Sixth Independent Review Committee on Non-Natural Deaths in Custody: April 1, 2019, to March 31, 2021

Submitted to Correctional Service Canada by: Michelle Mann-Rempel, LL.B., LL.M., Lawrence Ellerby, Ph.D., C. Psych.

Acknowledgments

In conducting this review, we had the benefit of great support from Correctional Service Canada (CSC) who were open and inviting of this independent review and offered to support us in a variety of ways to support our mandate. It was evident to us that there was a heartfelt recognition of the seriousness of non-natural deaths in custody and a desire to continue to evolve practices within the Incident Investigations Branch (IIB), National Headquarters and in seeking external observations, input, and recommendations to improve policy and procedures at an institutional and corporate level. We would like to particularly thank Dr. Terri Scott, A/Director of the IIB, CSC for being our point person, responding to our many questions and gathering information at our request to aid our review. We would like to thank and offer our appreciation to Ms. Marie-France Kingsley, Director General, IIB for taking time to meet with us and offer information, context, and insights on the IIB and Board of Investigations (BOI). Thanks also to Ms. Carla Di Censo, Director, IIB for her participation and involvement in meetings over the course of this project.

We would like to thank Ms. Anne Kelly, Commissioner, CSC and Mr. Jay Pyke, Senior Deputy Commissioner, CSC for their supportive position in respect of the 6th IRC and for highlighting the importance of these reviews. Ms. Kelly’s expression of CSC’s desire to continue to learn and evolve based on the observations and recommendations of the IRC’s and the organization’s desire to improve its capacity to address factors contributing to non- natural deaths in custody was appreciated.

We would like to acknowledge the individuals who lost their lives in custody and their families. We remained acutely aware that these were not simply investigation case files which we were reviewing to provide commentary and recommendations on, but representations of the tragic ending of people’s lives. People whose struggles resulted in them becoming in conflict with the law and ultimately incarcerated in federal penitentiaries where they died.

In conducting such a review, a key goal is to attend to where things went wrong and offer recommendations to help guide addressing these concerns. We benefit from being able to review how cases were managed outside the challenges and stressors of the correctional institutions and want to acknowledge that while we will offer recommendations related to areas of challenge and concern we identified both in terms of institutional management of cases and approaches to conducting independent investigations on non-natural deaths, we were impressed by the overall professionalism demonstrated, particularly by front line correctional officers and nurses responding to very difficult and distressing circumstances in an effort to save lives in precarious situations.

Lastly, we would like to commend the individuals who serve on the Boards of Investigation. Our goal is for our observations to be of service to you in doing the difficult job of having to review the histories and trajectories of individuals who died of non-natural causes in federal penitentiaries. This is a difficult task that has its impacts, and we salute you in your efforts to understand and identify ways CSC can advance policies and practices to create safer living environments for incarcerated persons.

Executive summary

The 6th Independent Review Committee was convened to review Board of Investigation reports completed on non-natural deaths in federal custody that occurred between April 1, 2019, and March 31, 2021, with the objective of offering recommendations to Correctional Service Canada on how BOIs and CSC can improve their practice. The 6th IRC reviewed 31 reports covering death by suicide, overdose, and homicide.

Like our predecessor review committees, the 6th IRC received extensive Terms of Reference (TOR) from Correctional Service Canada to shape our review. What we found were many well executed BOI reports, however, they were notably inconsistent across our review. We also noted significant shortcomings and areas for improvement by BOIs and CSC to better prevent non-natural deaths in custody. What follows is a summary of our findings and recommendations arising from these TOR (detailed below in the “Introduction” section).

With respect to TOR 1 and 2 - considering how BOIs report risk factors as key areas of the investigation and make related findings and recommendations - we found that BOI reports do not consistently provide a comprehensive review of the incarcerated person’s social, physical, and mental health history. When reporting on the deceased’s social, physical, and mental health history BOI reports do not consistently connect identified risk factors to vulnerability and risk relevant to the incarcerated person’s difficulty functioning and the non-natural death in custody. Further, BOI reports tend to focus exclusively or primarily on proximal risk factors to the death and often do not explore potential risk mitigating factors and case management strategies. Accordingly, we make the followed related recommendations: 

Recommendation 1

BOI reports should have sections for each of the key areas of investigation to enhance the thoroughness of the assessment and review of the deceased’s social, physical, and mental health history, as appropriate.

Recommendation 2

BOI reports should connect how the identified vulnerability and risk factors in the key areas of investigation contributed to the incarcerated person’s difficulty functioning and the non-natural death in custody.

Recommendation 3

BOI reports should assess for, identify, and discuss both proximal and distal risk factors to the non-natural death.

Recommendation 4

CSC should review and enhance training and professional development for BOI National Investigators:

• consider further training on assessing the key areas of investigation, risk factors, and how to connect identified vulnerability factors to risk factors relevant to the occurrence of a non-natural death
• consider a mentoring program that would have exceptional National Investigators provide training, professional development, and act as resource for BOI members involved in investigations

Recommendation 5

Consider having one investigator that has a background in mental health services or is a mental health professional on all investigations.

In considering BOI reporting and analysis of case management issues, we found that BOI reports did not consistently highlight observations, and recommendations specific to identified problems in case management practices, despite their pivotal role in risk management. We particularly noted that case management practices were not adequately analysed by BOIs where the deceased had demonstrated resistance to participation in the correctional plan and/or had their parole recently suspended or revoked. Accordingly, we make the following recommendation:

Recommendation 6

Case management practices should be a distinct area of review and assessment during BOIs:

• BOIs should specifically consider if the deceased had demonstrated resistance to their correctional plan and if so, what efforts were made to engage them
• in cases where the deceased has been suspended or had their parole revoked, BOIs should specifically explore the case management response to supporting the deceased’s integration back into the institution

While reviewing the key areas of BOIs relating to risk factors, offender’s social history, physical and mental health and case management practices, the 6th IRC noted multiple apparent systemic issues which were not being identified by BOIs as such. Given the significance of systemic issues for institutional functioning, safety of staff and the incarcerated person, and their role in contributing to the occurrence of non-natural deaths in custody, they require more in-depth attention from BOIs:

Recommendation 7

Convening orders should empower BOIs to investigate systemic issues and make recommendations where appropriate.

Recommendation 8

CSC should undertake a program of “tracking and training” around systemic issues to better inform itself and BOI investigators.

Finally, with respect to TOR 1 and 2, the 6th IRC believes that incorporating an examination of protective factors into BOIs would represent a more holistic approach. While risk factors focus on negative attributes, protective factors emphasize the positive about the incarcerated person. Nonetheless, we found that BOI Reports tend not to explore protective factors and their facilitation, making it difficult to determine if the case management team facilitated supporting protective factors that could potentially have mitigated the incarcerated person’s vulnerability, risk factors, and circumstances surrounding the non-natural death in custody. Accordingly, we make the followed recommendation:

Recommendation 9

BOIs should investigate and make recommendations regarding an incarcerated person’s protective factors and whether they were facilitated to support wellness, institutional functioning, and vulnerability/risk management.

In response to TOR 3 - analyse the timeliness of CSC’s response to recommendations; the implementation/tracking of corrective measures; and the need for an evaluation of outcomes - we found good examples of consultation grids identifying quick responsivity by CSC to issues raised by the BOI. It was, however, more common that we found it difficult to determine the timeliness of CSC’s responses to BOI recommendations and in several instances found significant delays in CSC’s implementation of initiatives to address BOI recommendations. We found that the consultation grids outlining CSC’s responses do not consistently offer a clear timeline of action and completion steps in response to BOI recommendations and at times identify resolution of a recommendation prior to actual completion. We also noted that CSC does not always provide a clear rationale for rejecting a recommendation. Finally, we observed that CSC responses did not always lend themselves to an evaluation of outcomes and there does not appear to be a process for evaluating the implementation of recommendations and whether they mitigate factors contributing to non- natural deaths in custody.

Accordingly, we make the followed related recommendations:

Recommendation 10

Consultation grids should have clear dates and clear deliverables for CSC action plans to address BOI recommendations for further transparency and accountability.

Recommendation 11

CSC should provide a supporting rationale where it rejects or does not fully implement a BOI recommendation for greater transparency and provide a clear alternative direction to deal with the issue identified by the BOI.

Recommendation 12

A protocol should be developed to identify an oversight function that can ensure CSC is held accountable for appropriate timelines for action and that can review findings when CSC rejects or does not fully implement a BOI recommendation. 

Recommendation 13

To further transparency and accountability, CSC should ensure that actions in response to BOI findings contain elements that are measurable, and thereby create outcomes that can be evaluated.

With respect to TOR 4, the 6th IRC was tasked with examining whether mental health concerns were sufficiently identified, monitored, and tracked in cases of suicide death and sufficiently shared among sectors to activate appropriate suicide prevention measures. In reviewing the cases of suicide, the 6th IRC focused on the BOIs identification of mental health issues, attention to intervention plans, and information sharing to mitigate risk for death by suicide. We found that not all BOIs have a good understanding of what constitutes vulnerability and contributing or risk factors for suicide. Limitations in this understanding impede a comprehensive assessment of the contributing factors and potentially meaningful and important recommendations. We further observed that BOIs predominantly focus on a medical model in investigating suicide cases - attending to medical and psychiatric involvement - with much more limited attention to psychological services, correctional programming, and cultural/spiritual or faith-based services. While we note that recommendations 1 to 9 and 20 apply equally in cases of non-natural death by suicide, specific to incidents of suicide, we additionally recommend that: 

Recommendation 14

BOI reports should have an enhanced focus on noting the deceased’s documented mental health history and recent mental health functioning; and any evident emotional and situational factors that may have contributed to mental health vulnerability and destabilization in cases of death by suicide.

We further noted cases where the results of mental health screening tools were incongruous with other information in the case and with the outcome of a non-natural death in custody, yet the BOI did not question these results despite their inconsistency. While we recognize that it is not the role of BOI to analyse the reliability of screening tools, they are uniquely positioned to ask questions and identify inconsistencies in their review. Accordingly, we make the following recommendation: 

Recommendation 15

BOIs should consider if there are any problematic implications related to the findings of mental health screening tools, testing, or assessments used for case management planning and the determination of appropriate interventions.

We further considered whether BOIs adequately analysed the provision of therapeutic interventions in cases of non-natural deaths by suicide. We concluded that BOI reports did not adequately offer recommendations related to case management, specific to mental health and therapeutic interventions, or efforts to support engagement and manage resistance to mitigate the risk for suicide. BOI reports rarely focused on or offered examples of suicide prevention efforts or proactive mental health care efforts that have been employed to mitigate the risk for death by suicide. We also concluded that BOIs could do a better job of identifying recommendations related to mental health monitoring and tracking and communication in suicide death investigations as being systemic, rather than only in relation to the individual case being investigated, however we concluded that this was dealt with in recommendations number 7 and 8 dealing with systemic issues.

Accordingly, we make the followed related recommendation:

Recommendation 16

BOI reports should offer a comprehensive review of medical care (psychiatry, nursing, physician involvement); mental health interventions (correctional programming, psychological, and therapeutic services); and spiritual care (cultural teaching, Indigenous healing, Elder services, chaplaincy) provided or not provided to the deceased prior to death.

Finally, pursuant to TOR 5, the 6th IRC was tasked with reviewing whether BOI reports relating to Indigenous incarcerated persons were written from an Indigenous Social History (ISH) perspective. We found in reviewing the 14 Indigenous cases (comprising approximately 45% of 31 total cases), that there was no consistency across the various BOI reports with respect to whether ISH analysis was conducted or how. The ISH is frequently given a cursory consideration and not integrated and analysed in context with the rest of the BOI report. We conclude that BOI reports are not adequately demonstrating that they have reviewed whether and how ISH was integrated and analysed in correctional decision making for Indigenous offenders and are inconsistent in this regard. Accordingly, we make the followed related recommendations:

Recommendation 17

BOI reports should focus on identifying and describing whether and how ISH was considered and implemented in correctional decision making for Indigenous incarcerated people. CSC should establish a minimum requirement for BOIs to demonstrate whether ISH was considered. 

Recommendation 18

When investigating the non-natural death in custody of an Indigenous incarcerated person BOIs should have a committee member with knowledge of ISH and of CSC’s obligations and capacities with respect to implementation of ISH.

The 6th IRC also noted that in addition to a lack of consistency in the integration of ISH throughout BOI reports, it also frequently was considered separately from any analysis of mental health concerns of the Indigenous incarcerated person, contrary to the purpose of incorporating ISH. We found that BOI reports are not adequately approaching ISH in a holistic way, particularly with respect to integrating ISH with mental health issues. We also considered if the BOI investigated whether culturally appropriate interventions were given due consideration by the CMT in decision making for an Indigenous offender in conjunction with the ISH. We found that BOI reports need to employ greater consideration of culturally appropriate interventions that were (or were not) offered to Indigenous offenders. Accordingly, we make the followed related recommendations:

Recommendation 19

BOI reports should give a holistic consideration to ISH context, through greater integration of mental health issues in analysing ISH.

Recommendation 20

BOIs need to consider whether culturally appropriate interventions were given due consideration by the CMT in decision making for an Indigenous incarcerated person in conjunction with the ISH.

Finally, with respect to TOR 5, in reviewing all cases involving Indigenous incarcerated persons, the 6th IRC noted that there was a shortage of ISH analysis or consideration of culturally appropriate interventions in CSC’s consultation grids / responses to BOI findings and recommendations in cases involving Indigenous incarcerated persons. Accordingly, we recommend that:

Recommendation 21

CSC should lead by example and incorporate ISH analysis into its responses to BOI findings and recommendations.

Beyond the scope of the TOR provided to the 6th IRC, in conducting this review, we were struck by how difficult and impactful it must be for CSC staff to be exposed to the direct and/or indirect effects of the deaths they are responding to. BOI reports did not consistently comment on services and supports provided to CSC staff responding to and impacted by the death and varied in the amount of information provided about the types of mental health and organizational supports offered to impacted staff. We therefore felt compelled to offer one additional recommendation beyond the scope of our TOR:

Recommendation 22

All BOI reports should attend to staff wellness and be tasked with commenting on the type and suitability of supports provided to CSC staff impacted by the non-natural death in custody. 

The investigation objectives and process

Correctional Service Canada has strived to learn from non-natural deaths in custody and to work towards mitigating factors identified as contributing to deaths occurring from suicide, overdose, and homicide. Following a non-natural death in custody, the Commissioner, Correctional Service Canada, appoints a committee, known as a Board of Investigation, to review issues surrounding the non-natural death. BOIs are typically comprised of CSC employees and a community member and are supported by the Incident Investigation Branch. Each BOI conducts their case review and provides a report with their findings, which can include recommendations. Correctional Service Canada then reviews the findings and responds to the underlying issues and areas of non-compliance identified and how they will proceed in addressing any recommendations.

As an additional line of review, accountability, and oversight, and in response to a recommendation by the Office of the Correctional Investigator, the CSC has established bi-annual Independent Review Committees (IRCs) that are managed by the IIB. IRCs review BOIs completed on non-natural deaths in custody and based on the terms of reference and the committee’s methodology, can examine all aspects of the investigative process with the objective of providing comments and offering recommendations on how BOI’s can evolve their practice. Additionally, IRCs have provided recommendations for CSC to further advance their efforts and success in working to prevent non-natural deaths in custody. To date 5 IRCs have been convened.

The 6th IRC was convened to review non-natural deaths in custody that occurred between April 1, 2019, to March 31, 2021. The 6th IRC was provided with 34 BOI reports to review falling into the categories of Suicide (17 cases), Overdose (12 cases) and Homicide (5). Of these 34 reports, 31 reports were reviewed as 3 BOI reports were written in French and unfortunately the unilingual English committee members were unable to review these. The 6th IRC originally consisted of 3 members, however at the early stages of the process one of the members terminated their involvement. A decision was made to proceed with this review process with the remaining members, Ms. Michelle Mann-Rempel, LL.M., LL.B., Lawyer and Consultant, and Dr. Lawrence Ellerby, Ph.D., C. Psych., Registered Psychologist and Clinical Director, Forensic Psychological Services.

Each IRC is provided with specific Terms of Reference to focus their review and to respond to specific questions of interest to CSC. The TOR for the 6th IRC were very focused and directed the IRC to examine the following areas of interest:

6th Independent Review Committee Terms of Reference

1. Assess the scope of Key Areas of Investigation to ensure they cover all risk factors, offenders’ social history, physical and mental health, as well as case management practices in relation to the incident under investigation

2. Assess whether the findings and recommendations made by Boards of Investigation (BOIs), and the corrective measures flowing from them, sufficiently address systemic factors and underlying issues (such as social history, mental health, and criminogenic factors of offenders) to prevent similar incidents from occurring. This will include:

   • examining how recommendations are formulated by the BOIs and assessing any need for improvement to adequately target systemic and underlying issue

3. Analyse the timeliness of CSC response to recommendations; the implementation/tracking of corrective measures following a non-natural death in custody; and the need for an evaluation of outcomes, to measure the effectiveness of the corrective measures’ action plans

4. Examine whether mental health concerns:
   • were sufficiently identified, monitored, and tracked in cases of suicide death

   • were sufficiently shared among sectors in an effort to activate appropriate suicide prevention measures

5. Ensure that BOI reports are written from an Indigenous Social History perspective, where appropriate

It is noteworthy, that the Convening Order and Terms of Reference for the 6th IRC also stipulated that we could adopt such procedures and methods as may be deemed necessary for the proper conduct of this review; be provided with adequate and secure working conditions and administrative support as required; have complete access to personnel under the employment of, or under contract with, CSC; and, communicate with any outside person, agency office or organization which may assist in the successful completion of this review.

Given the TOR for the 6th IRC, the methodology implemented primarily involved a review and analysis of the BOI reports. Reports from each category of non-natural death (suicide, overdose, and homicide) were equally randomly distributed between the 2 IRC members for review. Each BOI report along with the corresponding Recommendations, Action Plans, Supporting Facts and Corrective Measures were reviewed, and a content analysis was conducted with specific attention to recording information for each case relevant to the 5 questions in the TOR. The committee members met on an ongoing basis to review and discuss their findings to ensure they were following a consistent content analysis protocol and to review and discuss each other’s findings to optimize what each of the committee members attended to over the course of the BOI report review process. Given the number and range of BOI reports reviewed, the committee members at times identified unique case issues relevant to the TOR questions from the cases each reviewed. Most of the time we found our observations and impressions were consistent and supported our collective findings. The primary observations noted, and recommendations offered, are based off the key findings that both committee members identified and that were evident in several of the BOI reports revised and evaluated.

In addition to the review and analysis of BOI reports, the 6th IRC reviewed a range of relevant background information. This included background information provided at the commencement of the review process as well as background information requested by the committee members from IIB and gathered independently. Background information is identified in the list of References.

Finally, the 6th IRC gathered collateral information through ongoing dialogue and specific requests made to the IIB in response to specific questions and request for additional information related to our investigation and issues that presented themselves in the BOI reports we were reviewing and analysing. In addition, we also had the opportunity to participate in formal meetings with both senior representatives of CSC, as well as senior members of the IIB for briefings and information sharing and gathering.

We wanted to note the TOR did not request that we review and consider whether the impact of COVID 19 measures had any impact on non-natural deaths in custody. In reviewing the BOI reports between April 2019 and March 2021 it was evident there were some cases where COVID 19 measures were impactful on the correctional environment and the experience of incarceration for the deceased in the lead up to the non-natural death. The implications of COVID 19 will be an important consideration for future IRCs.

Findings in relation to the Terms of Reference

This section outlines our observations and findings related to the TOR. These findings form the basis of our recommendations, which are offered to support BOIs in evolving their processes and protocols for assessing factors contributing to non-natural deaths in custody and enhance BOI recommendations. It is our hope this will in turn lead to a tangible and meaningful outcome of enhancing the BOI’s capacity to guide CSC in implementing changes and advancing their practices of managing incarcerated persons and thereby promote prevention of non-natural deaths in custody.

Examination of Terms of Reference 1 and 2

In considering TOR 1 and 2, we viewed these as intrinsically linked. The level of investigation into the Key Areas of Investigation is directly related to the BOI report findings and recommendations. This then informs and guides corrective actions to address systemic factors and underlying issues. As a result, we have combined these 2 TOR inquiries in our analysis.

TOR 1: Assess the scope of Key Areas of Investigation to ensure they cover all risk factors, offenders’ social history, physical and mental health as well as case management practices in relation to the incident under investigation.

TOR 2: Assess whether the findings and recommendations made by Boards of Investigations (BOIs), and the corrective measures flowing from them, sufficiently address systemic factors and underlying issues (such as social history, mental health, and criminogenic factors of offenders) to prevent similar incidents from occurring. This will include:

• examining how recommendations are formulated by the BOIs and assessing any need for improvement to adequately target systemic and underlying issues

A central feature of investigating a non-natural death in custody is the comprehensive examination and identification of factors that can inform on the antecedents and potential contributing factors to the death. The 6th IRC was charged with exploring the BOI’s coverage of Key Areas of Investigation including the deceased's social history, physical and mental health issues, and case management practices.

We found BOI reports to vary in the extent to which they identified and discussed the key identified risk factors. There were some exemplary reports that did an excellent job of providing a thoughtful and comprehensive review of the deceased's social history (including, but not restricted to Indigenous Social History), and as applicable, physical and mental health history. These reports discussed the key risk factors in a manner that painted a picture of the individual, their life path, vulnerabilities, challenges, and helped provide insight into factors that contributed to their problematic community integration, institutional functioning and/or conduct, and to their death or, in the case of homicides, to their having been a victim. It was however the 6th IRC’s opinion that more frequently, BOI reports reflected a more limited and often superficial and incomplete examination of these key risk factors. Additionally, we found that when risk factors were identified, their relevance as risk factors and the impact they may have had on the incarcerated person’s functioning and their death, or their victimization, tended to receive limited attention. The following highlight our key observations and findings in relation to how key areas of investigation were handled in BOI reports and the implications of this on BOI recommendations addressing underlying and systemic issues.

Reporting of risk factors as part of the Key Areas of Investigation

The 6th IRC found that the wording of TOR 1 was helpful as it guided us to review the 4 Key Areas of Investigation. In exploring how BOI reports assessed and reported on the deceased’s social history, physical health, and mental health, it became evident that several BOI reports collapsed these into a general background history synopsis versus independently examining and addressing each of these factors. Additionally, we observed that when details of the incarcerated person’s social, physical, and mental health histories were reported, this information was not consistently used to assist in understanding the factors contributing to the deceased’s problematic functioning and/or behavioural issues, and the occurrence of the non-natural death in custody.

In reviewing the Key Areas of Investigation, we viewed case management practices as distinct from the review of social, physical health, and mental health history. Case management practices are a critical area for investigation and review, as recommendations stemming from case management concerns can support systemic improvements in multiple areas that could mitigate non-natural deaths in custody. This could include areas such as recommendations to improve staff accountability for case planning and follow up; compliance with institutional policies and procedures; making and following up on appropriate referrals; and reporting and communicating key information (from one institution to another, as well as between institutional parole officers, correctional officers, mental health and medical service providers, and security officers). It was the 6th IRC observation that there were common gaps in BOI reports not consistently focusing on some noteworthy case management areas (for example, the suitability of the correctional plan developed for the deceased; the presence or absence of referrals for correctional programming, psychological and/or psychiatric services; the role of cultural, spiritual and religious services; the response and management of any non-compliance demonstrated by the deceased person in regard to their correctional plan). Further, recommendations related to these areas tended to not be focused and were often case specific versus considering how these concerns often present as systemic issues.

Board of Investigation review of social, physical health, and mental health history

In considering what would constitute a comprehensive synopsis of a social history, one would anticipate BOI reports to highlight central aspects of the deceased’s developmental and social history. This would include examination of the person’s family of origin experiences, trauma history, education and employment history, relationship history, substance use/abuse, and criminal history. Part of this analysis would also include considering the individual’s physical health and mental health and history, which are identified as separate risk factor areas to review. Physical health history should identify any relevant physical health related concerns the individual was experiencing; consider how this may have impacted their overall functioning; speak to relevant medical care and outcomes, and to case management planning and responses, to ensure appropriate assessment and treatment was undertaken and to identify if physical health issues were relevant in understanding the non-natural death. A mental health history should identify the person’s diagnostic history if one exists; primary presenting symptoms; case management planning and responses to ensure appropriate assessment and treatment was obtained; and interventions employed and program and/or treatment outcome; as well as the individual’s response to treatment and how resistance and/or non-compliance was managed. The link between any mental health concerns and their relevance to the non- natural death should be identified.

There were some BOI reports that investigated and reported the incarcerated person’s social and mental health history in a sophisticated manner, which allows for greater capacity to develop an understanding of potential risk factors relevant to the non-natural death. Although a review of the deceased individual’s physical history appeared to be less often as relevant as social and mental health factors, and therefore not as frequently reported and considered, there was one BOI that offered a good illustration of considering the individual’s physical health history and the role and implications this played in conjunction with the deceased’s drug use, which resulted in an overdose death.

In contrast, there were several reports that suggest that not all investigators have a good grasp of what constitutes a precipitating or contributing vulnerability or risk factor. We observed this to be evidenced in a few different ways: reports not identifying any precipitating or contributing risk factors; reports describing what should be considered precipitating or contributing risk factors but not identifying them as such; reports identifying what appears to be a relevant area to explore to better understand the case but not examining the issue; and BOI reports providing a limited or superficial report of the deceased’s social, physical, and mental health history, and not capturing likely precipitating or contributing risk factors.

As examples of what appears to be a lack of understanding of precipitating or contributing vulnerability and risk factors, one report identified that in the case of an overdose death, the only pre-incident indicator or precipitating event was a history of substance abuse. A history of substance abuse would likely be a contributing factor for most overdose deaths. Identifying the underlying factors contributing to the history of substance abuse would best inform how to mitigate overdose deaths in custody. It was also interesting to note that some BOI reports identified and described what would be considered key elements of the deceased’s social and/or mental health history, which appear related to deficits in functioning, and present as contributing factors to the problematic behaviours resulting in the death, however, the BOI did not identify them as such.

In a suicide death investigation, the BOI report described key relevant factors (for example, a longstanding history of shame as a result of the index offence and an ongoing negative perception of self, a number of prior suicide attempts, the suspension of parole and return to custody) yet did not appear to recognize or identify these as central vulnerability and risk factors. In this case it appeared apparent that the role of the shame, self-loathing, instability in the community, and the impact of the suspension and a return to custody were relevant to understanding the death and should have been identified as such with corresponding recommendations on ways these risk factors may have been mitigated.

In other reports we noted examples of the BOI reporting historical information that is useful but less likely to reveal contributing factors to the non-natural death. For example, there were reports where the BOI offered a good synopsis on the individual’s criminal history and addiction and/or diagnostic history, however, as previously described, gave little attention to the vulnerability factors that contributed to these problem areas, which could be relevant to understanding contributing factors to their death. As previously stated, capturing this information on vulnerability factors that can present as precipitating or contributing risk factors is critical. The ability for BOIs to offer meaningful recommendations to support improved services to mitigate non-natural deaths in custody is impaired if investigators are not able to recognize, identify, explore, and assess for relevant precipitating or contributing risk factors to the incarcerated person’s death.

We further observed that social histories tended to be limited in several BOI reports. A good example highlighting incomplete and limited social review and why this is important to attend to was seen in an overdose case. This BOI report did a thorough job of describing the deceased's history of addiction, which is important in an overdose case, however dedicated only 2 sentences to this individual’s social history. In another overdose case the BOI report provided limited details related to the deceased’s social history that would allow for an understanding of the factors that contributed to the history of drug use/abuse and criminal conduct. No information was offered related to historical or situational contributing factors, no indication of trauma history was provided, and there was no information about what emotional vulnerabilities were relevant to the individual’s poor level of functioning. As a result, these reports were unable to speak to the underlying contributing factors to the drug abuse of these individuals, which is necessary to understand the addiction, what was done or could/should have been done to attempt to address the social history risk factors, and to understand the factors contributing to the death because of overdose. Having a comprehensive understanding of the factors contributing to the core issues related to the non- natural death has significant implications for considering potential case management and mental health interventions that could have been attended to in an effort to address the social history issues to mitigate this outcome.

In reporting on the deceased’s mental health history, we often found that like social history reports, the information provided tended to be limited and incomplete. When mental health issues were evident, the primary focus of BOI reports tended to be outlining an individual’s diagnostic history and some cursory information about past intervention plans. It was again our impression that some investigators are unclear on what is important to look for and report on, when it comes to reviewing and analysing mental health history and management of mental health concerns. Again, as a result, this impedes appropriate and meaningful recommendations being offered that could support enhanced services and contribute to mitigating and preventing non-natural deaths in custody. We will discuss this further in TOR 4, which is specific to attending to the mental health needs of individuals who died by suicide; however, the areas of concern noted in our observations of BOI reports on death by suicide cases were also evident in BOI reports on cases of death by overdose and homicide. As a result, our primary observations and comments on attending to mental health will be offered in this section.

In summary, in both overdose and homicide BOIs, as in suicide cases, it was noteworthy that often, the exploration of mental health issues was limited, the information provided vague, and key areas that should be attended to were neglected. For example, not speaking to or exploring reported inconsistencies and contradictions in the deceased’s file related to the need for treatment in an overdose BOI, or accepting information from a Correctional Plan indicating the deceased had made progress over the year with no indication of how this was determined.

What we found most surprising and concerning was how little attention was given to: investigating the mental health assessment and treatment plans, or lack thereof, for individuals with mental health concerns; considering participation and progress in intervention programs; and attending to how resistance and non-compliance in intervention plans were managed. Despite several BOI reports noting information that should be of concern about access to intervention programs, problematic responses to resistance, and information that should raise questions and concerns about how mental health issues are being assessed, case managed and treated, many BOI reports are silent on these issues both in their case analysis and in recommendations. It was striking that although BOI reports would reference if an individual had participated in interventions, there was typically limited information about the type of intervention, the individual’s level of participation and progress, or any issues and challenges and how these were managed.

When treatment was discussed, the focus was most frequently on a medical model and oriented towards health care or psychiatry involvement with little to no attention on the provision, or lack thereof, of psychological services or correctional programming. A significant opportunity for moderating mental health concerns and behavioural issues, including risk for drug use/abuse and overdose, violence as well as suicide, is the provision of appropriate interventions and supporting the individual to engage in, participate, and benefit from the intervention.

An interesting example of this is a report that outlined how the deceased had struggled with substance abuse prior to their overdose - the individual disclosed the use of fentanyl, made 3 requests for Opioid Agonist Treatment (OAT), and declared a hunger strike to expedite acceptance into the OAT program, however no comments or recommendations were made specific to the potential role of not providing the requested and required treatment in this individual’s death by overdose. The report did identify incidents of this individual being non- compliant and CSC’s approach to managing this, which appeared to be consistently punitive, however, the BOI did not speak to this and there was no information as to whether efforts were made to understand, and work through the resistance. As well, an account is offered of the individual being suspended from the multi-level maintenance program for lying about attendance but does not explore whether this resistance was processed in an effort to re-engage them. This report further described the deceased as having stopped participating in important aspects of their correctional plan, having stopped attending school, and going off the prescribed Suboxone treatment. The investigation did not explore if/or what contributed to this change in behaviour or examine case management responses (from the institutional parole officer, medical staff) to address these changes and attempt to re-engage the individual. This highlights a gap in both describing issues related to this individual’s mental health as well as case management practices.

Integration of risk factors

The importance of doing a risk factor analysis is that relevant elements of the deceased’s social history, physical health history, mental health history, and the case management dynamics inform as to what factors may have contributed to that individual’s problematic community and institutional functioning prior to and leading up to their death, and reveal factors that may have contributed to the non-natural death in custody. CSC staff managing cases and national investigators conducting BOI’s having an adequate understanding of these static and dynamic risk factors offers the potential to bolster prevention efforts and can inform CSC’s policies and procedures and BOI recommendations.

The 6th IRC noted that when the Key Areas of Investigation were identified, BOI reports often offered a compartmentalized synopsis of the deceased’s history in the domains of interest. It was less common for BOI reports to integrate this information and offer connections between identified risk factors and their implications on the individual’s functioning in the community and institution, how the case was managed, and the occurrence of the non-natural death in custody. In cases of the non-natural death of an Indigenous individual, these Key Areas of Investigation were often not tied to providing analysis of their Indigenous Social History. It is the identification and integration of the risk factors evident in the key areas of investigation and how they are tied to the deceased’s community and institutional functioning and the case management that can best support the formulation of recommendations and offer strategies to mitigate and prevent non-natural deaths. This is further explored in TOR 5.

Proximal versus distal risk factors

The 6th IRC also noted what seems to be an inconsistent understanding of how a “precipitating event” is defined. In our review of BOI reports it appeared that investigations tended to focus exclusively or primarily on proximal risk factors; those risk factors evident near to the time of death. Most often this involved examining and highlighting events that transpired in the hours proceeding the death. Common proximal risk factors noted in BOI reports include communication gaps, level of monitoring by correctional officers, and access to something that facilitated the death (objects used to commit suicide or a homicide, or the presence of drugs). It was noteworthy that pre-existing vulnerabilities or distal risk factors were much less often considered. Distal risk factors can include historical factors such as experiences of childhood neglect and abuse, parental substance abuse or aggression, and other difficult developmental and potentially traumatizing experiences. Such distal experiences have been identified as risk factors linked to proximal risk factors related to substance abuse (potentially linked to overdose), psychological distress and depression (potentially linked to suicide), and aggression (potentially linked to homicide). Distal risk factors can also include events that transpired some time prior to death, such as having been suspended and returned to custody, or experiencing a significant failure, rejection, or loss in the months (or longer period) leading up to death. As such it is critical that CSC staff are developing correctional plans that include interventions to address distal risk factors and that in investigating non-natural deaths, national investigators conducting BOI’s review whether there were relevant distal risk factors and if these had been identified and interventions provided to address them.

In one BOI investigating a death occurring because of an overdose, the report identified important proximal factors (for example, communication issues, lack of monitoring), however did not identify or link evident distal risk factors to the occurrence of the overdose death. In this case the distal risk factors included a trauma history, mental health issues, absence of social supports, the absence of or difficulties engaging in treatment, accessibility of drugs, problematic peer group, and institutional placement. By not recognizing the relevance of distal factors in the investigation and attempting to identify these, the BOI was not able to explore if these distal risk factors had been addressed as part of the deceased’s correctional plan. The omission of distal factors did not allow for an opportunity to provide recommendations related to how addressing these could have the potential to mitigate or prevent non-natural deaths in custody.

Similarly, in reviewing several cases involving death because of suicide, again important proximal factors were considered and were the subject of BOI recommendations. These included findings such as:

• communication issues (for example, between health care and correctional officers, case managers and correctional officers)
• lack of monitoring (for example, by correctional officers, health care, case managers)
• access to objects to use for death by suicide
• issues related to the construction of a cell
• time elapsed in correctional officers’ response after discovering something was wrong
• the accessibility of medical equipment

Limited attention and connection to risk and risk management was given to key contributing distal risk factors evident in many of these cases such as:

• trauma history
• longstanding depression
• feelings of loss, hopelessness, and failure
• a history of problematic interpersonal relationships
• shame in relation to criminal behaviours
• unmanaged mental health issues, including Fetal Alcohol Spectrum Disorders and intellectual disabilities
• an absence of or difficulties engaging in treatment

As with overdose and suicide cases, distal risk factors are also important to consider in homicide occurring in custody. Again, in addition to any proximal events that might be identified (for example, a preceding conflict, possession of a weapon, peer pressure/group think, accessing a blind spot outside staff and camera view), distal factors, such as the ones described above, seem to receive limited attention.

Assessing for these distal risk factors as well as proximal risk factors would enhance BOI reports to offer the most comprehensive recommendations to help mitigate non-natural deaths in custody.

Key findings

• BOI reports do not consistently provide a comprehensive review of the incarcerated persons social, physical, and mental health history
• When reporting on the deceased’s social, physical, and mental health history, BOI reports do not consistently connect identified risk factors in the key areas of investigation to vulnerability and risk factors relevant in contributing to the incarcerated person’s difficulty functioning and the non-natural death in custody
• BOI reports tend to focus exclusively or primarily on proximal risk factors to the death

Recommendations

Recommendation 1: BOI reports should have sections for each of the key areas of investigation to enhance the thoroughness of the assessment and review of the deceased’s social, physical and mental health history, as appropriate.  

Recommendation 2: BOI Reports should connect how the identified vulnerability and risk factors in the key areas of investigation contributed to the incarcerated person’s difficulty functioning and the non-natural death in custody.  

Recommendation 3: BOI reports should assess for, identify, and discuss both proximal and distal risk factors to the non-natural death.  

Recommendation 4: CSC should review and enhance training and professional development for BOI National Investigators:

• consider further training on assessing the key areas of investigation, risk factors and how to connect vulnerability factors to risk factors relevant to the occurrence of a non-natural death
• consider a mentoring program that would have exceptional National Investigators provide training, professional development, and act as resource for BOI members involved in investigations

Recommendation 5: Consider having an investigator that has a background in mental health services or is a mental health professional on all investigations. 

Reporting and analysis of case management issues

In this section we assess whether BOI investigations and recommendations adequately considered case management practices in relation to the incident. The case management practices which stood out as problematic to us in our review were communications and transfer practices; response to resistance/non-compliance with correctional plan and managing suspensions and revocations/return to custody.

BOI reports tended to assess and comment on these issues, however we found there were common gaps in BOI reports not consistently focusing on some noteworthy case management areas. Problematic issues related to case management we observed included:

• the level of staff engagement with the incarcerated person
• treatment and risk management planning and follow up
• responses to signs of the incarcerated person demonstrating compliance issues and destabilization in institutional functioning

While believing the role of BOI reports should not be fault finding in their orientation, it would be beneficial for these reports to provide further information, observations, and recommendations specific to identified problems in case management practices. This would assist in establishing the factors that may have contributed to staff having difficulty managing a case, and offering recommendations specific to supporting enhanced training, capacity building, and staff support and accountability mechanisms to enhance case management practices.

The 6th IRC is not the first review committee to note that communications between sectors within CSC pertaining to incarcerated persons can be problematic. We noted numerous cases where pivotal information was not being shared across sectors - for example, between the case management team and correctional officers, or with mental health services. We noted information sharing issues related to transfers between institutions; drug use and overdose; suicide attempts; and mental health issues. These issues were captured well in BOI reports.

With respect to transfers between institutions, there were cases involving incarcerated persons with noted vulnerability concerns, particularly related to mental health issues (depression and past self-harm, suicidal ideation, and past suicide attempts) where the information appeared unattended to in the receiving institution. In one case for example, an Indigenous inmate with known mental health issues ultimately overdosed after not having been seen by mental health services in the receiving institution for over approximately 2.5 months post transfer. We further observed that recommendations arising from these issues - for example how to ensure better information sharing relating to mental health - were generally not approached as systemic.

We also noted that BOIs did not always take an in depth look at what had been done by the case management team to engage an incarcerated person who was resistant to programming or treatment, and non-compliant with their correctional plan. Where an incarcerated person had non-completion of treatment or programming due to drop out/refusal/or termination, BOIs generally did not identify what measures the case management team had put in place to facilitate engagement. For example, it was not always clear if the incarcerated person had been offered the motivational/refusers module or whether other interventions might have assisted with compliance to the correctional plan.

Finally, we noted that BOI reports did not adequately consider and review how case management deals with the impacts of an individual being suspended on conditional release and returned to custody, as this is a potentially high-risk time. When an offender has their parole or statutory release suspended in the community, they are returned to federal custody to await a hearing with the Parole Board of Canada. This can take weeks to months. If their release is revoked by the Parole Board, they are returned to federal custody to serve their remaining sentence, subject to further conditional release. Offenders may have their release revoked for reoffending; for breaching imposed special conditions; or due to an escalation in risk to undue for any other reason. The interim period after suspension but prior to revocation can be wrought with mental health issues including depression and anxiety, self-harm, suicidal ideation, and withdrawal. Similarly, post revocation, incarcerated persons may experience mental health difficulties due to their return to prison. We noted cases where suspension and return to custody was a distal risk factor to the non-natural death in custody that BOIs did not consider.

Key findings

BOI reports did not consistently highlight information, observations, and recommendations specific to identified problems in case management practices, including interventions and programming

Recommendations

Recommendation 6: Case management practices should be a distinct area of review and assessment during BOIs.

• BOIs should specifically consider if the deceased had demonstrated resistance to their correctional plan and if so, what efforts were made to engage them
• in cases where the deceased has been suspended or had their parole revoked, BOIs should specifically explore the case management response to supporting the deceased’s integration back into the institution

Attention to systemic issues

While reviewing the key areas of BOI investigations relating to risk factors, offender’s social history, physical and mental health, and case management practices, the 6th IRC noted multiple apparent systemic issues which were not being identified by BOIs as such. Recommendations were often related to case specific factors which are of course important, but they rarely focussed on getting at repeat core issues. Given the significance of systemic issues for institutional functioning, safety of staff and the incarcerated person, and their role in contributing to the occurrence of non-natural deaths in custody, they require more in-depth attention from BOIs. They should be highlighted in BOI reports and where appropriate, be a central focus of BOI recommendations. They should also be key issues that CSC responds to, given their significance and the presence of these systemic concerns in multiple cases, across multiple institutions, in various regions of the country.

The 6th IRC is aware that the role of systemic issues in BOIs have been raised and addressed by preceding Independent Review Committees but feel it would be remiss not to add our voices to this ongoing dialogue with CSC. There appears to be a significant shortcoming with BOIs not identifying and examining systemic issues or offering recommendations specific to systemic issues that appear in the occurrence of non-natural deaths in custody.

Our predecessor, the 5th IRC, was also tasked with assessing whether recommendations made by BOIs addressed any need for systemic change to policy and procedures. They noted that CSC had recently introduced a new Enhanced Investigation Analysis (EIA) process which they viewed as useful tool for identifying potential systemic issues early in an investigation. They recommended that CSC consider expanding the Enhanced Investigation Analysis process to more investigations, where appropriate (refer to Recommendation 17 in the 5th IRC report). Nonetheless, we noted significant overlap with the 5th IRC in identifying issues in BOIs that had a systemic element that was not addressed in either the investigation or in the recommendations. This was particularly the case with staff compliance issues, also noted by the 5th IRC.

We noted that the issue of inadequate security patrols and counts by correctional officers not “of sufficient quality to ensure the presence of a live breathing body or verify the wellbeing of inmates” as per Commissioner’s Directive (CD) 566-4 Counts and Security Patrols was present in numerous reports. Even when this issue clearly appeared more systemic in nature, BOIs had made recommendations - if any - that related only to the case at hand. This left us wondering – given the frequency of this type of staff compliance issue, whether BOIs should consider recommending, and CSC should consider implementing, additional ongoing correctional officer staff training, emergency drills, etc. Recommendations also rarely addressed accountabilities for staff for clearly disregarding rules or policies with serious consequences.

As noted by the 5th IRC (2019):

We identified instances of where it was unclear whether compliance issues were being dealt with appropriately by BOIs, in some - though certainly not all - of the cases we reviewed. This was particularly so when multiple compliance issues were identified by a BOI. This may result in potential systemic issues - for example issues relating to training, supervision, and culture - not being identified and dealt with, including those that may not have had a direct impact on a particular death but may be a factor in preventing future ones.

Indeed, the 5th IRC (2019) pointed to the importance of scrutinizing the prior history of CSC staff involved in an incident in order to determine whether there was a systemic issue with training and supervision that might need to be addressed:

For example, in cases where a Correctional Officer did not make sufficient efforts to determine if an inmate was alive in a cell during rounds, is there any evidence that is not the first time that this Correctional Officer has failed to do this?

Ultimately, the 5th IRC concluded - as have we - that compliance issues are not being adequately attended to in the BOI reports. The 5th IRC recommended that CSC develop a thematic report focused on Board of Investigation reports into deaths in custody to determine if there exist any patterns and/or potential systemic issues in relation to compliance (refer to Recommendation 30, 5th IRC, 2019). Scenarios and lessons learned could then be incorporated into staff training.

We were however, informed by the Incident Investigations Branch that since the dates of our cases under review, the IIB has undertaken a study of 40 BOIs that involved issues with correctional officer counts and patrols. One pagers have been issued to each region on this challenge.

We also noted several other key systemic concerns assessed through our review of BOI reports, although not typically flagged as such. Clearly, the presence of illicit substances/contraband (drugs and alcohol) entering institutions and not being caught in a timely fashion is an issue that repeats itself and played a role in non-natural deaths by homicide, suicide, and of course, overdose.

While we recognize the challenging nature of keeping contraband out of penitentiaries, particularly with the availability of drones, and the efforts of CSC to control this perennial issue, we still questioned whether there might not be patterns that emerge within or across institutions that it might be useful for BOI to identify and address on a broader scale. For example, one BOI report stood out for its comprehensive review in an investigation of multiple overdoses on one unit. This report asked how the drugs entered the institution, how they were missed in cell searches, and conducted a background analysis of structural issues at the institution that presented challenges with respect to drug interdiction. The 6th IRC considered this approach an optimal example for the examination of the introduction of contraband to the institution and the numerous tangible responses that resulted from this investigation, including a site-specific drug response strategy.

We also wondered whether there might be a way for BOIs or CSC to circle back in the future where the investigation of how drugs arrived at the institution is still active with police and security intelligence at the time of the BOI, to answer the question of how the drugs are being brought in.

Similarly, the 5th IRC noted that the presence of homemade weapons in the institution was not treated as a systemic issue, though it also clearly presents as a systemic issue across reports and could facilitate broader recommendations for weapons prevention and management. We share this opinion and note how in instances where weapons were referred to in BOI reports, there was rarely any commentary about or recommendations made regarding managing weapons coming into the institution; monitoring for homemade weapons; and/or focusing on responses to and consequences for being found in the possession of a weapon.

Further, we noted further possible systemic issues with respect to the inadequate frequency of an incarcerated person meeting with their institutional parole officer (discussed in TOR 3) that have not been addressed.

Finally, we noted that many of the individuals who overdosed or committed suicide were described as having low mental health needs while the outcome of them dying because of suicide or overdose tends to suggest otherwise. (See TOR 4)

In sum, the 6th IRC was concerned by what appears to be an apparent disconnect between individual BOI investigations and systemic issues. It was unclear to us if information on systemic issues is shared by CSC with investigators or how systemic issues are compiled in an ongoing manner and shared across investigations. The 5th IRC recommended that the IIB develop a thematic report focused on BOI reports into deaths in custody to determine if there exist any patterns and/or potential systemic issues in relation to compliance. We concur that there is a critical need to further develop and evolve protocols to flag systemic issues so that BOIs can be aware of and attentive to observing if issues identified in a single case have larger implications and so that BOI recommendations and CSC’s responses can address systemic issues of concern on a larger basis.

In that regard, we considered whether the convening orders were broad enough to empower BOI to investigate systemic issues. Boards of Investigation appear limited to the issues identified in their convening order which are generally not framed as systemic. It appeared to us that the BOI should have some residual discretion to investigate what they deem to be necessary and appropriate as the investigation evolves. We note that the 5th IRC recommended that BOI Terms of Reference be allowed to be developed mid-investigation if the evidence warrants it and agree with and support this position. We were informed by the IIB that CSC has committed to greater flexibility in the Terms of Reference for BOI as indicated in BOIs more recent than those we examined.

The 6th IRC did note one BOI report that had a systemic component to the investigation in its convening order as a good example of what could be done more frequently:

Investigation Area B (from BOI Report)

Inclusive of the current incident under investigation, a review of the previous Boards of Investigation conducted on inmates within/from [redacted] Institution, in which acts of violence resulted in serious bodily injury, in order to examine the potential for any relevant similarities across events, including but not limited to, consideration of: 1) the profile of the inmates involved; 2) the intervention strategies employed to address/manage the criminogenic risk factors of the inmates; and, 3) the role, if any, that the placement and/or transfer of inmates may have had on the incidents.

Given that BOI reports focus on individual incidents, without there appearing to be a mechanism for tracking re-occurring issues - in an institution, region, or the country - there appears to be limited flagging of more system wide concerns that require attention and correction. However, we were informed by the IIB that currently each BOIs team leader is provided with like-minded BOI reports and there is a focus on looking at systemic issues, particularly at the institutional level where they seek to amalgamate numerous related or similar incidents into one investigation. The 6th IRC did review several BOI reports where multiple non-natural deaths in custody were investigated together and views this as positive progress towards a more systemic approach to BOI.

Key findings

Systemic issues are generally not highlighted in BOI reports with accompanying recommendations.

Recommendations

Recommendation 7: Convening orders should empower BOIs to investigate systemic issues and make recommendations where appropriate.  

Recommendation 8: CSC should undertake a program of “tracking and training” around systemic issues to better inform itself and BOI investigators.  

Protective factors

The 6th IRC views protective factors as the other side of the risk factors “coin” and believe that incorporating an examination of protective factors into BOI investigations would represent a more holistic approach. Further, while risk factors focus on negative attributes, protective factors emphasize the positive about the incarcerated person. Public Safety Canada (2015) defines protective factors:

These are positive influences that can improve the lives of individuals or the safety of a community. These may decrease the likelihood that individuals engage in crime or become victims. Building on existing protective factors makes individuals and communities stronger and better able to counteract risk factors.

Examples of protective factors that might be present for federal incarcerated persons include a desire for greater education; a drive for employment; strong social supports; and participation in traditional healing and cultural activities that facilitate self-worth. Protective factors will of course differ for each incarcerated person, but a BOI might consider what that individual’s protective factors were and whether they were being adequately leveraged by the CMT factoring them into the correctional plan, much like what is already done for risk factors. For example, was an incarcerated person with a good work ethic working? Did someone who wanted to further their education, have that access to schooling? Was contact being facilitated for an incarcerated person with good social supports, by phone, or personal family or volunteer visits? Was an Indigenous offender able to access traditional and cultural supports where desired? Taking advantage of protective factors for an incarcerated person could reduce their likelihood to overdose, commit suicide or be the victim of a homicide and is therefore relevant to the work of a BOI investigating a non-natural death in custody.

Key findings

BOI Reports tend not to explore protective factors and their facilitation in cases, making it difficult to determine if the case management team took advantage of supporting protective factors that could potentially have mitigated the incarcerated person’s vulnerability, risk factors, and circumstances surrounding the non-natural death in custody.

Recommendations

Recommendation 9: BOIs should investigate and make recommendations regarding an incarcerated person’s protective factors and whether they were facilitated to support wellness, institutional functioning, and vulnerability/risk management.

Examination of Terms of Reference 3

The 6th IRC decided to analyse each of these 3 measures of CSC’s responsivity to BOIs separately as follows.

TOR 3: Analyse the timeliness of CSC response to recommendations; the implementation/tracking of corrective measures following a non-natural death in custody; and the need for an evaluation of outcomes, to measure the effectiveness of the corrective measures’ action plans.

Timeliness and identification of status of recommendation completion

In our review of BOI reports, we found good examples of consultation grids identifying instances of quick responsivity by CSC to issues raised by the BOI. It was observed that CSC had sometimes undertaken corrective action to address identified deficiencies long before the BOI had completed its investigation and report. Examples of this include CSC providing staff training on the relevant issue and by issuing tool kits to facilitate cell entry. We also noted examples of consultation grids providing clear and detailed accounts of the plan of action to implement BOI recommendations. In one case, the grid narrative indicated dates for pilot studies and procurement dates for the acquisition of new ION scanners for the prevention of drug contraband entering the institution. A subsequent update identified the signing of a new Memorandum of Understanding with a drug testing partner and the addition of Fentanyl to the urinalysis program.

It was however more common that we found it difficult to determine the timeliness of CSC’s responses to BOI recommendations and in several instances found significant delays in CSC’s implementation of initiatives to address BOI recommendations.

In attempting to consider the status of recommendation completion, we found that the dates a BOI report was presented and closed, and when consultation grids were considered closed are ascertainable, however, the way consultation grids are written, there was no clear indication of when the BOI recommendation was received by CSC, when CSC’s responses to recommendations were made, and what the timelines were for implementation of the recommendations. This included limited information being easily accessible to ascertain the dates of specific milestones in CSC planning for action on recommendation items; the dates of implementation of actions to address the recommendations, and the date the full implementation had been completed.

We also found some CSC actions in response to BOI reports seemed to take inordinately long to complete. For example, where the CSC response is to issue a security bulletin, it can appear to be unduly delayed by ongoing consultation and revisions. Further examples of seemingly undue/unexplained delay included for example: the time required to obtain a crime scene tent; a decision to wait for vehicles to be retired before retrofitting new ones to accommodate cameras so operators can see what is happening in the back; and a recommendation related to the transfer process that was still under review after 18 plus months of consideration.

We also noted several instances where the CSC response indicated that an action was deemed “completed” when it was not, and the changes were still in progress or waiting to occur. For example, in one case, CSC’s response to a recommendation for moving beyond Elder centric services and expanding provision of services was to say the actions required to resolve this recommendation were completed; however, what is completed was the work plan, with no identification of what the plan was or when it would be implemented. Another BOI report contained a recommendation relating to engaging Elders/spiritual advisors on practices to inform Indigenous family members of a death in custody in a culturally appropriate manner. This is indicated as supported by CSC and there was agreement to update CD 530 - Death of an Inmate: Notifications and Funeral Arrangements. The consultation grid then notes that the issue was discussed with the National Elders working Group and notes were shared, marking the action as completed, despite the CD not having yet been updated.

Further, as noted earlier, the 6th IRC observed that in several BOI reports there were issues of staff member accountability for oversights or errors. In consultation grids, CSC noted that responsible individuals were on long–term leave and “direct corrective action cannot presently occur” and follow up will be required upon their return. However, this was then marked as completed despite the acknowledgement by CSC that direct corrective action could not be completed at the time.

Key findings

The consultation grids outlining CSC’s response do not consistently offer a clear timeline of action and completion steps in response to BOI recommendations, and at times identify resolution of a recommendation prior to actual completion.

Recommendations

Recommendation 10: Consultation grids should have clear dates and clear deliverables for CSC action plans to address BOI recommendations for further transparency and accountability. 

Implementation/Tracking of corrective measures

In reviewing CSC’s implementation and tracking of corrective measures, the 6th IRC wondered what the expectations are for a supporting rationale where CSC rejects or is not fully responsive to a BOI recommendation? The 6th IRC determined that there is not always full transparency from CSC in why a recommendation is being rejected or does not get acted upon; and a clear alternative direction is not always provided to deal with the issue identified by the BOI.

For example, in several cases there were issues involving frequency of contact between incarcerated persons and institutional parole officers and one BOI report recommended that a minimum frequency of contact between inmates and parole officers be instituted in the relevant CD. This recommendation was rejected by CSC which pointed to a review of “all case management policies which provides direction to parole officers in maintaining regular and meaningful engagement with inmates on their caseload.” CSC concluded that “these responsibilities require maintaining regular contact with the inmate.” CSC further issued a case management bulletin to staff in order to “address policy compliance issues regarding offender interactions and the importance of documenting these interactions in casework records.” However, the 6th IRC observes that none of these initiatives, however laudable, address the recommendation that a minimum requirement for frequency of contact between incarcerated persons and parole officers be implemented and no justification was offered for its rejection.

Further, while the 6th IRC recognizes the inherent challenges in implementing recommendations relating to infrastructure issues, CSC responses to infrastructure issues were not always adequate and timelines were not always clear, thereby not lending themselves to tracking. While CSC appears to be acting on various cell suspension point issues across institutions related to suicide, there are other instances where the 6th IRC questions the implementation of corrective measures on structural issues.

For example, in 1 suicide case the BOI identified:

In terms of safety and security of inmates and staff, the Board of Investigation (BOI) identified an underlying issue that the cell door handle/lock could be tampered with, and this then also impacted staff immediate ingress to respond to the incident.

The accompanying action undertaken by CSC was as follows:

The door to the cell was completely replaced on February 11, 2021, and a metal plate was secured to the door which blocks the ability to tamper with the door handle.

The BOI further noted:

In terms of safety and security of inmates and staff, the Board of Investigation (BOI) also identified an underlying issue that the cell door, itself, could be opened by being kicked in a couple of times. The cell doors are solid wood, painted gray so they look like metal, but are not. The only metal on the door was the hardware. Consultation with Institutional Works confirmed that it would be easy to kick with the tampered cell door handle/lock and hardware removed. It was unknown by staff that kicking the cell door a couple of times would open it – rather, this was considered a result of the tampered cell door handle/lock.

Again, the CSC action was:

The door to the cell was completely replaced on February 11, 2021, and a metal plate was fastened on the door to reinforce the latch and prevent manipulation of the door handle.

These actions are then marked by CSC as completed.

This left the 6th IRC questioning whether this door - and only this door - had the structural flaw as identified by the BOI or whether other doors in the institution would be similar and require at least a review? Was this the only cell door handle/lock that could be tampered with and opened by being kicked in?

In a homicide case the BOI found that the infrastructure of the room where the assault occurred impacted effective line of sight monitoring, and there was no camera coverage because of privacy needs. The BOI recommended that the Assistant Commissioner, Corporate Services review options that could enhance the safety of inmates accessing them.

While CSC accepted this recommendation in the consultation grid, it ultimately appears that little was actually done to this location in response to the recommendation due to structural issues, and the institution indicating it was “not able to secure larger monitors for the monitoring of inmate movement in the area [redacted], nor is the site supportive of increasing patrols from hourly as outlined in CSC policy” however this response is not explained.

On a more positive note, the 6th IRC noted overall apparent timely rollout of support services to staff and inmates by CSC after an incident and that in some cases CSC undertook additional measures to address staff wellness and mental health where there had been an increased number of incidents of serious bodily injury in recent history.

Key findings

When CSC rejects a recommendation, there is not always a clear indication for the rationale related to that recommendation being rejected.

Recommendations

Recommendation 11: CSC should provide a supporting rationale where it rejects or does not fully implement a BOI recommendation for greater transparency and provide a clear alternative direction to deal with the issue identified by the BOI.  

Recommendation 12: A protocol should be developed to identify an oversight function that can ensure CSC is held accountable for appropriate timelines for action and that can review findings when CSC rejects or does not fully implement a BOI recommendation. 

Need for outcome evaluation

The 6th IRC found that certain types of CSC responses did not readily lend themselves to an evaluation of outcomes. Perhaps most common were CSC actions/responses of “e-mail reminders sent” to reinforce staff awareness. The 6th IRC questioned the efficacy of sending e-mail reminders or how an outcome from that action could be evaluated? Similarly, we questioned how to evaluate the effectiveness of CSC issuing further directives or checklists. Oftentimes, the policy tools/directives were already in effect and the issue identified by the BOI is implementation related. The 6th IRC observes that education and training - for example - might at times be more meaningful interventions that lend themselves to evaluation of outcomes (for example, increased staff understanding of the issue). The 6th IRC was somewhat troubled by what it perceived to be a substantial reliance by CSC on written notices to “remind” as compared to more measurable protocols to enhance adherence to policy/directives such as training, mentoring, follow up and review, and connecting compliance with employee performance appraisal. There does not appear to be a process for evaluating the effectiveness of implementing the recommendations and if they prove to be of assistance in mitigating factors contributing to non-natural deaths in custody. Similarly, there does not appear to be an external monitoring and oversight of the adequacy of CSC's response to addressing the recommendation to address/resolve the problem area, and the frequency of CSC rejecting or not responding to recommendations.

Key findings

CSC responses did not always lend themselves to an evaluation of outcomes. There does not appear to be a process for evaluating the implementation of recommendations and whether they mitigate factors contributing to non-natural deaths in custody.

Recommendations

Recommendation 13: To further transparency and accountability, CSC should ensure that actions in response to BOI findings contain elements that are measurable, and thereby create outcomes that can be evaluated.

Examination of Terms of Reference 4

TOR 4: Examine whether mental health concerns:

• were sufficiently identified, monitored, and tracked in cases of suicide death
• were sufficiently shared among sectors in an effort to activate appropriate suicide prevention measures

Examining the contributing role of mental health issues in cases of incarcerated persons dying by suicide is a critical component for BOIs. Suicide is typically the function of a number of contributing factors, however central precursors to someone dying by suicide are mental health vulnerabilities, particularly depression (World Heath Organization, 2024). Other mental health issues such as anxiety disorders, bipolar disorder, post-traumatic stress disorder, and substance abuse disorder all are risk factors (American Foundation for Suicide Prevention, 2024).

A comprehensive review of the extent to which mental health issues were identified among incarcerated persons who died by suicide and an analysis of the type and sufficiency of intervention plans evident in these cases is critical to enhancing CSC’s capacity to respond to this risk. Key areas of review and investigation in this regard would include consideration of the deceased's diagnostic history; history of psychiatric and psychological interventions; evident symptoms and behavioural indicators of mental health vulnerability prior to suicide; identification of a prior history and incidents of suicidal ideation/statements of intent or suicide attempts prior to death by suicide.

It would also require evaluating the intervention plans put in place to address and manage mental health vulnerability and potential suicide risk. This can include mental health interventions (for example, use of screening tools, assessments, psychopharmacological intervention, therapy, correctional programming, Indigenous healing services) and/or institutional management interventions (for example, institutional placement, cell searches, wellness checks, communication of vulnerability factors and risk for suicide). A comprehensive review of mental health concerns and interventions by BOIs in suicide cases can inform and highlight areas CSC can enhance to identify individuals at risk for suicide; the implementation of empirically supported mental health intervention strategies; and strategic monitoring, tracking and communication protocols when dealing with at risk incarcerated persons. Comprehensive BOI reviews and recommendations in suicide cases can also guide institutional operational management strategies and procedures, policy development and potentially stimulate research (for example, projects conducted by CSC’s Research Branch) to better understand and mitigate loss of life in custody because of suicide.

According to the Mental Health Commission of Canada (2020), the prevalence rates of mental health problems among justice involved people is considerably higher, approximately 3 times as high, as that of the general population, and presents as worsening over time. Additionally, the rates of expressions of suicidal ideation and attempted suicide in Canadian prisons is between 3 to 11 times higher than in the community. Suicide rates in federal corrections have been identified as 7 times higher than in the general population whereas the suicide rates for persons in provincial custody has been identified as 4 times higher than that in the general population. Suicide has been identified as most common cause of non-natural death in federal correctional institutions. Of the 34 cases provided to the 6th IRC to review, 50% were incidents of incarcerated persons dying by suicide (17 suicide, 12 overdoses, and 5 homicides). Given the disproportionally high incidence of mental health issues in federal correctional intuitions, the association between mental health concerns and suicide, and the corresponding elevated incidents of suicidal ideation, suicide attempts, and death by suicide in federal correctional institutions, a comprehensive examination of the link between mental health and suicide is indeed a critical task for BOIs to attend to in their investigations.

In reviewing the suicide cases, the 6th IRC focused on the extent to which mental health issues were examined and in doing so focused on BOI’s identification of mental health issues in suicide cases, attention to intervention plans, and the identification of information sharing to mitigate risk for death by suicide. We note that recommendations 1 to 9 and 20 apply equally in cases of non-natural death by suicide.

Identification of mental health issues and risk factors in death by suicide

The 6th IRC found BOI reports varied in the extent to which they both recognized and examined relevant mental health factors in death by suicide cases.

There were excellent BOI reports that provided a comprehensive and thoughtful review of the deceased’s mental health history and outlined and explored key factors such as the deceased's:

• diagnostic history
• behavioural indicators of concern
• assessments of mental health functioning
• historical and proximal triggers that potentially contributed to the death by suicide
• the availability and outcomes of mental health interventions
• the level of monitoring of the deceased prior to suicide
• the sharing of information about the deceased’s vulnerability factors prior to the suicide

In these BOI’s, investigators identified and interviewed key collaterals relevant to gaining insight into the deceased‘s state of mind and emotional functioning prior to suicide.

A strong example of a comprehensive investigation can be found in one BOI that did an excellent job of focusing on identifying proximal and distal factors contributing to the death by suicide. Proximal factors identified included an emotional reaction to talking about the recent loss of a family member to suicide and questions about how this was processed. The BOI noted limited empathic engagement to better understand and attempt to address the emotional experience the individual was struggling with; withdrawal from methamphetamine use and the impacts of this; and erratic behaviours in their cell flagged by correctional officers and a neighbouring incarcerated person. The report also offered a thoughtful and insightful account of distal precursors that including history of substance/intoxicant use; treatment “failures” (terminated from placement in a healing lodge and a residential substance abuse treatment program, multiple supervision failures and breaches of conditions); loss of support from family and members of the home community; and historical documented incidents of past self-harm and report of depressed mood and hopelessness. This report further noted issues with this individual's cognitive capacity and how this impacted their ability to respond to questions, such as questions used to assess for suicide risk, as well as concern about English language comprehension as Oji Cree was the first language. This report also did an excellent job of connecting the association between depression and the psychological impacts of withdrawal from drugs/alcohol as associated with increased risk for suicide.

In contrast, we found several reports that were more limited, incomplete, or superficial in their identification of mental health issues relevant to understanding the risk factors and precursors to the death by suicide. In these reports, the focus appeared narrow, giving the greatest level of attention to operational issues in the time immediately preceding the death.

In focusing specifically on BOI reports on death because of suicide, the same themes identified in TOR 1 and 2 were evident. It appeared that some investigators did not have a sophisticated understanding of factors contributing to suicide risk and death by suicide. As noted in TOR 1, several BOI reports on suicide cases did not:

• provide a comprehensive review of issues relevant to the individual’s mental health history
• identify what appeared to be relevant risk factors in the information they were privy to
• link key case dynamics to risk and the occurrence of the death
• focus on distal risk factors

The 6th IRC was struck by the predominate focus on what presents as a medical model orientation in investigating suicide cases. Although mental health needs and issues are attended to by various departments in corrections, gathering and considering medical information was the most common focus. This orientation may have further impacted conducting a comprehensive review as noted above, as some investigators appeared to be most focused on considering the case from a medical perspective. Much less attention was given to exploring and identifying the provision of psychological services and a psychological perspective, and there was limited attention given to institutional programming (access to, participation and progress in, and outcome). For cases involving Indigenous incarcerated persons, there was typically limited, if any consideration of ISH factors as contributing to mental health vulnerabilities or focusing on the deceased’s involvement in cultural and spiritual programming (see TOR 5 for greater detail). It was found that BOI reports most often identified interviewing nurses, physicians, and psychiatrists, and much less often sought information from psychology, correctional program staff, Indigenous cultural staff or Elders about the deceased’s mental health status and functioning, and their contacts with mental health services such as psychology, programming, cultural and/or spiritual care, or peer support.

Consistent with this focus on a medical orientation to investigating suicide cases, BOI reports on suicides often, but not consistently, provide good account of the deceased’s diagnostic history and recommended psychopharmacological intervention and compliance. It was infrequent that BOI reports focused on core emotional, cognitive, and behavioural indicators of mental health instability or oriented to pertinent historical and situational risk factors that could potentially be associated with death by suicide. Consistent with our findings related to the reporting of social histories and physical and mental health histories in TOR 1, we found that BOI reports did not consistently identify key core relevant risk factors or attend to identifying how the evident risk factors were deemed to be associated with the death by suicide. There were several BOI reports on suicide that listed prior diagnosis as the primary focus, however, did not indicate how these diagnoses may be relevant to the death by suicide. It was surprising that BOIs were not asking questions such as:

• were they being treated for the diagnosed mental health issues
• were they experiencing active symptoms associated with the diagnosis
• if in correctional programming or treatment, were they compliant and if not, was there any indication why and were actions taken to address resistance

As discussed in TOR 1, BOI reports on suicide at times identified a host of historical and situational factors that appeared relevant to understanding mental health destabilization and risk factors that could be associated with suicidal ideation, suicide attempts or suicide, without being identified as such. As identified earlier in this report, in the case of a suicide death investigation, the BOI report focused on the deceased’s diagnostic history and psychopharmacological interventions, which are appropriate and important factors to identify and discuss, but provided limited attention to what appeared to be the core factors related to mental health destabilization and suicide, even though the information was contained in the report (for example, a longstanding history of shame as a result of the index offence and an ongoing negative perception of self; a number of prior suicide attempts; and the suspension of parole and return to custody). In another example, the BOI report focused on stress because of conflict over the incarcerated persons mothers' estate as a precipitating factor. Less attention was given to the importance of other information contained in the report: a long history of antisocial behaviour; a mental health diagnosis; no recommendation for or participation in any type of therapeutic services; the suspension of parole and return to custody; and significant relationship conflict and rejection.

The 6th IRC noted that BOI reports on suicide tended to focus on examining and identifying proximal events to the suicide that either a) might shed light on the motivation for suicide (for example, a recent negative event in the deceased’s personal life), or b) highlighting institutional operational factors that contributed to death by suicide occurring (for example, the design and structure of the cell, gaps in communicating the individual’s risk for suicide, the adequacy of staffing and correctional officer monitoring, staff response when the deceased was identified as being in medical crisis). All these factors are important and should be considered, identified and the subject of related recommendations, as appropriate. However, although, these factors can facilitate death by suicide, they typically do not represent the core mental health factors that would contribute to an individual either being triggered by a recent negative event or acting on opportunities to self-harm or commit suicide. As previously noted, there were several cases where potential risk factors were evident that were not immediately proximal to the suicide, but were likely contributing factors, that BOI reports did not recognize and/or identify.

BOI recommendations tend not to focus on the systemic issues evident in several cases and repeated themes in suicide investigations that could be addressed to attempt to reduce and mitigate death by suicide including:

• the impacts of a trauma history
• failure to integrate into the community and a return to custody
• limited access to psychological and/or therapeutic services
• issues related to managing program non-compliance and attempting to facilitate engagement
• institutional transfer and placement issues and impacts, including institutional associates
• provision of support to incarcerated persons when there is a significant relationship conflict or loss

Key findings

• It was apparent that not all national investigators serving on BOIs have a good understanding of what constitutes vulnerability and contributing or risk factors for suicide. Limitations in this understanding impede a comprehensive assessment of the contributing factors and potentially meaningful and important recommendations
• BOIs predominantly focus on a medical model orientation in investigating suicide cases - attending to medical and psychiatric involvement - with much more limited attention to psychological services, correctional programming, and cultural/spiritual or faith-based services

Recommendations

Recommendation 14: BOI reports should have an enhanced focus on noting the deceased’s documented mental health history and recent mental health functioning; and any evident emotional and situational factors that may have contributed to mental health vulnerability and destabilization in cases of death by suicide.

Screening tools and assessments

A central component of being able to explore the role of mental health concerns in a suicide case is reviewing and understanding past mental health assessments conducted on the deceased. These could include, but are not limited, to psychological reports, program reports, and psychiatric reports. Mental health reports would typically speak to mental health issues of concern, diagnosis, level of functioning, and risk (often recidivism risk, but in some cases risk for self-harm and suicide). Assessments may also include reporting on standardized mental health test measures, such as psychological testing. Some assessment and/or case background information may also include CSC internal scales to rate mental health issues, which provide further information related to mental health issues of concern and stability, including risk for suicide. It is not the BOI’s role to be an expert in assessment, however a BOI should be able to identify a concern if no recent assessment, testing, or screening was conducted in a case where an individual demonstrating mental health issues of concern dies by suicide.

Similarly, members of a BOI cannot be expected to have an understanding on issues such as test construction; test validity and reliability; and the required training to administer, score and interpret mental health assessments and screening tools (unless they possess the requisite training). However, a BOI should be able to identify if there appear to be questions or concerns related to information contained in an assessment, testing, or screening tool reviewed during the investigation.

This issue is raised by the 6th IRC, as we were troubled by the information found in several reports (suicide, overdoses, and homicide) where the reported findings of a screening tool - the Mental Health Need Scale (MHNS) - appeared problematic and yet none of the reports considered or drew attention to this as a concern and relevant factor in reviewing the case. The MHNS is a tool designed to assess the degree of psychiatric symptomology among persons incarcerated in federal correctional institutions to assist in determining the appropriate allocation of care. In our review of BOI reports we noted instances of significant discrepancies between the MHNS finding, the BOI account of the deceased’s functioning prior to the suicide (or overdose) and the outcome of a non-natural death. Boards of Investigation reports repeatedly seem to miss flagging any issues of obvious concern related to the use of this tool. In some cases, BOI reports refer to the incarcerated person being scored as Low Need on the MHNS, despite it being evident, from the report that the individual presented with a significant number of factors indicative of multiple criminogenic issues, psychological vulnerabilities, and risk factors. In one BOI the report identifies how the MHNS score had shifted from assessing the individual as Substantial Need to Low Need in a brief amount of time, and with the occurrence of a suicide occurring at the point of being assessed as Low Need. The BOI indicated that the deceased’s assessment on the MHNS was as follows:

• May 31 - Considerable need
• June 3 - Elevated/Substantial need
• June 27 - Low need
• July 27 - Suicide

This BOI did not note that the incarcerated person went from Elevated/Substantial Need to Low Need in less than a month and then one month later died by suicide.

While this is a blatant example, there were other illustrations of the need score on the MHNS being inconsistent with the individual’s identified level of mental health and behavioural functioning and the outcome of death, which BOI reports consistently failed to attend to. This is significant as scores on screening tools, assessments of risk for suicide, and assessment report data impacts an individual’s access to mental health services, programming and support, and may also impact the level of case management and monitoring directed to that case. If a BOI finds information reported on a screening tool, or an assessment report that does not seem to fit with the information they have gathered, this should be noted, and appropriate questions asked and recommendations for further evaluation considered. In our review of cases, it was evident that BOI reports should as necessary, raise questions about the application of screening tools and risk assessment protocols that they have concerns about.

Key findings

BOIs do not question screening tools, testing or assessments even if on face value the result is not consistent with the other information gathered.

Recommendations

Recommendation 15: BOIs should consider if there are any problematic implications related to the findings of mental health screening tools, testing, or assessments used for case management planning and the determination of appropriate interventions.

Therapeutic intervention

The 6th IRC noted that overall, BOI reports did not focus on exploring the role of therapeutic interventions in their investigations in a comprehensive manner. This appeared to us as a significant shortcoming. A primary means of addressing the distal risk factors noted across cases in BOI reports would be through targeting mental health needs and vulnerabilities, and to assist in managing the risk factors associated with self-harm and suicide. This also holds true in cases of overdose and homicide.

Therapeutic interventions that could play a role in mitigating non-natural deaths in custody could include a variety of therapeutic modalities including, but not limited to, institutional correctional programs; Indigenous cultural and spiritual healing initiatives, individual and/or group therapy; psychiatric consultation; and psychopharmacological intervention.

Although it was common for BOI reports on suicide cases to identify therapeutic interventions the deceased had participated in, been terminated from, dropped out of or were on a wait list for, the investigations were more limited in providing any further commentary. BOIs did not speak to instances where there was an evident lack of access to therapeutic interventions for an individual who demonstrated a need; little attention was given reviewing the perceived adequacy of the therapeutic interventions offered; and reports tended not to consider the deceased’s known level of engagement or participation in the therapeutic interventions. Where the deceased had been terminated from or dropped out of a therapeutic intervention, BOI reports did not explore why this occurred, what efforts were made to re-engage the individual, or the potential relevance of this to the outcome of the case.

An illustration of this was evident in a BOI report on suicide, where the deceased, who had a history of suicidal ideation and prior suicide attempts, was described as having requested to see the psychiatrist after reporting symptoms of psychosis and demonstrating behavioural challenges. The individual refused to attend the scheduled psychiatric appointment, however later made another request to see the psychiatrist and was told this might not be possible due to the previous refusal to attend the appointment. The BOI report does not identify this individual (reporting symptoms of psychosis and demonstrating behavioural challenges) as being seen by any mental health professional prior to their death by suicide and offered little or no information on:

• the individual’s history of being provided mental health interventions
• specific details related to the reasons for the referral to psychiatry
• if there were efforts to engage this person and support them to attend the psychiatrist appointment (at the time of the initial missed appointment or a plan to support a second requested appointment)
• if the individual was referred to and participated in any other therapeutic interventions

In this BOI report no recommendations were offered specific to the case management of or provision of mental health services to ensure appropriate care was put in place.

There were multiple cases where the adequacy of the supports that had been put in place despite prior knowledge of mental health issues and suicide risk concerns could have been better explored by the BOIs. Reports tended not to comment on the implications of no or limited intervention opportunities; assessments that had been completed indicating treatment was not required when there appeared to be information, and a case outcome, to the contrary; or examination of if the therapeutic intervention services offered appeared appropriate for the level of mental health need and suicide risk of the individual. As well, there was little attention given to investigating and commenting on issues related to termination of therapeutic interventions or dropping out of recommended therapeutic interventions. We were also struck by and concerned by BOI reports that accepted a correctional plan that did not identify a need for programming or treatment as being consistent with policy and professional practice standards, despite the case demonstrating multiple and obvious indicators of the need for therapeutic intervention (for example, serious mental health psychopathology, evidence of problematic behavioural dysregulation), and ultimately that incarcerated person dying by suicide, as a result of mental health vulnerabilities. It was rare to see recommendations specific to the provision of mental health services and ways of improving access to and engagement in these to help mitigate mental health destabilization and death by suicide.

Key findings

• BOI reports did not offer recommendations related to case management specific to mental health services and therapeutic interventions; access to therapeutic interventions, the timeliness and appropriateness of therapeutic interventions provided, or efforts to support engagement and manage resistance of incarcerated individuals requiring therapeutic intervention to mitigate their risk for suicide (or overdose or homicide)
• BOI reports rarely focused on or offered examples of suicide prevention efforts or proactive mental health care efforts that have been employed to mitigate of the risk for death by suicide

Recommendations

Recommendation 16: BOI reports should offer a comprehensive review of medical care (psychiatry, nursing, physician involvement); mental health interventions (correctional programming, psychological and therapeutic services); and spiritual care (cultural teaching, Indigenous healing, Elder services, chaplaincy) provided or not provided to the deceased prior to death.

Communication and information sharing

It was our opinion that overall, BOI reports did a good job of investigating and highlighting communication issues and challenges in suicide case investigations. BOI reports identified examples of problems with communication that included information not being shared or not shared in a timely manner; information being shared but there being no response or action; or information being shared but there being no resources to act on the information, even when deemed urgent. As examples, one BOI report notes only one out of 4 prior events of suicide attempt/ideation had been documented in the Alerts section of OMS. Another BOI indicated no follow up from the Mental Health department despite knowing the deceased’s trauma and identifying a need for follow-up with no explanation as to why. In another case, while there was a BOI recommendation about responses to urgent referrals inclusive of weekends and holidays, CSC did not respond to this. Also noted in another report was the absence of guidance to correctional officers on how to appropriately monitor behaviours and attend to risk factors more closely with incarcerated people at risk of suicide.

Consistent with our comments on systemic issues in TOR 2, one area of communications challenge in regard to suicide investigations noted by the 6th IRC was the apparent absence of protocols for information sharing across BOIs and by CSC to allow for flagging re-occurring themes specific to communication gaps across reports for better identification, intervention, and systemic change. This is critical as we noted repeated instances of problematic issues described in single reports that appear more system wide in multiple investigations (for example, lack of clear protocols and instructions to support correctional officers to conduct mental health monitoring; a lack of coordinated response to mental health concerns; and infrequency of a multi-disciplinary approach to mental health and suicide management).

Key findings

Overall, Overall, BOIs did a good job of identifying recommendations related to mental health monitoring and tracking and communication in suicide death investigations. The one gap was that BOI reports identified these in relation to an individual case being investigated, whereas recommendations around these issues could optimally be systemically oriented.

Recommendations

See Recommendations 7 and 8, Attention to Systemic Issues.

Examination of Terms of Reference 5

TOR 5: Ensure that BOI reports are written from an Indigenous Social History perspective, where appropriate.

The 6th IRC was tasked with reviewing whether BOI reports relating to Indigenous incarcerated persons were written from an Indigenous Social History perspective. At the outset the Committee believes it would be valuable to establish what ISH is, and why CSC is required to implement it.

The starting point in any discussion of ISH is the drastic over-representation of Indigenous people in Canada’s correctional facilities. With the Indigenous population much younger than the overall Canadian population and experiencing a higher growth rate among other factors, the problem of Indigenous over-representation in the criminal justice system continues to worsen rather than improve. According to the Office of the Auditor General, in the 2020 to 2021 fiscal year, the overrepresentation of Indigenous peoples in the federal correctional system continued to grow. Indigenous peoples were estimated to make up an estimated 4% of the Canadian adult population, yet accounted for 27% of federal offenders.

Concern about Indigenous over-representation in the Canadian criminal justice system (and in the prison population) has been growing over many decades. There have been many initiatives introduced into the criminal justice system in an attempt to ameliorate Indigenous over-representation in the incarcerated population of Canada, in particular subsection 718.2(e) of the Criminal Code which introduced significant reforms to sentencing, recognizing the disproportionate numbers of Indigenous persons in penal institutions. In the seminal Gladue case, the Supreme Court of Canada - tasked with interpreting and applying subsection 718.2(e) - observed a crisis in the Canadian criminal justice system relating to Indigenous over-representation.

The 6th IRC recognizes that the federal correctional system is at the tail end of the criminal justice system, has no role in sentencing and is responsible for offenders who may have extensive criminal histories, mental health issues, and present with both significant risk to society and significant need for rehabilitation. Nonetheless, CSC has responded over the years, in an attempt to ameliorate Indigenous over-representation in federal corrections and to address what has come to be understood as a correctional outcomes gap. This refers to disproportionate correctional outcomes, for Indigenous offenders compared to non- Indigenous offenders to their detriment, as they continue to disproportionately have fewer positive and more negative correctional outcomes than non-Indigenous offenders. Numerous reports over many years have documented a disproportionate correctional outcomes gap between Indigenous and non-Indigenous offenders, ranging from security classification and penitentiary placement at intake all the way through to conditional release (parole). As noted by the Office of the Auditor General (2022), many of these gaps have been noted to be increasing.

Sections 79-84 of the Corrections and Conditional Release Act (CCRA) deal with the specifics of CSC’s obligations with respect to Indigenous inmates. For the purposes of this review, section 79 is perhaps most significant for incorporating Indigenous Social History into CSC decision making pertaining to Indigenous offenders. When making decisions under the CCRA affecting an Indigenous offender, the following shall be taken into consideration:

• (a) Systemic and background factors affecting Indigenous peoples of Canada

• (b) Systemic and background factors that have contributed to the overrepresentation of Indigenous persons in the criminal justice system and that may have contributed to the offender’s involvement in the criminal justice system

• (c) The Indigenous culture and identity of the offender, including his or her family and adoption history

Specific to programming, section 80 provides that CSC shall provide programs designed particularly to address the needs of Indigenous offenders. The intent of culturally specific Indigenous programming was to develop culturally informed and culturally appropriate programming, delivered by Indigenous people, which would better address risk and need factors, and contribute to rehabilitation and their successful reintegration into society. In doing so, it would contribute to improved correctional outcomes for Indigenous offenders and to reducing Indigenous over - incarceration.

Section 83 of the CCRA mandates that where appropriate, CSC is to seek advice from an Indigenous spiritual leader or elder when providing correctional services to an Indigenous inmate, particularly in matters of mental health and behaviour. Section 83 further identifies that the CSC is to take all reasonable steps to make available to Indigenous inmates the services of an Indigenous spiritual leader or elder after required consultations. Finally, section 81 pertains to the provision of correctional services by the Indigenous community in the form of healing lodges for Indigenous offenders.

Pursuant to the aforementioned section 79 of the CCRA, Commissioner’s Directive 702 Indigenous Offenders, paragraph 6, mandates that the Institutional Head:

[e]nsure that the unique circumstance of the Indigenous offender, as described in the definition of the Indigenous Social History, as well as culturally appropriate/restorative options are given due consideration in the decision-making process.

In CD 702, Indigenous Social History is defined as:

[t]he various circumstances that have affected the lives of most Indigenous people. Considering these circumstances may result in alternate options or solutions and applies only to Indigenous offenders (not to non-Indigenous offenders who choose to follow the Indigenous way of life). These circumstances include the following (note that this is not an exhaustive list):

• effects of the residential school system
• sixties scoop into the adoption system
• effects of the dislocation and dispossession of Inuit people
• family or community history of suicide
• family or community history of substance abuse
• family or community history of victimization
• family or community fragmentation
• level or lack of formal education
• level of connectivity with family/community
• experience in the child welfare system
• experience with poverty
• loss of or struggle with cultural/spiritual identity

The requirement for CSC to consider Indigenous Social History as well as culturally appropriate/restorative options in the decision-making process for Indigenous offenders reflects jurisprudence, but more practically, also reflects an awareness by CSC that the risk/need areas of Indigenous offenders often have their roots in colonialism and attempts at assimilation. These systemic and background factors of Indigenous offenders - known in CSC parlance as “Indigenous Social History” - are often related to substance abuse, inter- generational abuse, involvement in the child welfare system, being adopted, spending time in foster care or a group home, low levels of education, employment and income, and substandard housing and health care, among other factors. These causal factors include inter- generational tools of colonization and assimilation, such as residential schools and the sixties scoop, often resulting in dislocation, community fragmentation, and breakdown. The requirement to consider alternate options that are culturally appropriate in the decision-making process for Indigenous offenders reflects an awareness that mainstream approaches may not be working, and culturally specific Indigenous programming may better address risk and need factors and contribute to rehabilitation and successful reintegration into society.

As noted in the Introduction, the 6th IRC reviewed 31 cases of non-natural death in custody, in which 14 of the deceased individuals were Indigenous, thereby representing just under half (approximately 45%) of the cases of death in custody we reviewed. The 2nd IRC noted that in 2010 to 2011, about a third of the cases of deaths in custody that they reviewed were Indigenous, thereby demonstrating that the proportion of Indigenous deaths in custody appear to have increased (Weinrath and Arboleda-Flórez, 2012). Similarly, Indigenous people appear over-represented among non-natural deaths in custody given that they comprise approximately 27% of federal offenders, but 45% of non-natural deaths in custody for the time period reviewed.

Are the Board of Investigation reports written from an Indigenous Social History perspective

At the outset, it was identified that the 6th IRC would review whether any BOIs relating to an Indigenous incarcerated person investigated whether the ISH had been considered in their case management prior to their demise, and what had been done with that analysis - in other words, did it impact correctional decision making for the incarcerated person? Were culturally appropriate interventions considered and implemented?

We found in reviewing the 14 Indigenous cases, that there was no consistency across the various BOI reports with respect to whether ISH analysis was conducted or how. Numerous BOI reports indicate that ISH was addressed in correctional decision making for the incarcerated person but failed to provide any details or application to demonstrate how. The ISH is frequently given a cursory consideration and not integrated and analysed in context with the rest of the BOI report. This left the 6th IRC unable to determine whether the deficiency was in the BOI report itself only, or whether this deficiency originated in a failure of implementation of ISH by the case management team in correctional decision making for this incarcerated person.

For example, in one case, the BOI observes that “Aboriginal social history was documented as having been considered during the transfer decision making process”. This is the extent of the analysis and no demonstration of why and how this conclusion is reached is included. However, a supplementary finding observes:

While [redacted]'s Aboriginal social history (ASH) was documented in the Assessment for Decision (CSC 2028) for institutional transfer (involuntary) to alleviate Administrative Segregation status dated March 16, 2018, and in the associated Referral Decision Sheet (CSC 1090) dated April 23, 2018, consistent with policy, the analysis and alternative/restorative options were not depicted in these decision documents as required in the Memorandum: To All Regional Deputy Commissioners - From Senior Deputy Commissioner Documenting Consideration of the Aboriginal Social History, (August 5, 2016). (emphasis added)

The 6th IRC questions how Aboriginal social history was “documented as having been considered” given this noted absence of analysis and alternative/restorative options.

In another BOI investigating multiple overdoses at 1 institution, the BOI concluded:

The initial security classification of all of the principal inmates involved in these incidents and their placement at [redacted] Institution were appropriate. The Indigenous Social History of [redacted] was given consideration for his most recent security classification and penitentiary placement.

And,

The unique circumstances of [redacted] Indigenous Social History and culturally appropriate/restorative options were given due consideration in his original Correctional Plan and the Referral Decision Sheets related to his Offender Security Level and Penitentiary Placement...

This is the extent of the analysis of whether the ISH had been adequately considered and implemented for this Indigenous offender. While recognizing the daunting task faced by BOI, there nonetheless needs to be some expectation that they support their findings as to whether and how ISH has been implemented by the CMT.

Conversely, there were several BOI reports that did offer a comprehensive consideration of ISH in their review of the circumstances surrounding the incarcerated person’s non-natural death in custody. 1 BOI report for example, contained an analysis of how an offender’s ISH had been considered by his case management team, resulting in an over-ride from maximum to medium security, which is a good demonstration of how ISH can be operationalized by CSC where appropriate:

The Institutional Adjustment Rating score was 148 and the Security Risk Rating score was 71. This resulted in an overall level of security classification of Maximum Security. The community and institutional Case Management Teams (CMTs) disagreed with the rating of Maximum Security and believed could be managed in a Medium Security setting was assessed by his CMT as Moderate for Institutional Adjustment, Escape Risk, and Public Safety risk. After taking into account the unique factors of [redacted]'s Indigenous Social History (ISH), his CMT recommended an OSL of Medium Security and Penitentiary Placement to (Medium Security). In a Referral for Decision Sheet for OSL and Penitentiary Placement on June 29, 2018, that included the unique factors of [redacted]'s ISH, the Warden approved a rating of Medium Security and placement to [redacted].

There were some other excellent examples of BOIs investigating and providing recommendations based on a comprehensive consideration of ISH. These reports do an admirable job reporting on relevant ISH domains, connecting key elements of ISH to the incarcerated person’s functioning, and whether and how ISH was or was not considered and impacted on case management. Some BOIs also focused on access (and lack of access) to Indigenous cultural programming, the importance of such programming, and of the work of Elders. It was also positive to see Indigenous program officers interviewed as part of the BOI process.

Another BOI report does a very thorough job of discussing ISH and trauma lived by the incarcerated person, connecting it to an increased risk of suicide. This same report also considers the role of culturally appropriate interventions for this incarcerated person and concludes that while the CMT was aware of the incarcerated person’s ISH and trauma, it was not utilized to provide trauma informed care. This report ultimately facilitated culturally appropriate changes to the exit process from Pathways, demonstrating the connection between a thorough BOI analysis of ISH and a recommendation that was accepted by CSC to redress some of the factors that may have contributed to this person’s suicide.

While the 6th IRC notes that the 5th IRC documented that the Incident Investigations Branch has retained experts from the Indigenous community to be community board members on BOIs involving Indigenous offenders, this does not appear to necessarily translate into adequate analysis of the ISH by the BOI. In that regard, it is important to note the importance of BOI understanding how ISH is intended to be incorporated into correctional decision making.

Key findings

BOI reports are not adequately demonstrating that they have reviewed whether and how ISH was integrated and analysed in correctional decision making for Indigenous offenders and are inconsistent in this regard.

Recommendations

Recommendation 17: BOI reports should focus on identifying and describing whether and how ISH was considered and implemented in correctional decision making for Indigenous incarcerated people. CSC should establish a minimum requirement for BOIs to demonstrate whether ISH was considered.

Recommendation 18: When investigating the non-natural death in custody of an Indigenous incarcerated person, BOIs should have a committee member with knowledge of ISH and of CSC’s obligations and capacities with respect to implementation of ISH.

Integration of Indigenous Social History with mental health

The 6th IRC also noted that while there was a lack of consistency in the integration of ISH throughout BOI reports, it also frequently appeared to be considered separately from any investigation or analysis of mental health concerns of the Indigenous incarcerated person, contrary to the intent and purpose of incorporating ISH. In reading the definition of ISH contained in CD 702, Indigenous Offenders, as detailed above, the overlap between ISH and mental health is abundantly clear. Impacts on the Indigenous incarcerated person such as the effects of the residential school system and the sixties scoop; suicide; substance abuse; victimization; community fragmentation; and many other ISH factors are clearly related to mental health.

For example, in one case involving the overdose of an Indigenous incarcerated person, the incarcerated person's ISH factors are duly listed in the background section of the report. However, in the body of the report discussing the incarcerated person’s substance abuse, withdrawal, and mental health issues, the ISH is not even mentioned, let alone integrated into this analysis of pre-incident indicators, precipitating events, and contributing risk factors.

In this regard, the 6th IRC was particularly concerned about cases where it was indicated that the Indigenous incarcerated person either had or likely had, Fetal Alcohol Spectrum Disorder, but this was not integrated into the ISH analysis, nor was it integrated adequately into the investigation. While FASD occurs throughout the non-Indigenous population, for an Indigenous incarcerated person it is likely connected to their ISH, given the trauma experienced through generations.

In one case, for example, the role of FASD and ISH in the homicide of a particularly vulnerable Indigenous inmate with a history of substance abuse arising from impacts of colonialism was not adequately considered or factored in by the BOI, in the events surrounding his death. Here, the BOI indicates that ISH was addressed in decision making but provides no details on its application, particularly with respect to the decision to randomly order inmates into shared cells during a range refusal to lock up. The BOI noted that the inmate had diagnosed FASD, may have been under the influence of prison made alcohol at the time of the incident, and was known to become violent when under the influence of alcohol (precipitating event). The BOI concluded that the 2 offenders sharing a cell for more than one hour without their consent, and without a recognition of the risk created and a strategy to mitigate that risk, was a precipitating event.

The 6th IRC notes that given the multiple cognitive/developmental challenges, including emotions management and impulse control, often presenting in individuals with FASD - and particularly with an incarcerated person prone to substance abuse and violence - the role FASD may have played in the homicide should have been considered by the BOI, and could have represented an integration of the incarcerated person’s ISH with the events in question. An awareness of this incarcerated person’s FASD should have facilitated consideration as to who the individual could be placed in a cell with given these circumstances, if anyone. While the BOI recommends that the Assistant Commissioner, Correctional Operations and Programs implement national policy “to acknowledge the risk created by this type of situation and require that institutions implement risk mitigation strategies in their intervention plans, that are adapted to their specific infrastructure and the emergency situation that is being managed,” there is no specific mention of the unique vulnerabilities often present for incarcerated persons with FASD or of the need to consider ISH as part of this risk mitigation strategy.

In another case with compelling ISH factors impacting mental health including suspected FASD, the BOI found that the Indigenous incarcerated person was not referred or assessed for FASD during his federal sentences and concluded that “a thorough mental health assessment concerning these psychiatric disorders could have helped to devise a treatment plan according to his needs.” Nonetheless, the BOI report concludes that the ISH was considered in the decision-making process. Simultaneously, the BOI report also notes that the incarcerated person was suspended from the Indigenous Multi Target High Intensity Program after failing to attend the program for 4 consecutive days, and for failing to participate when they did attend the program. Further, while the individual requested and was accepted to participate in Creative Healing Therapy, it was noted that participation was sporadic, and did not demonstrate a commitment to the program. However, there was no exploration in the BOI report of what additional interventions, if any, were attempted for an Indigenous incarcerated person with a compelling ISH, suspected FASD, and confirmed low IQ to support their participation and completion of these programs or to find modified alternatives.

For example, the decision to suspend this individual from Indigenous programming should be documented and demonstrate an analysis of the ISH, and the FASD/cognitive difficulties.

Nonetheless, as mentioned above, there were BOI reports that connected ISH with mental health and trauma and analysed them in an integrated fashion. In addition to the cases mentioned above, another case highlighted that the incarcerated person’s ISH and mental health contributed to the risk for suicide, which was not adequately documented or weighted in decision making by the CMT, pertaining to the penitentiary placement:

Elements of [redacted]'s Indigenous Social History may have contributed to [their] risk factors to the incident which were known to staff. These elements were significant for intergenerational trauma, which included physical abuse, neglect, instability, inconsistent caregivers – including abandonment from family members, foster care placements, domestic violence in [the] home, familial and personal substance use, lack of formal education, and loss of heritage/spiritual identity including the ongoing effects of Indian Residential School ([redacted]'s father).

And,

[redacted] had a familial history of loss, including suicide; [redacted]'s brother committed suicide when [redacted] was ten; [redacted]'s mother was killed in a fire when [redacted] was 11, and another brother was beaten to death when [redacted] was 12. The Board of Investigation recognized these as contributing risk factors, known to staff.

This demonstrates an integration of ISH with mental health by connecting it to the incarcerated person’s risk for suicide. Far too often in the BOI reports the ISH is not integrated into the events in question, whether homicide, suicide, or overdose.

Findings

BOI reports are not adequately approaching ISH in a holistic way, particularly with respect to integrating ISH with mental health issues.

Recommendations

Recommendation 19: BOI reports should give a holistic consideration to ISH context, through greater integration of mental health issues in analysing ISH.

Culturally appropriate interventions

The 6th IRC also considered if the BOIs investigated whether culturally appropriate interventions were given due consideration by the CMT in decision making for an Indigenous offender in conjunction with the ISH, as mandated by CD 702, Indigenous Offenders, detailed above. We found that BOI reports need to employ greater consideration of culturally appropriate interventions that were (or were not) offered to Indigenous offenders.

For example, one BOI report notes that while the incarcerated person’s ISH was documented by the CMT in the Assessment for Decision for involuntary institutional transfer and in the associated Referral Decision Sheet:

[t]he analysis and alternative/restorative options were not depicted in these decision documents as required in the Memorandum: To All Regional Deputy Commissioners - From Senior Deputy Commissioner Documenting Consideration of the Aboriginal Social History (August 5, 2016).

Statements such as this, left the 6th IRC wondering how then, had the ISH been considered by the CMT, if the analysis and the consideration of alternative/restorative options was missing from the documentation?

The 6th IRC further noted that there were BOI reports where the incarcerated person had requested cultural supports proximal to the incident and did not receive interventions, but this was not delved into in any great detail, contrary to the requirements of section 83 of the CCRA, mandating that CSC seek advice from an Indigenous spiritual leader or Elder when providing correctional services to an Indigenous inmate, particularly in matters of mental health and behaviour.

However, there were examples of BOI reports that contained a consideration of both ISH and culturally appropriate interventions; one report for example contained a thorough account of the ISH; a discussion of language barriers; and of the incarcerated person’s introduction to, and connection with, traditional ceremonies and healing. This BOI report identified many culturally appropriate supports and approaches initiated for this incarcerated person, including healing lodges, pathways, elder interventions, Indigenous programming, and the use of ceremony. This report contains a very thorough analysis of the incarcerated person’s ISH and the many culturally appropriate initiatives utilized to try to address it prior to the incident.

Key findings

BOI reports did not adequately analyse whether culturally appropriate interventions were considered by the CMT in decision making for an Indigenous incarcerated person in conjunction with the ISH.

Recommendations

Recommendation 20: BOIs need to consider whether culturally appropriate interventions were given due consideration by the CMT in decision making for an Indigenous incarcerated person in conjunction with the ISH.

Indigenous Social History and CSC’s responses

Finally, the 6th IRC, in reviewing all cases of non-natural deaths in custody from April 1, 2019, to March 31, 2021, that involved Indigenous incarcerated persons, noted that there was a shortage of ISH analysis or consideration of culturally appropriate interventions in CSC’s responses to BOI findings and recommendations.

For example, in one case where an Indigenous incarcerated person’s withdrawal from Pathways without a sharing circle preceded their suicide, the BOI noted:

With regard to [redacted]'s withdrawal from Pathways Unit (at [their] request), the Board of Investigation (BOI) was informed that a withdrawal or removal for an infraction from the Pathways Unit generally resulted in the occurrence of a sharing circle with members of the inmate’s case management team (CMT) (such as parole officer, Indigenous Liaison Officer, Elder, and Pathways Managers), particularly under circumstances wherein the individual may be in crisis or heading toward crisis.

Accordingly, and to their credit, the institution revised their Pathways handbook to require a sharing circle to be held prior to an offender’s transfer out. However, the 6th IRC questions why CSC’s response would not go further with respect to culturally appropriate protocols to follow when an Indigenous incarcerated person leaves Pathways. These might not be the same across the country but given that this was identified as an oversight in the death of an Indigenous offender, CSC could have considered the question on a national scale to better operationalize ISH.

The CSC is uniquely positioned to be a national leader in the implementation of ISH for federally incarcerated Indigenous people, who are grossly over-represented in federal institutions and often present with myriad ISH factors and who are disproportionally represented in non-natural deaths in custody. The CSC can lead by example by remedying the overall lack of substantive mention of ISH or culturally appropriate interventions in its lengthy responses to BOI reports for Indigenous incarcerated persons. Messaging around the importance of integrating ISH analysis into BOI reports should start from the top down.

Findings

CSC does not integrate ISH considerations in responses (consultation grids) to BOI findings and recommendations.

Recommendations

Recommendation 21: CSC should lead by example and incorporate ISH analysis into its responses to BOI findings and recommendations.

An additional finding, observation, and commentary beyond the Terms of Reference

In conducting this review, the 6th IRC was struck by how difficult and impactful it must be for CSC staff to be exposed to the direct and/or indirect effects of the deaths they are responding to.

Responding to a non-natural death in custody can be a significantly distressing experience for CSC staff as well as impact staff familiar with and/or working with the deceased. We were impressed that most BOI reports reviewed attended to how staff responding to a non-natural death took efforts to attend to other incarcerated persons in the area to mitigate, support, and address any negative impact on them. While several reports also commented on services and supports provided to the staff responding to the death, this was not consistent across BOI reports. We believe assessing and reporting on the care provided to CSC staff impacted by the non-natural death in custody would be an important way to formally recognize the challenges faced by staff having to respond to these circumstances and demonstrate care and responsiveness to their wellbeing.

Key findings

The BOI reports did not consistently comment on services and supports provided to CSC staff responding to and impacted by the death, and varied in the amount of information provided about the types of mental health and organizational supports offered to impacted staff.

Recommendations

Recommendation 22: All BOI reports should attend to staff wellness and be tasked with commenting on the type and suitability of supports provided to CSC staff impacted by the non-natural death in custody.

Recommendations

The following recommendations are respectfully offered based on the findings of the 6th IRC in response to the 5 TOR presented to the 6th IRC for review. We appreciate that CSC is committed to the prevention of non-natural deaths in custody and that the IIB, BOIs, and CSC strive to do meaningful work to identify and mitigate factors that contribute to these tragic outcomes for individuals incarcerated in federal correctional institutions. The following recommendations are our observations of ways IIB, BOIs, and CSC can evolve their practices with the goals of enhancing the safety and wellbeing of individuals incarcerated in federal institutions, mitigate factors that contribute to or create vulnerability and risk, and to prevent non-natural deaths in custody.

1. BOI reports should have sections for each of the key areas of investigation to enhance the thoroughness of the assessment and review of the deceased’s social, physical and mental health history, as appropriate

2. BOI reports should connect how the identified vulnerability and risk factors in the key areas of investigation contributed to the incarcerated person’s difficulty functioning and the non-natural death in custody

3. BOI reports should assess for, identify, and discuss both proximal and distal risk factors to the non-natural death

4. CSC should review and enhance training and professional development for BOI National Investigators:
   • consider further training on assessing the key areas of investigation, risk factors and how to connect identified vulnerability factors to risk factors relevant to the occurrence of a non-natural death

   • consider a mentoring program that would have exceptional National Investigators provide training, professional development, and act as resource for BOI members involved in investigations

5. consider having one investigator that has a background in mental health services or is a mental health professional on all investigations

6. case management practices should be a distinct area of review and assessment during BOIs
   • BOIs should specifically consider if the deceased had demonstrated resistance to their correctional plan and if so, what efforts were made to engage them

   • in cases where the deceased has been suspended or had their parole revoked, BOIs should specifically explore the case management response to supporting the deceased’s integration back into the institution

7. convening orders should empower BOIs to investigate systemic issues and make recommendations where appropriate

8. CSC should undertake a program of “tracking and training” around systemic issues to better inform itself and BOI investigators

9. BOIs should investigate and make recommendations regarding an incarcerated person’s protective factors and whether they were facilitated to support wellness, institutional functioning, and vulnerability/risk management

10. consultation grids should have clear dates and clear deliverables for CSC action plans to address BOI recommendations for further transparency and accountability

11. CSC should provide a supporting rationale where it rejects or does not fully implement a BOI recommendation for greater transparency and provide a clear alternative direction to deal with the issue identified by the BOI

12. a protocol should be developed to identify an oversight function that can ensure CSC is held accountable for appropriate timelines for action and that can review findings when CSC rejects or does not fully implement a BOI recommendation

13. to further transparency and accountability, CSC should ensure that actions in response to BOI findings contain elements that are measurable, and thereby create outcomes that can be evaluated

14. BOI reports should have an enhanced focus on noting the deceased’s documented mental health history and recent mental health functioning; and any evident emotional and situational factors that may have contributed to mental health vulnerability and destabilization in cases of death by suicide

15. BOIs should consider if there are any problematic implications related to the findings of mental health screening tools, testing or assessments used for case management planning and the determination of appropriate interventions

16. BOI reports should offer a comprehensive review of medical care (psychiatry, nursing, physician involvement); mental health interventions (correctional programming, psychological and therapeutic services); and spiritual care (cultural teaching, Indigenous healing, Elder services, chaplaincy) provided or not provided to the deceased prior to death

17. BOI reports should focus on identifying and describing whether and how ISH was considered and implemented in correctional decision making for Indigenous incarcerated people. CSC should establish a minimum requirement for BOIs to demonstrate whether ISH was considered

18. when investigating the non-natural death in custody of an Indigenous incarcerated person BOIs should have a committee member with knowledge of ISH and of CSC’s obligations and capacities with respect to implementation of ISH

19. BOI reports should give a holistic consideration to ISH context, through greater integration of mental health issues in analysing ISH

20. BOIs need to consider whether culturally appropriate interventions were given due consideration by the CMT in decision making for an Indigenous incarcerated person in conjunction with the ISH

21. CSC should lead by example and incorporate ISH analysis into its responses to BOI findings and recommendations

22. all BOI reports should attend to staff wellness and be tasked with commenting on the type and suitability of supports provided to CSC staff impacted by the non-natural death in custody

References

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