1. Preventing Deaths in Custody: Recommendations, Impacts and Change 13 th Biennial CCJA Congress Hyatt Regency Hotel Vancouver, BC October 5, 2013 0830 – 1000 hrs Howard Sapers, Correctional Investigator of Canada

2. Outline of Presentation I.Role and Mandate of the Office of the Correctional Investigator II.Context: Deaths in Custody III.OCI Deaths in Custody Publications and Recommendations IV.Assessment of Progress V.The Way Forward VI.Concluding Remarks 2

3. I. Office of the Correctional Investigator Mission Statement “As the ombudsman for federally sentenced offenders, the Office of the Correctional Investigator serves Canadians and contributes to safe, lawful and humane corrections through independent oversight of the Correctional Service of Canada by providing accessible, impartial and timely investigation of individual and systemic concerns.” 3

4. I. OCI By the Numbers The Office has 34 staff, the majority of which are directly involved in the day-to-day addressing of inmate complaints. 2012-2013 –Investigators spent cumulatively 337 days in federal penitentiaries. –Responded to approximately 5,450 offender complaints. –Interviewed 1,500 offenders. –Conducted more than 1,400 use of force reviews and 165 reviews of deaths in custody and serious bodily injury cases. –Recorded over 18,000 toll-free contacts. 4

5. II. Context: Deaths in Custody 5 Death of Ashley Smith 10/19/2007 Source: CSC Data Warehouse, accessed on: September 20, 2013

6. 6 Death of Ashley Smith 10/19/2007 II. Context: Unnatural Cause* Deaths in Custody * includes: suicide, accident, murder, use of force, overdose, and unknown causes. Source: CSC Data Warehouse, accessed on: September 20, 2013

7. II. Context: Deaths in Custody by Cause of Death 7 Death of Ashley Smith 10/19/2007 Source: CSC Data Warehouse, accessed on: September 20, 2013

8. III. OCI Deaths in Custody Publications February 2007Deaths in Custody Study (Gabor Report) May 2008Report on the Circumstances surrounding the Death of a Federal Inmate – A Failure to Respond June 2008A Preventable Death (Ashley Smith Report) September 2009 First Quarterly Assessment of CSC’s Response to Deaths in Custody Reports and Investigations December 2009 Second Quarterly Assessment of CSC’s Response to Deaths in Custody Reports and Investigations March 2010 Third Quarterly Assessment of CSC’s Response to Deaths in Custody Reports and Investigations September 2010 Final Assessment of CSC’s Response to Deaths in Custody Reports and Investigations 8

9. III. Preventing Deaths in Custody OCI Recommendations Key Areas of Concern: 1.Governance and Accountability 2.Policy Amendments & Review of Practices/Processes 3.Training 4.Clinical Practices 5.Operations 6.Infrastructure 7.National Strategy for Corrections and Mental Health 8.Alternative Service Delivery 9

10. IV. Assessment of Progress Identification and removal of in-cell suspension points Timely and appropriate response to medical emergencies Strengthened monitoring of pre-suicidal indicators Quality of security rounds, patrols and counts Improved information-sharing between clinical and frontline staff. Management of suicidal and chronic self-injurious offenders Prevention of natural deaths in custody Quality of CSC investigative reports and processes 10

11. Independent Review Committee (IRC) into Federal Deaths in Custody In February 2009, CSC committed to establishing an Independent Review Committee, on an annual basis, to examine all unnatural deaths in custody. The review examined 25 unnatural deaths in custody (suicide, overdose, homicide, unknown causes, death due to staff intervention) that occurred between April 1, 2010 and March 31, 2011. 11

12. IRC Findings There was evidence of precipitating factors in 60% of all unnatural deaths in custody. 32% of cases indicated problems with the quality of security patrols and monitoring. 33% of cases indicated concerns with the emergency response. Information-sharing concerns were present in 20% of cases. In cases where the cause of death was suicide: –83.3% of inmates had had a change to their medication (withdrawn, dosage change, new prescription) in the weeks preceding their death. –50% were currently on segregation status at the time of their death. 12

13. The Way Forward Expand Alternative Mental Health Service Delivery options. Create a national advisory forum for preventing deaths in custody. Improve the Mortality Review Process for natural cause deaths. Appoint a Senior Manager responsible for Safe Custody practices Share lessons learned widely across Service. 13

14. Concluding Remarks The promotion of safe custody practices in corrections requires dedicated focus and ongoing vigilance across all sectors. The CSC has to continue to develop its capacity to recognize and implement best practices and lessons learned from in-custody deaths that are premature (i.e. natural deaths) or preventable (i.e. suicides, accidents, overdoses). 14

15. 15 WWW.OCI-BEC.GC.CA