 2016/2017
Cardiovascular 180 28 208
Central nervous system 57 11 68
Blood-borne virus/Infection 92 18 110
Endocrine 85 18 103
Gastrointestinal 100 24 124
Musculoskeletal 96 13 109
Reproductive 25 3 28
Respiratory 116 17 133
Total number of natural deathsa 254 37c 291c

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a These totals will not add to the total number of natural deaths as offenders may have multiple types of chronic health conditions.
c One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 10
Types of Chronic Health Conditions for Natural Deaths Over an 8-year Period (2009/2010 - 2016/2017) by Region.
Chronic Health Condition Types Region Totala
Atlantic Quebec Ontario Prairie Pacific
Cardiovascular 14 66 59 36 33 208
Central nervous system 3 11 26 13 15 68
Blood-borne virus/Infection 7 23 37 23 20 110
Endocrine 6 32 28 20 17 103
Gastrointestinal 11 25 45 23 20 124
Musculoskeletal 10 20 37 19 23 109
Reproductive 1 8 9 4 6 28
Respiratory 5 43 35 24 26 133
Total number of natural deathsa 19 80 91 51 50 291c

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a These totals will not add to the total number of natural deaths as offenders may have multiple types of chronic health conditions.
c One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 11
Total Number of Chronic Health Conditions Identified for Natural Deaths, 2009/2010 - 2015/2016 and 2016/2017.
Number of Chronic Health Conditions Identified Fiscal Year Total
2009/2010 -2015/2016 2016/2017
None 14 2 16
One 12 1 13
Two 33 4 37
Three 40 3 43
Four 41 6 47
Five 33 5 38
Six 27 2 29
Seven 18 2 20
Eight 10 6 16
Nine 13 3 16
Ten or more 13 3 16
Total number of natural deaths 254 37c 291c

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
c One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 12
Natural Deaths by Day of the Week, 2009/2010 - 2015/2016 and 2016/2017.
Day of the Week Fiscal Year Total
2009/2010 -2015/2016 2016/2017
Sunday 50 4 54
Monday 36 3 39
Tuesday 23 8 31
Wednesday 42 10 52
Thursday 33 4 37
Friday 32 5 37
Saturday 38 3 41
Total 254 37c 291c

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
c One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 13
Natural Deaths by Time of Day, 2009/2010 - 2015/2016 and 2016/2017.
Time of Day1 Fiscal Year Total
2009/2010 -2015/2016 2016/2017
Morninga 77 6 83
Afternoonb 70 10 80
Eveningc 61 11 72
Overnightd 46 10 56
Total 254 37e 291e

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
1 Time of day refers to the time of day the death was confirmed and not necessarily the exact incident time.
a Deaths that occurred between 6:00am and 12:00pm.
b Deaths that occurred between 12:00pm and 6:00pm.
c Deaths that occurred between 6:00pm and 12:00am.
d Deaths that occurred between 12:00am and 6:00am.
e One investigation is ongoing and therefore detailed information is available for only 37 of 38 cases in the 2016/2017 fiscal year. As a result, totals in some columns may not match actual total number of deaths in this fiscal year.

Table 14
Number of Non-Natural Deaths in Custody by Manner of Death Over an 8-year Period (2009/2010 - 2016/2017).
Fiscal Year Non-Natural Manner of Death Total
Suicide Overdose Accident Homicide Staff Involved Undetermined
2009/2010 10 4 1 2 - 2 19
2010/2011 4 4 - 5 1 1 15
2011/2012 8 5 1 3 - 1 18
2012/2013 14 2 2 1 - 3 22
2013/2014 9 2 1 2 - - 14
2014/2015 13 6 2 1 - - 22
2015/2016 9 8 2 3 1 - 23
2016/2017 3 4 - 2 - - 9
Total 70 35 9 19 2 7 142
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 15
Non-Natural Deaths in Custody by Manner of Death Over an 8-year Period (2009/2010 - 2016/2017) by Region
Manner of Deatha Region Total
Atlantic Quebec Ontario Prairie Pacific
Suicide 11 15 16 17 11 70
Overdose 2 9 12 7 5 35
Accident 1 2 3 1 2 9
Homicide 3 1 2 11 2 19
Staff Involved 1 - 1 - - 2
Undetermined - 3 3 - 1 7
Total 18 30 37 36 21 142

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aThere are too few cases to display the regional distribution in 2016/2017 in a table individually.

Table 16
Events Surrounding Non-Natural Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Factor/Eventa Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
History of substance misuse 15 13 13 19 11 12 16 7 106
Prior drug-related offences/incidents 13 11 10 11 10 13 17 7 92
In segregation at time of death 4 2 3 8 5 2 4 2 30
Other offenders involved in incident 3 5 2 1 2 6 2 - 21
Any chronic health condition identified 8 6 10 15 3 9 12 3 66
Any mental health condition identified 15 12 11 17 12 12 14 6 99
Total number of non-natural deaths 19 15 18 22 14 21 22 8 139

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Information for these variables is available for only 139 of 142 cases in the 2009/2010 - 2016/2017 period. Totals in these columns therefore may not match actual total number of deaths in all fiscal years.

Table 17
Events Surrounding Non-Natural Deaths Over an 8-year Period (2009/2010 - 2016/2017) by Region.
Factor/Eventab Region Total
Atlantic Quebec Ontario Prairie Pacific
History of substance Misuse 15 23 27 27 14 106
Prior drug-related offences/incidents 14 15 25 23 15 92
In segregation at time of death 5 6 4 10 5 30
Other offenders involved in incident 4 3 7 2 5 21
Any chronic health condition identified 11 14 20 10 11 66
Any mental health condition identified 14 19 26 27 13 99
Total number of non-natural deaths 17 30 36 35 21 139

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aThere are not enough cases to display the regional distribution in 2016/2017 in a table individually.
bInformation for these variables is available for only 139 of 142 cases in the 2009/2010 - 2016/2017 period. Totals in these columns therefore may not match actual total number of deaths in all fiscal years.

Table 18
Compliance Issues in Relation to Non-Natural Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Compliance Issuea Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Compliance issues related to post-use handling of AEDb 1 - 1 - 1 2 2 - 7
Staff levels at time of incident not in accordance with policy 3 1 - - - - 1 - 5
Offender security level at time of incident deemed not appropriate 1 1 - 2 1 - 1 - 6
Staff compliance issues with exposure protocol 8 3 5 6 4 3 4 1 34
All staff implicated in incident not up to date with certifications 2 1 - 2 5 2 2 1 15
Lack of appropriate and necessary equipment available to respond to medical emergency 2 4 - 2 - 1 4 1 14
Non-compliance with search protocols 6 2 5 2 3 6 - - 24
Non-compliance with search logs and documentation of items found 3 5 5 3 1 5 6 2 30
Non-compliance with reporting requirements as per policy 13 11 11 12 4 5 5 2 63
Support not provided to staff following incident 2 - 2 - - - 1 - 5
Support not provided to offenders following incident 2 - - 2 - - 1 - 5
Aboriginal social history not taken into account in offender related decisions 1 - 2 5 2 - 1 1 12
Total number of non-natural deaths 19 15 18 22 14 21 22 8 139

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Information for these variables is available for only 139 of 142 cases in the 2009/2010 - 2016/2017 period. Totals in these columns therefore may not match actual total number of deaths in all regions.
b Automated External Defibrillator.

Table 19
Characteristics of Offenders who Died in Federal Custody by Suicide, 2009/2010 - 2015/2016 and 2016/2017.
Characteristic Fiscal Year(s) Total
2009/2010 -2015/2016 2016/2017
Ethnicity
White 43 2 45
Indigenous 18 1 19
Black 4 - 4
Other 2 - 2
Age
18 - 24 6 - 6
25 - 34 21 2 23
35 - 44 12 1 13
45 - 54 17 - 17
55 - 64 8 - 8
65 - 74 3 - 3
75 - 79 - - -
80 + - - -
Offender security level
Maximum 20 1 21
Medium 33 2 35
Minimum 9 - 9
Undetermined 5 - 5
Index offence
Homicide related 26 3 29
Sexual 11 - 11
Assault 8 - 8
Robbery 14 - 14
Other violent 3 - 3
Property 2 - 2
Drug 1 - 1
Other non-violent 2 - 2
Sentence length
2 to less than 4 years 16 - 16
4 to less than 6 years 9 - 9
6 to less than 10 years 9 - 9
More than 10 years 5 - 5
Indeterminate 28 3 31
Total 67 3 70
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 20
Sub-types of Suicide Deaths in Custody Over an 8-year Period (2009/2010 - 2016/2017).
Subtype Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Hanging 9 3 8 11 8 9 8 - 56
Ligature - - - 1 - - - 2 3
Asphyxiation - 1 - - - 2 1 - 4
Cutting - - - 1 - 2 - 1 4
Other 1 - - 1 1 - - - 3
Total 10 4 8 14 9 13 9 3 70
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 21
Suicide Deaths by Day of the Week Over an 8-year Period (2009/2010 - 2016/2017).
Day of Week Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Sunday 1 - 2 - 1 1 2 - 7
Monday 1 1 2 2 1 1 1 - 9
Tuesday 2 1 1 1 1 3 1 - 10
Wednesday 1 - 3 3 1 3 3 1 15
Thursday 3 - - 4 2 1 1 - 11
Friday - 2 - 3 1 1 - 1 8
Saturday 2 - - 1 2 3 1 1 10
Total 10 4 8 14 9 13 9 3 70
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 22
Suicide Deaths by Time of Day Over an 8-year Period (2009/2010 - 2016/2017).
Time of Day1 Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Morninga - 1 1 4 3 1 - 1 11
Afternoonb 4 1 4 5 4 5 4 1 28
Eveningc 1 1 3 3 1 3 2 1 15
Overnightd 5 1 - 2 1 4 3 - 16
Total 10 4 8 14 9 13 9 3 70

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
1 Time of day refers to the time of day the death was confirmed and not necessarily the exact incident time.
a Deaths that occurred between 6:00am and 12:00pm.
b Deaths that occurred between 12:00pm and 6:00pm.
c Deaths that occurred between 6:00pm and 12:00am.
d Deaths that occurred between 12:00am and 6:00am.

Table 23
Events Surrounding Suicide Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Time of Day Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
History of substance misuse 7 4 7 12 8 7 9 2 56
Prior drug-related offences/incidents 7 3 4 8 6 7 8 2 45
In segregation at time of death 2 2 3 8 5 2 4 1 27
Other offenders involved in the incidenta 1 - 1 - 1 2 1 - 6
Any chronic health condition identified 4 1 6 9 3 6 8 1 38
Any mental health condition identified 9 4 7 11 9 11 9 2 62
Total number of suicides 10 4 8 14 9 13 9 3 70

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Includes reporting or alerting staff.

Table 24
Events Surrounding Suicide Deaths Over an 8-year Period (2009/2010 - 2016/2017) by Region.
Characteristica Region Total
Atlantic Quebec Ontario Prairie Pacific
History of substance misuse 10 11 13 14 8 56
Prior drug-related offences/incidents 10 6 10 11 8 45
In segregation at time of death 5 4 4 9 5 27
Other offenders involved in incidentb 1 1 1 1 2 6
Any chronic health condition identified 8 5 10 8 7 38
Any mental health condition identified 10 13 15 15 9 62
Total number of suicides 11 15 16 17 11 70

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aThere are not enough cases to display the regional distribution in 2016/2017 in a table individually.
bIncludes reporting or alerting staff.

Table 25
Other Elements in Suicide Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Element Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Prior suicide attempts 6 4 6 10 5 4 4 2 41
Prior Regional Treatment Centre placement 2 1 3 3 2 5 4 2 22
Prior mental health services 9 4 7 12 8 10 8 3 61
Presence of a suicide note 4 1 3 8 2 5 4 2 29
On medication for mental illness at time of death 6 3 5 7 6 7 8 - 42
Was being monitored prior to death 3 1 - 3 2 1 4 2 16
Total number of suicides 10 4 8 14 9 13 9 3 70
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 26
Other Elements in Suicide Over an 8-year Period (2009/2010 - 2016/2017) by Region.
Elementa Region Total
Atlantic Quebec Ontario Prairie Pacific
Prior suicide attempts 6 9 10 12 4 41
Prior Regional Treatment Centre placement 3 4 5 6 4 22
Prior mental health services 9 13 15 16 8 61
Presence of suicide note 2 8 6 8 5 29
On medication for mental illness at time of death 8 7 9 10 8 42
Was being monitored prior to death 5 3 2 4 2 16
Total number of suicides 11 15 16 17 11 70

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aThere are not enough cases to display the regional distribution in 2016/2017 in a table individually

Table 27
Compliance Issues in Relation to Suicide Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Compliance Issue Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Compliance issues related to post-use handling of AEDa 1 - 1 - - 1 - - 3
Staff levels at time of incident not in accordance with policy 1 - - - - - - - 1
Offender security level at time of incident deemed not appropriate 1 1 - 1 1 - 1 - 5
Staff compliance issues with exposure protocol 4 - 2 5 2 2 - 1 16
All staff implicated in incident not up to date with certifications 1 - - 2 4 1 1 1 10
Lack of appropriate and necessary equipment available to respond to medical emergency 1 2 - 2 - - 1 1 7
Non-compliance with search protocols 3 1 - 2 3 2 - - 11
Non-compliance with search logs and documentation of items found 2 2 - 2 - 2 5 - 13
Non-compliance with reporting requirements as per policy 7 4 4 7 3 4 2 1 32
Physical layout of institution impeded ability of staff to observe incident while happening - - 1 3 - - - - 4
Support not provided to staff following incident 1 - 2 - - - 1 - 4
Support not provided to offenders following incident - - - 2 - - - - 2
Aboriginal social history not taken into account in offender related decisions - - - 3 2 - 1 1 7
Total number of suicide deaths 10 4 8 14 9 13 9 3 70

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Automated External Defibrillator.

Table 28
Characteristics of Offenders who Died by Overdose, 2009/2010 - 2015/2016 and 2016/2017.
Characteristic Fiscal Year(s) Total
2009/2010 -2015/2016 2016/2017
Ethnicity
White 26 4 30
Indigenous 4 - 4
Black - - -
Other 1 - 1
Age
18 - 24 1 1 2
25 - 34 15 - 15
35 - 44 8 1 9
45 - 54 3 - 3
55 - 64 4 2 6
65 - 74 - - -
75 - 79 - - -
80+ - - -
Offender security level
Maximum 7 - 7
Medium 22 3 25
Minimum 1 1 2
Undetermined 1 - 1
Index offence
Homicide related 8 1 9
Sexual 1 - 1
Assault 2 1 3
Robbery 8 - 8
Other violent 3 - 3
Property 4 - 4
Drug 2 2 4
Other non-violent 3 - 3
Sentence length
2 to less than 4 years 7 1 8
4 to less than 6 years 6 1 7
6 to less than 10 years 6 - 6
More than 10 years 4 1 5
Indeterminate 8 1 9
Total number of overdose deaths 31 4 35
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 29
Type of Substance in Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Sub-type Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Offender’s prescription - - 1 - - - 1 1 3
Other prescription drugs 2 1 - - - 1 - 1 5
Illegal substance 2 2 4 2 2 5 7 2 26
Undetermined - 1 - - - - - - 1
Total number of overdose deaths 4 4 5 2 2 6 8 4 35
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 30
Specific Substance in Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Substance Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Mixa 3 2 1 2 1 - 2 2 13
Fentanyl - - 1 - 1 3 4 1 10
Heroin - - 1 - - 1 1 - 3
Morphine - 1 1 - - - - - 2
Other 1 1 1 - - 2 - 1 6
Unknown - - - - - - 1 - 1
Total number of overdose deaths 4 4 5 2 2 6 8 4 35

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a This category includes those where multiple substances were identified. For example, in 2015/2016, the two deaths listed in this category also included Fentanyl. Please refer to table 31 for the total number of cases where Fentanyl was involved.

Table 31
Opioid-related Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Substance Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Opioid involved a 4 2 5 2 2 5 7 4 31
Fentanyl involved - - 2 - 1 3 6 1 13
Total number of overdose deaths 4 4 5 2 2 6 8 4 35

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Involved as a standalone or contributing substance.

Table 32
Overdose Deaths by Day of the Week Over an 8-year Period (2009/2010 - 2016/2017).
Day of the Week Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Sunday - 2 1 - - 1 - - 4
Monday 1 - - - 1 - - - 2
Tuesday - - - - - 2 1 - 3
Wednesday 1 1 1 - - 1 - 2 6
Thursday - - 1 2 1 - 4 - 8
Friday 1 - - - - 1 3 - 5
Saturday 1 1 2 - - 1 - 2 7
Total number of overdose deaths 4 4 5 2 2 6 8 4 35
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 33
Overdose Deaths by Time of Day Over an 8-year Period (2009/2010 - 2016/2017).
Time of Day1 Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Morninga 1 - 1 1 1 3 4 3 14
Afternoonb 1 2 1 - 1 1 1 - 7
Eveningc 1 1 - - - 2 1 1 6
Overnightd 1 1 3 1 - - 2 - 8
Total number of overdose deaths 4 4 5 2 2 6 8 4 35

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table. 1 Time of day refers to the time of day the death was confirmed and not necessarily the exact incident time.
a Deaths that occurred between 6:00am and 12:00pm.
b Deaths that occurred between 12:00pm and 6:00pm.
c Deaths that occurred between 6:00pm and 12:00am.
d Deaths that occurred between 12:00am and 6:00am.

Table 34
Information Related to Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Characteristic/Event Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
History of substance misuse 4 4 4 2 2 5 5 4 30
Prior drug-related offences/incidents 4 4 4 2 2 6 5 4 31
In segregation at time of death 2 - - - - - - 1 2
Positive urinalysis test(s) within one year prior 1 2 2 - 1 1 4 1 12
Other offenders involved in the incidenta 1 2 1 - 1 3 1 - 9
Any chronic health condition identified 1 2 2 1 - 2 2 2 12
Any mental health condition identified 2 4 2 1 2 1 4 3 19
Total number of overdose deaths 4 4 5 2 2 6 8 4 35

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
*Not enough information available to determine.

Table 35
Information Related to Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017) by Region.
Characteristic/Eventa Region Total
Atlantic Quebec Ontario Prairie Pacific
History of substance misuse 2 9 10 7 2 30
Prior drug-related offences/incidents 2 8 11 6 4 31
In segregation at time of death - 1 - 1 - 2
Positive urinalysis test(s) within one year prior 1 - 4 5 2 12
Other offenders involved in the incidenta 1 2 4 - 2 9
Any chronic health condition identified - 5 5 - 2 12
Any mental health condition identified 1 3 7 7 1 19
Total number of overdose deaths 2 9 12 7 5 35

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aThere are not enough cases to display the regional distribution in 2016/2017 in a table individually.
*Not enough information available to determine.

Table 36
Compliance Issues in Relation to Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017).
Compliance Issue Fiscal Year Total
2009/ 2010 2010/ 2011 2011/ 2012 2012/ 2013 2013/ 2014 2014/ 2015 2015/ 2016 2016/ 2017
Compliance issues related to post-use handling of AEDa - - - - 1 2 2 - 4
Staff levels at time of incident not in accordance with policy 2 - - - - - 1 - 3
Offender security level at time of incident deemed not appropriate - - - - - - - - -
Staff compliance issues with exposure protocol 2 2 1 1 1 1 2 - 10
All staff implicated in incident not up to date with certifications 1 - - - - - - - 1
Lack of appropriate and necessary equipment available to respond to medical emergency 1 - - - - 1 2 - 4
Non-compliance with search protocols 2 - 3 - - 3 - - 8
Non-compliance with search logs and documentation of items found 1 - 4 - 1 3 1 1 11
Non-compliance with reporting requirements as per policy 3 2 4 1 1 1 2 1 15
Support not provided to staff following incident - - - - - - - - -
Support not provided to offenders following incident 1 - - - - - - - 1
Total number of suicide deaths 4 4 5 2 2 6 8 4 35
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Automated External Defibrillator.
Table 37
Compliance Issues in Relation to Overdose Deaths Over an 8-year Period (2009/2010 - 2016/2017) by Region.
Compliance issuea Region Total
Atlantic Quebec Ontario Prairie Pacific
Compliance issues related to post-use handling of AEDb - - 3 1 - 4
Staff levels at time of incident not in accordance with policy - 1 1 1 - 3
Offender security level at time of incident deemed not appropriate - - - - - -
Staff compliance issues with exposure protocol - 5 4 - 1 10
All staff implicated in incident not up to date with certifications - - 1 - - 1
Lack of appropriate and necessary equipment available to respond to medical emergency - - 3 1 - 4
Non-compliance with search protocols 1 - 4 2 1 8
Non-compliance with search logs and documentation of items found - - 6 3 2 11
Non-compliance with reporting requirements as per policy - 3 3 6 3 15
Support not provided to staff following incident - - - - - -
Support not provided to offenders following incident - - 1 - - 1
Total number of overdose deaths 2 9 12 7 5 35

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
aThere are not enough cases to display the regional distribution in 2016/2017 in a table individually.
bAutomated External Defibrillator.

Table 38
Characteristics of Offenders who Died in Custody by Accident, Homicide, and Undetermined Manner, 2009/2010 - 2015/2016 and 2016/2017.
Characteristics Accident Homicide Undetermined Total
2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017
Ethnicity
White 7 - 11 - 4 - 22
Indigenous 2 - 4 2 1 - 9
Black - - 1 - - - 1
Other - - 1 - 2 - 3
Age
18 - 24 0 - 2 - - - 2
25 - 34 1 - 6 - 1 - 8
35 - 44 1 - 4 1 - - 6
45 - 54 2 - 2 1 4 - 9
55 - 64 3 - 2 - 2 - 7
65 - 74 1 - 1 - - - 2
75 - 79 - - - - - - -
80 + 1 - - - - - 1
Offender security level
Maximum 2 - 4 1 3 - 10
Medium 7 - 10 1 2 - 20
Minimum - - 1 - 1 - 2
Undetermined - - 2 - 1 - 3
Index offence
Homicide related 4 - - 8 2 - 14
Sexual 2 - - 1 2 - 5
Assault - - - 1 1 - 2
Robbery 1 - - 4 1 - 6
Other violent - - - - - - -
Property - - 1 - 1 - 2
Drug - - - 1 - - 1
Other non-violent 2 - 1 2 - - 5
Sentence length
2 to less than 4 years 1 - 1 2 4 - 8
4 to less than 6 years 1 - 6 - - - 7
6 to less than 10 years - - 1 - - - 1
More than 10 years 1 - 2 - - - 3
Indeterminate 6 - 7 - 3 - 16
Total number of other deaths 9 - 2 17 7 - 35
Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
Table 39
Day of the Week for Non-Natural Deaths in Custody by Accident, Homicide, and Undetermined Manner, 2009/2010 - 2015/2016 and 2016/2017.
Day of Week a Accident Homicide Undetermined Total
2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017
Sunday - - 1 - 3 - 4
Monday 2 - 6 - - - 8
Tuesday 3 - 1 - 1 - 5
Wednesday 1 - 1 1 - - 3
Thursday 1 - 1 - - - 2
Friday 2 - 3 - 2 - 7
Saturday - - 4 - 1 - 5
Total 9 - 17 1 7 - 34

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Information is only available for 18 of 19 homicide deaths n the 2009/2010 - 2016-2017 period. Totals in columns may therefore not match the actual total number of deaths.

Table 40
Time of Day for Non-Natural Deaths in Custody by Accident, Homicide, and Undetermined Manner, 2009/2010 - 2015/2016 and 2016/2017.
Time of Day 1a Accident Homicide Undetermined Total
2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017
Morningb 1 - 1 - 1 - 3
Afternoonc 3 -   - 3 - 10
Eveningd 2 - 12 1 2 - 17
Overnighte 3 - - - 1 - 4
Total 9 - 17 1 7 - 34

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
1 Time of day refers to the time of day the death was confirmed and not necessarily the exact incident time.
a Information is only available for 18 of 19 homicide deaths n the 2009/2010 - 2016-2017 period. Totals in columns may therefore not match the actual total number of deaths.
b Deaths that occurred between 6:00am and 12:00pm.
c Deaths that occurred between 12:00pm and 6:00pm.
d Deaths that occurred between 6:00pm and 12:00am.
e Deaths that occurred between 12:00am and 6:00am.

Table 41
Characteristics of Offenders who Died in Custody by Accident, Homicide, and Undetermined Manner, 2009/2010 - 2015/2016 and 2016/2017.
Characteristica Accident Homicide Undetermined Total
2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017
History of substance misuse 5 - 7 1 5 - 18
Prior drug-related offences/incidents 2 - 9 1 2 - 14
In segregation at time of death - - - - 1 - 1
Other offenders involved in incident - - 4 - 2 - 6
Any chronic health condition identified 5 - 4 - 6 - 15
Any mental health condition identified 4 - 6 1 5 - 16
Total number of deaths 7 - 17 1 7 - 32

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Information is only available for 7 out of 9 accidents and 18 of 19 homicide deaths in the 2009/2010 - 2016-2017 period. Totals in columns may therefore not match the actual total number of deaths.

Table 42
Compliance Issues in Relation to Deaths by Accident, Homicide, and Undetermined Manner, 2009/2010 - 2015/2016 and 2016/2017.
Characteristica Accident Homicide Undetermined Total
2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017 2009/2010-2015/2016 2016/2017
Staff levels at time of incident not in accordance with policy - - - - - - -
Offender security level at time of incident deemed not appropriate 1 - - - - - 1
Staff compliance issues with exposure protocol 2 - 4 - 2 - 8
All staff implicated in incident not up to date with certifications - - 3 - - - 3
Non-compliance with search protocols - - 4 - 1 - 5
Non-compliance with search logs and documentation of items found - - 3 1 1 - 5
Non-compliance with reporting requirements as per policy 3 - 7 - 4 - 14
Support not provided to staff following incident - - 1 1 - - 2
Support not provided to offenders following incident 1 - 1 - - - 2
Total number of deaths 7 - 17 1 7 - 32

Note: Results are accurate as of December 12, 2018. Subsequent investigations or reviews may result in changes to this table.
a Information is only available for 7 out of 9 accidents and 18 of 19 homicide deaths n the 2009/2010 - 2016-2017 period. Totals in columns may therefore not match the actual total number of deaths.

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