Corrective Measures and Management Action Plan, April 1st, 2019, to March 31st, 2021

ASH

Aboriginal Social History

BOI

Board of Investigation

CCRA

Corrections and Conditional Release Act

CD

Commissioner’s Directive

CISM

Critical Incident Stress Management Program

CMT

Case Management Team

CSC

Correctional Service Canada

EIA

Enhanced Investigation Analysis

FASD

Fetal Alcohol Spectrum Disorder

IA

Investigation Areas

IIB

Incident Investigations Branch

IRC

Independent Review Committee

ISH

Indigenous Social History

MHNS

Mental Health Need Scale

NI

National Investigator

NIM

National Investigations Meeting

OAT

Opioid Agonist Treatment

OMS

Offender Management System

OPI

Office of primary interest

SMART

Specific, measurable, accountable, realistic, and timely

TOR

Terms of Reference

Response

Board of Investigation (BOI) reports currently have sections that correspond to each of the key Investigation Areas (IA) identified in the Convening Order and are presented in a top-down approach. Each IA is introduced in the report and is immediately followed by an overarching finding in relation to that IA. When relevant to the incident, IAs include a review of the thoroughness of the assessment and review of the deceased’s social, physical, and mental health history, in line with CSC policies and guidelines.

In collaboration with the appropriate offices of primary interest (OPIs), the Incident Investigations Branch (IIB) will hold information sessions with the current roster of National Investigators to ensure this is applied consistently and thoroughly across BOI reports. This direction will also be integrated into guidance materials for all current and future National Investigators.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

June 30, 2025 (ongoing).

Update

The Incident Investigations Branch (IIB) has undertaken several concrete steps to strengthen the overall rigour and relevance of our investigative practices. As part of this effort, the IIB has completed the development of a comprehensive repository of Investigation Areas. These Investigation Areas are designed to provide greater precision and focus to investigations. They allow for a more tailored approach as Boards of Investigation are convened to review and assess key elements specific to each case, including social, physical, and mental health history where appropriate, including the proximal and distal risk factors for death from non-natural causes.

A revised set of Investigation Areas was finalized in June 2025 and is currently undergoing consultation with the appropriate Offices of Primary Interest (OPI). Once this consultation process is complete, these revised Investigation Areas will be implemented for upcoming Convening Orders. This will ensure that critical factors - such as mental health and social context - are systematically considered at the outset of each investigation.

In support of these changes, the IIB has also taken steps to enhance capacity through training, education and awareness. The IIB has delivered targeted information sessions to National Investigators on topics including, and not limited to, mental health, Indigenous Social History, Quality of Care, Trauma Informed Approach. Additionally, training materials for Board members were revised during Winter 2025 to better incorporate considerations related to social, physical, and mental health histories. Recognizing that learning must be continuous, the IIB has developed a plan to sustain and expand this learning continuum. Future sessions will continue to deepen understanding of the contextual factors that may contribute to incidents, with upcoming topics to include trauma-informed approaches and culturally responsive investigation practices. These collective efforts reflect the IIB’s ongoing commitment to strengthening the quality, relevance, and thoroughness of investigations, while ensuring that they are informed by a deeper understanding of the individual and systemic factors at play.

Response

As noted in the response to Recommendation 1, IIB will ensure that the information shared with National Investigators will provide emphasis on defining, identifying, and connecting risk factors, in order to inform mitigation strategies and recommendations to help prevent non-natural deaths in custody.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

June 30, 2025 (ongoing).

Update

Multiple, planned learning sessions with both internal and external (such as outside CSC) subject-matter experts are planned to ensure National Investigators are equipped to identify and integrate all factors relevant to the individual offender. To date, learning sessions have been held on Indigenous Social History and the Trauma-Informed Approach, with additional sessions planned for October 2025, to further educate National Investigators on important vulnerability, risk, and protective factors, including the proximal and distal risk factors for death from non-natural causes.

Response

Please refer to the responses to Recommendations 1 and 2, which are inclusive of this recommendation.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

June 30, 2025 (ongoing).

Update

Please refer to the updates for Recommendations 1 and 2, which are inclusive of the actions taken to address this recommendation.

• 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 a resource for BOI members involved in investigations

Response

The IIB implemented a Learning Continuum initiative in January 2022 which provides continuous learning opportunities for NIs. A range of learning opportunities have been offered to ensure all IIB staff are well placed to conduct investigations in a correctional context and, as noted in responses to Recommendations 1 and 2, this will further be reinforced in upcoming information sessions.

The IIB offers a gradual and incremental on-boarding process to all new National Investigators, as well as mentoring opportunities whereby less experienced National Investigators are paired with experienced Investigators to assist in developing their skill set and reinforcing best practices. The sharing of knowledge, identified trends, and best practices in conducting investigations is also supported and facilitated on an on-going basis.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

June 30, 2025 (ongoing).

Update

The IIB has enhanced its training framework by integrating advanced content focused on the assessment of investigative domains, systemic and situational risk factors, and the analysis of vulnerability indicators within the context of non-natural deaths. These enhancements are designed to deepen the analytical capacity of National Investigators and promote more consistent, risk-informed decision-making throughout the investigation processes.

To further support professional growth and excellence in practice, the IIB has launched a targeted mentoring initiative. The Mentoring Program strategically pairs newly recruited National Investigators and BOI members with seasoned National Investigators recognized for their subject matter expertise and leadership. Through this initiative, Mentors provide tailored guidance, serve as consultative resources during complex files, and contribute to the ongoing professional development of our investigation teams. This structured peer-to-peer learning model ensures the transfer of knowledge and strengthens consistency and rigour in the conduct of investigations.

In addition, the IIB continues to invest in its Onboarding Program for National Investigator recruits. This program provides a solid foundation in investigative methodology, policy frameworks, and analytical tools, enabling recruits to engage meaningfully and effectively in the conduct of investigations from the outset. Many National Investigators have already benefited from this initiative, implemented in January 2023, which reinforces a culture of learning, preparedness and confidence in the field.

Continued engagement of the National Investigators in the Learning Continuum initiative implemented in January 2022 has included a range of learning opportunities to ensure they are equipped to review and assess all factors relevant to the both the individual and the incident. As described in the Update Section to the response to Recommendation 1, the IIB has delivered targeted information sessions to National Investigators on topics including, and not limited to, mental health, Indigenous Social History, Quality of Care, Trauma Informed Approach and on how to avoid confirmation bias.

Additionally, training materials for Board members were revised during Winter 2025 to better incorporate considerations related to social, physical, and mental health histories. Recognizing that learning must be continuous, the IIB has developed a plan to sustain and expand this learning continuum. Future sessions will continue to deepen understanding of the contextual factors that may contribute to incidents, with upcoming topics to include trauma-informed approaches and culturally responsive investigation practices which will also include the review and assessment of vulnerability and protective factors.

Taken together, these initiatives reflect a deliberate and forward-looking approach to capacity building. They support the development of a knowledgeable, confident, competent, and agile investigation workforce - one that is well-positioned to respond to complex cases, drive systemic insights, and contribute to the broader mandate of public safety and accountability.

Response

The majority of CSC’s investigations into non-natural deaths in custody already include either a registered Psychologist or other registered health professional with a mental health background as a member of the Board. The Correctional Service Canada will continue to ensure that all investigations related to a suspected death by suicide or overdose, or other in-custody deaths where a mental health component may be present, will include a Board Member with a mental health background.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

• 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

Response

Moving forward, CSC will ensure that the review and assessment of case management practices is more specifically addressed in Investigation Areas of Convening Orders into BOIs relevant to deaths in custody.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

May 31, 2025 (ongoing).

Update

As described in the Update Section of the response to Recommendation 1, the IIB has completed the development of a comprehensive repository of Investigation Areas. Case management practices have been added as a key area of focus. The revised Investigation Areas will provide greater precision and focus to our investigations. They allow for a more tailored approach, enabling BOIs to review and assess key elements specific to the individual’s case management, including and not limited to the social, physical, mental health history where appropriate, and the notions of resistance, engagement and support to individuals.

Through the revision of the Investigation Areas, BOIs will be required to specifically consider whether the deceased had demonstrated resistance to their Correctional Plan and, where applicable, assess what efforts to engage and support the individual. This will help ensure a more complete understanding of how resistance was addressed and whether appropriate interventions were attempted.

In addition, in incidents where the deceased had been suspended or had their parole revoked, BOIs will be expected to explore the case management response to supporting the individual’s integration back into the institution. This ensures that institutional reintegration efforts and continuity of care are thoroughly reviewed.

The revised Investigation Areas were finalized and are currently undergoing consultation with the appropriate Offices of Primary Interest. Once this process is completed, the updated Investigation Areas will be implemented for use in all Convening Orders.

To support this implementation, training will be offered to National Investigators to ensure consistency in the application of the revised framework. This training will reinforce the importance of assessing case management responses and engagement strategies, particularly in complex cases involving resistance to correctional planning or institutional reintegration.

Response

The IIB is committed to empowering BOIs through the strategic use of Convening Orders, ensuring they can thoroughly examine systemic issues and provide informed recommendations.

The IIB began grouping similar multiple incidents into single overarching investigations in 2022, with the goal of identifying systemic issues, where applicable. Information from these multiple incident investigations and other investigations is routinely collected by the Branch and is made available to the National Investigators to assist them in formulating effective recommendations to help CSC address underlying challenges.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

The IIB has developed and currently maintains multiple internal databases for this purpose, which include:

• all BOIs conducted from 2013 to 2014 tracked from Convening Order to File Closure
• qualitative and quantitative coding of all investigation findings (such as compliance, underlying issues, policy gaps, secondary issues, and best practices) stemming from BOI reports
• all Office of Primary Interest action plans and corrective measures in response to investigation recommendations and findings
• all incidents submitted to the IIB via a Warden’s/District Director’s Situation Report
• all deaths in custody resulting in a coroner’s inquest/inquiry/investigation, and the subsequent recommendations and OPI responses to Coroner recommendations

These databases are primarily used for tracking investigations and reporting key themes and trends. Analyses of these data sources are typically conducted in response to requests from National Investigators, CSC senior management, and other stakeholders such as the Learning and Development Branch, with whom the IIB collaborates to share findings pertaining to identified gaps in training. Results are disseminated through presentation decks to the CSC Executive Committee at the quarterly National Investigations Meeting and information bulletins (lessons learned), where applicable.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

Please refer to responses to Recommendations 1 through 4, where BOIs will examine risk factors, including the incarcerated person’s protective factors (for example, prosocial attitudes and beliefs, strong positive social supports, motivation for treatment) to ensure they were identified and examine to what extent they were considered in case management and correctional interventions.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

June 30, 2025 (ongoing).

Update

Please refer to the updates for Recommendations 1 and 4, which are inclusive of the actions taken to address this recommendation.

Response

When BOIs make recommendations, the CSC produces Management Action Plans (consultation grids) for Offices of Primary Interest to respond to and propose corrective actions to address issues. All grids include deliverables and clear due dates. The IIB now has a robust process in place for monitoring the deliverables and all grids are subject to review by CSC’s senior Executive Committee during the quarterly National Investigation Meetings. To ensure accountability, consultation grids are normally only closed by the IIB once all deliverables have been completed. Further supporting transparency and accountability, finalized BOI reports and grids are also shared with the Office of the Correctional Investigator.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

As indicated in the response to Recommendation 10, IIB presents consultation grids to the senior Executive Committee at the quarterly National Investigations Meetings. If an OPI does not support a recommendation from a BOI, they are required to provide a written rationale within the grid, and to outline what actions they may take to otherwise respond to the issue identified.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

As indicated in the response to Recommendation 10, CSC’s Executive Committee serves an oversight function with support from the IIB. All consultation grids are monitored by the IIB who provides updates to CSC’s senior Executive Committee on a quarterly basis and follows up with relevant OPIs to ensure appropriate action is taken and commitments are met. Further supporting transparency and oversight, finalized BOI reports and closed grids are also shared with the Office of the Correctional Investigator.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

As indicated in the response to Recommendation 10, OPIs are responsible for proposing corrective measures in consultation grids. The grids include an Annex with guidance to support the development of SMART corrective measures. The SMART concept promotes specific, measurable, accountable, realistic, and timely measures, and includes a hierarchy of effectiveness for those measures.

With respect to evaluating outcomes, recommendations that result in policy/program changes are evaluated via different ongoing exercises within CSC, such as internal and external audits, policy reviews and program evaluations, etc.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

In cases of death by suicide, Boards of Investigation are composed of 3 members (one of whom has a mental health competency profile): a National Investigator, a CSC Board Member, and a Community Board Member. The BOI conducts a thorough review of both the physical and mental health information available, and examines the care that was provided to the inmate leading up to and at the time of the incident. BOIs may also conduct interviews with correctional, case management, and health care staff to ensure understanding of the factors that may have contributed to the death by suicide. Moving forward, the CSC will continue to provide specialized training to National Investigators to further increase this area of specialization.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

See response to Recommendation 14.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

See response to Recommendation 14.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.

Response

All Boards of Investigation into incidents which involve Indigenous offenders include an Investigation Area requiring the Board to assess whether the Indigenous offenders’ social histories were adequately considered in processes relevant to those incidents.

In collaboration with CSC’s Indigenous Initiatives and Health Services Sectors, IIB will be strengthening the Investigator training to ensure that all Board Members have a full understanding and capacity to review and assess the extent to which the ISH was considered and appropriately implemented in decision making, case management and in the provision of health services, in particular mental health.

During regional-national debriefings, discussions will occur with OPIs to ensure that responses to BOI findings and recommendations incorporate an analysis of the ISH.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Collaborator: Deputy Commissioner for Indigenous Corrections.

Timeline for implementation

Ongoing.

Update

Completed.

Response

As part of our investigations, Boards review the post-incident response and the care provided to staff who were involved in the incident. The CSC has a Critical Incident Stress Management Program (CISM) that is activated immediately following a critical incident. Peer driven, voluntary, and confidential, the Program has 2 elements: to educate and prepare employees to deal with potential hazards, and providing support, help and follow-up services as needed. It is current practice for Boards of Investigation to review whether appropriate supports were provided to all CSC staff following an incident and this will continue moving forward.

Accountability

Lead: Senior Deputy Commissioner Sector (Incident Investigations Branch).

Timeline for implementation

Ongoing.

Update

Completed.