Commissioner's directive 048-1: Information sharing and provision of support services associated with coroner’s/cedical examiner's death investigations or inquests/inquiries

• Corrections and Conditional Release Act (CCRA), paragraph 4(b)
• Privacy Act, subsection 8(2)

To outline a process for coordination of communications and support services in relation to Coroner’s/Medical Examiner’s death investigations, or inquests/inquiries in cases of death of federally sentenced offenders, to:

• ensure national consistency where appropriate
• allow for mechanisms which ensure information sharing remains consistent with relevant law and CSC policy
• allow for the selection and attendance of appropriate CSC witnesses at inquests/inquiries when required

To outline the process for staff to seek professional and legal assistance

Applies to CSC staff responsible for coordinating, managing or responding to requests and recommendations put forth to CSC during a Coroner’s/Medical Examiner’s death investigation or inquest/inquiry into the death of a federally sentenced offender

• General Information
• When the Death of an Offender Under CSC Jurisdiction/Custody Occurs
• Coroner’s/Medical Examiner’s Investigation, Part I: Day of the Death
• Coroner’s/Medical Examiner’s Investigation, Part II: Following Attendance at the Scene
• Coroner’s/Medical Examiner’s Investigation Report Including the Autopsy and/or Toxicology Reports (if applicable) Indicating Cause of Death
• Coroner’s/Medical Examiner’s Decision to Hold an Inquest/Inquiry
• Reception of Recommendations Stemming from Inquest/Inquiry
• Annex A - Cross-References and Definitions

1. CSC takes death in custody seriously and voluntarily shares information related to deaths in custody^{Footnote 1} with Coroners/Medical Examiners to facilitate inquests/inquiries to the extent possible under applicable federal law. Coroners/Medical Examiners investigate deaths within their provincial/territorial boundaries in accordance with their applicable legislation. With regard to federal offenders, inquests/inquiries are typically held for cases of unexpected deaths, but in a number of jurisdictions also include natural deaths.
2. When police first attend the institution/community setting in relation to the death of an offender, their initial concern relates to whether a crime has occurred. If criminal concerns are identified, a warrant/production order is required for seizing material in relation to a criminal investigation. If there are no criminal concerns, the police will often investigate together with, and under the authority of, the Coroners/Medical Examiners.
3. A Coroner/Medical Examiner will generally attend the institution/community setting to examine both the deceased and the scene of death. At this point, it is not a criminal investigation and therefore a warrant is not necessary but a letter of request is required. The Coroners/Medical Examiners may also request a later visit to the institution/community setting to establish the circumstances of death. Coroners/Medical Examiners are responsible for body removal and transportation to a morgue or funeral home, and may authorize an autopsy or other procedures as part of a death investigation.
4. Often, when a death occurs, both a death investigation and a public inquest/inquiry are completed. Provincial/territorial death investigation services involve Coroners/Medical Examiners, Coroner/Medical Examiner Investigators, and members of the local police force as Coroner’s Constables.
5. Provincial/territorial legislation requires Coroners/Medical Examiners to establish via an investigation:
1. the identity of the deceased
2. the location where the death occurred
3. when the death occurred
4. the medical cause of death
5. the manner in which the death occurred (i.e., natural, suicide, accident, homicide or undetermined).
6. If an inquest/inquiry is called following a death investigation, a jury/panel may make recommendations to prevent future deaths from occurring in similar circumstances. The inquest/inquiry will usually focus on the specific events in question; however, the jury/panel may also hear evidence regarding general practices to support the jury’s/panel’s understanding of the death and to assist in their formulation of recommendations to prevent similar incidents.

7. The Institutional Head/District Director will ensure:
1. staff contain the scene of the death, pursuant to CD 568-4 – Preservation of Crime Scenes and Evidence
2. staff comply with processes set out in CD 568-1 – Recording and Reporting of Security Incidents, including securing the deceased offender’s file
3. police and Coroner/Medical Examiner in the geographical area in which the institution/community setting is located are notified, regardless of the location of the death (i.e., outside hospital), as per CD 530 – Death of an Inmate: Notifications and Funeral Arrangements
4. established procedures are followed and required notifications are completed, as per CD 530 – Death of an Inmate: Notifications and Funeral Arrangements
5. following consultation with the regional and national Communications staff, as well as coordination with the staff member responsible for liaison with the family/next of kin, a news release is issued as per CD 022 – Media Relations.

8. Following the death of an offender, the Institutional Head, or the District Director if the death occurred at a CCC, will facilitate the Coroner’s/Medical Examiner’s access to the institution/ community setting in order to prepare for their investigation, which generally includes:
1. attending the scene
2. taking possession of and examining the body
3. taking photographs of the scene and the body for documentation purposes
4. removing any physical evidence found at the scene of the incident or with the body (i.e., pill bottle, weapon, suicide note, etc.)^{Footnote 2}
5. consulting with institutional/community staff, reviewing, while on site, any relevant documentation relating to the deceased (including obtaining a copy of the Warrant of Committal), as well as reviewing (but not removing) any CSC audio/video surveillance recording of the offender/offender location of death specific to the immediate period surrounding the time of death. Any photographs and audio/video of the offender and/or the location of the death should be maintained on file per the official Records Retention and Disposition Schedule and applicable policies on retention and preservation or until such time that the inquest/inquiry is completed, whichever comes first.
9. The Institutional Head, or the District Director if the death occurred at a CCC, will ensure, if circumstances permit, photographs are taken by CSC staff of the scene of the incident including physical evidence subsequent to, or in parallel with, those taken by the Coroner/Medical Examiner and prior to the physical evidence being removed. Any photographs and audio/video of the offender and/or the location of the death should be maintained on file per the official Records Retention and Disposition Schedule and applicable policies on retention and preservation or until such time that the inquest/inquiry is completed, whichever comes first.
10. When evidence/documents are provided to any law enforcement agency or a Coroner/Medical Examiner, and prior to leaving the scene of the incident, the Security Intelligence Officer (or staff member performing the security intelligence function) will ensure a Transmittal Note and Receipt form (GC 044A) is completed and signed by both parties.
11. The Institutional Head/District Director will identify a contact for follow-up required by the Coroner/Medical Examiner.

12. After the death, the Coroner/Medical Examiner should contact the Institutional Head/District Director (or delegate) to outline what documentation is required for the purposes of the death investigation.
13. In consultation with the Regional Deputy Commissioner who will engage the Department of Justice, the Institutional Head/District Director will ensure that the request is time limited to within the last several months of the offender’s life and related to the offender’s death. The information will be sought by and copies will be provided to Coroners/Medical Examiners. This information could include, but is not limited to:
1. basic sentence information relating to the deceased
2. Warden Situation Report
3. Statement/Observation Reports from witnesses to the death and staff involved in the management of the incident/death
4. Statement/Observation Reports or Casework Records immediately prior to the death
5. case management information as it relates to the nature of the death
6. health care information as it relates to the possible cause of the death
7. mental health information as it relates to the nature of the death
8. if applicable, Structured Intervention Unit and transfer information as it relates to the location of the death
9. audio/video surveillance recording of the offender/offender location of death specific to the immediate period surrounding the time of death. Any photographs and audio/video of the offender and/or the location of the death should be maintained on file per the official Records Retention and Disposition Schedule and applicable policies on retention and preservation or until such time that the inquest/inquiry is completed, whichever comes first
10. reports regarding security patrols, counts and logs
11. recent inmate requests, complaints and/or grievances as they relate to the nature of the death.
14. There may be occasions, depending on the nature of the death, where Coroners/Medical Examiners will request broader information. In these cases, Coroners/Medical Examiners will liaise with the relevant Regional Deputy Commissioner and the Director General, Incident Investigations, for document production that is outside of the parameters outlined above. The following information is not routinely shared with Coroners/Medical Examiners but may be requested and provided in certain circumstances:
1. visits and correspondence file(s)
2. education and training file(s)
3. employment file(s)
4. discipline and dissociation file(s)
5. preventive security file(s)
6. Board of Investigation reports
15. All requests for information from or interviews with the Coroners/Medical Examiners must be approved by the Institutional Head/District Director in collaboration with the Regional Deputy Commissioner, prior to being provided or granted to the Coroners/Medical Examiners. Copies of information provided will be sent to the Director General, Incident Investigations, by the Regional Deputy Commissioner or delegate.
16. Information provided to the Coroner/Medical Examiner must be accompanied by a covering letter, listing what is being provided, as well as indicating that it is the responsibility of the Coroner/Medical Examiner to vet the information if it will be further distributed/shared, pursuant to applicable provincial/territorial privacy legislation.

17. Coroners/Medical Examiners routinely provide CSC with Coroner’s Investigation Reports (when authorized and available), including autopsy and/or toxicology reports (if applicable). In cases where a report has not already been provided by the Coroner/Medical Examiner, the Director General, Incident Investigations, or delegate, will contact the Coroner/Medical Examiner to request a copy of the reports. In cases of death by natural causes, the Director General, Clinical Services and Public Health, or delegate, will contact the Coroner/Medical Examiner. If a report is unavailable, the Coroner/Medical Examiner is expected to provide the cause of death as determined by the death investigation.

18. Upon notification that an inquest/inquiry will be held, the Regional Deputy Commissioner, or delegate, will advise the Senior Deputy Commissioner, the Assistant Commissioner, Communications and Engagement, the Director General, Incident Investigations, the Assistant Commissioner, Health Services, relevant Assistant Commissioner(s), including the Deputy Commissioner for Women in the case of the death of a woman offender, and the Department of Justice. The latter will ensure that counsel is assigned to represent CSC.
19. CSC will be represented by the Department of Justice, and all further contact between CSC and the Coroner’s/Medical Examiner’s Office will be through ongoing liaison by the Department of Justice. Further, the Regional Deputy Commissioner, in consultation with the Department of Justice, will determine whether or not independent legal counsel is required for any of the principals involved in the incident in accordance with the Treasury Board Policy on Legal Assistance and Indemnification.
20. The Regional Deputy Commissioner, or delegate, will forward a brief outline of the circumstances surrounding the incident and copies of any relevant documents and any media coverage to date on the incident in question to the Department of Justice.
21. The Regional Deputy Commissioner, or delegate, will assume overall responsibility for the coordination of communications (including the media and regular internal briefings at all levels), staff support (including Employee Assistance Program and Critical Incident Stress Management Program services where required) and technical support to the Department of Justice counsel, in collaboration with the Senior Deputy Commissioner and relevant Assistant Commissioners, or the Deputy Commissioner for Women in the case of a woman offender, ensuring that:
1. staff are advised that the Department of Justice is representing the Service at the inquest/ inquiry and all requests from the Coroners/Medical Examiners/Judges/inquiry counsel for interviews, documents, etc. should be officially requested via counsel
2. staff are aware that the Regional Deputy Commissioner, or delegate, is the “instructing client” and any requests for further information, requests for interviews, requests for appropriate witnesses, etc. (all of which should only be sent from the Department of Justice directly) are approved by the Regional Deputy Commissioner
3. staff are advised that requests for offenders’ in-person attendance at an inquest/inquiry are not normally granted, but all attempts will be made to secure their attendance by video conference
4. staff are aware that in cases where a Coroner/Medical Examiner wishes to have a subpoena served on an offender, this must be done by way of a process server.

22. The Regional Deputy Commissioner and the Senior Deputy Commissioner will ensure the recommendations sent by the Department of Justice are immediately forwarded to the Director General, Incident Investigations.
23. The Director General, Incident Investigations, will:
1. distribute the recommendations to the appropriate policy holders for their review and response
2. draft CSC’s response to the recommendations, through consultation with relevant policy holders for review and approval/signature by the Commissioner
3. distribute the approved response to the provincial/territorial Chief Coroner/Medical Examiner and Regional Deputy Commissioner, as applicable
4. in the case that CSC is provided with official results of an inquest/inquiry with no recommendations directed to CSC, the Director General, Incident Investigations, will send a letter, on behalf of the Commissioner, to the Chief Coroner/Medical Examiner thanking them for the information and indicating the date on which the Service convened an investigation into the same incident
5. in the case that CSC is provided with an official cause of death noted by the Coroner/Medical Examiner that differs from the suspected cause of death reviewed by the Board of Investigation, the Director General, Incident Investigations, will review the Board of Investigation report to determine whether the investigation should be reopened.

Senior Deputy Commissioner,

Original Signed:

Alain Tousignant

Annex A
Cross-references and Definitions

CD 001 – Mission, Values and Ethics Framework of the Correctional Service of Canada
CD 022 – Media Relations
CD 041 – Incident Investigations
CD 253 – Employee Assistance Program
CD 530 – Death of an Inmate: Notifications and Funeral Arrangements
CD 568-1 – Recording and Reporting of Security Incidents
CD 568-4 – Preservation of Crime Scenes and Evidence
CD 568-8 – Authority for Use of Surveillance Equipment
CD 701 – Information Sharing

Corrections and Conditional Release Act
Privacy Act, subsection 8(2)
Treasury Board Policy on Legal Assistance and Indemnification

Autopsy report: a report prepared by the Coroner/Medical Examiner’s Office outlining the examination performed on the body of a deceased person to provide information related to cause of death.

Death investigation: provinces and territories are legislated to conduct death investigations by their provincial/territorial statutes unique to their jurisdiction. Often, when a death occurs, both an investigation and a public inquest/inquiry are completed. A death investigation is a process whereby a Coroner/Medical Examiner seeks to understand how and why a person died.

Inquest/inquiry: a public hearing on the circumstances of the death often involving a jury/panel of community members, and a Coroner/Medical Examiner (as defined by geographical boundaries within Canada). A report is often completed following the inquest/inquiry and may result in recommendations to prevent future deaths from occurring in similar circumstances.

Process server: an individual who gives legal notice to a party (usually the defendant) requiring them to respond to a proceeding scheduled to be held before a court, government body, or tribunal. Notice is usually provided by presenting the party in question with a court document such as a summons, a statement of claim, a plaintiff’s claim, etc.

Stakeholders: anyone who is interested in or impacted by CSC’s business. Primary stakeholders for deaths in federal custody include the media and inmate advocacy groups, CSC employees impacted by the death (e.g. Correctional Officers, Parole Officers, Health Services staff or any other employees who had a connection with the deceased inmate), and family/friends/next of kin of the deceased inmate. The general public can also be considered a stakeholder.

Toxicology report: a report prepared for the Coroner/Medical Examiner’s Office outlining the results of the lab procedures identifying and quantifying potential toxins, which include prescription medications and drugs of abuse, and interpretations of the findings.