Investigating incidents

When an incident involving an offender occurs in 1 of our institutions or in the community, CSC must determine if further administrative review is needed. The following people may convene an investigation or file a review:

• Commissioner
• Chairperson of the Parole Board of Canada (for joint investigations with CSC)
• Director General, Incident Investigations Branch
• Institutional Head, or District Director

The investigation or review is done to:

• assess and report on all the circumstances surrounding the incident
• provide information to CSC so that, if required, actions can be taken to prevent similar incidents
• learn about and share best practices
• identify findings and make recommendations where required.

When a Board of Investigation (BOI) is convened, they report on findings and recommendations (if any) to assist in preventing similar incidents from occurring in the future.

• Commissioner's Directive 041 - Incident Investigations outlines the process for investigations into institutional and community incidents. It outlines the responsibilities for action, analysis, and reporting significant findings
• Corrections and Conditional Release Act sections 19, 20, 97, 98, and subsection 152(4) provide the authority to convene investigations

• National Joint Board of Investigation into the Release and Supervision of an Offender in relation to a Tragic Incident in Quebec in January 2020
  • Summary of Key Observations and Recommendations
  • Management Action Plan: Board of Investigation (BOI) Recommendations and CSC Actions
• Case summary: Escape of two inmates from William Head Institution (Minimum) on July 7, 2019
• Board of Investigation into the Riot at Saskatchewan Penitentiary

Independent Review Committees (IRCs) are convened every 2 to 3 years to provide CSC with an external review of non-natural deaths in custody. CSC's first IRC was convened in 2010. This was a response to a recommendation made by the Office of the Correctional Investigator's 2007 report called Deaths in Custody.

IRC reports are available on our publications page:

• Report of the Independent Review Committee into Deaths in Custody: 2009 to 2010
• Report of the Independent Review Committee into Federal Deaths in Custody 2010 to 2011
  • Independent Review Committee on Deaths in Custody 2010 to 2011 Corrective Measures and Management Action Plan (CMMAP)
• Third Independent Review of Deaths in Custody, April 1st, 2011 to March 31st, 2014 
  • Independent Review Committee on Deaths in Custody 2011 to 2012 and 2013 to 2014 Corrective Measures and Management Action Plan (CMMAP)
• Fourth Independent Review Committee on Non-natural Deaths in Custody that occurred between April 1st, 2014 to March 31st, 2017
  • Fourth Independent Review Committee on Non-natural Deaths in Custody 2014 to 2015 and 2016 to 2017 Corrective Measures and Management Action Plan (CMMAP)

When the death of an offender occurs while either in custody or during release to the community, the coroner or medical examiner of the province or territory where the death occurred is immediately notified by CSC.

It is the responsibility of each province or territory to conduct an inquest or inquiry into these incidents in line with provincial or territorial legislation.

The inquest or inquiry process reviews the circumstances in which the death occurred and makes recommendations, if required, in order for CSC to improve its interventions with offenders and its ability to prevent such incidents. This process is concurrent and independent of CSC's Board of Investigations.

When a verdict from an inquest or inquiry is received from a coroner or medical examiner it can take 2 forms:

• no recommendations for CSC
• recommendation(s) for CSC

When recommendations are presented from these inquests or inquiries, CSC formally responds.

For more information related to CSC's processes with respect to deaths in custody:

• Deaths in custody