Audit of emergency response teams, 2021
Internal Audit Sector
May 3, 2021
Acronyms & Abbreviations
- CCRA
- Corrections and Conditional Release Act
- CCRR
- Corrections and Conditional Release Regulations
- CD
- Commissioners Directive
- CSC
- Correctional Services Canada
- CX
- Correctional Officer
- ERT
- Emergency Response Team
- L&D
- Learning and Development
- MOU
- Memorandum of Understanding
- NHQ
- National Headquarters
- NTS
- National Training Standard
- RCMP
- Royal Canadian Mounted Police
- RHQ
- Regional Headquarters
- SEM
- Security Equipment Manual
- SMEAC
- Situation, Mission, Execution, Administration and Communications Action Plan
- SMO
- Security Maintenance Officer
Glossary
- Crisis manager
- Crisis managers within an institution are typically the Warden, Deputy Warden and the Assistant Warden of Operations and have overall responsibility for managing all aspects of an emergency. Footnote 3
- Emergency
- A situation with the potential to endanger the public, staff or inmates, damage or destroy public property, or affect the public image of the Government of Canada. Footnote 4
1.0 Introduction
1.1 Background
The Audit of Emergency Response Teams was conducted as part of the Correctional Service of Canada (CSC) Internal Audit Sector’s 2018-2020 Risk-Based Audit Plan (RBAP). The audit links to CSC’s priorities of “safety and security of the public, victims, staff and offenders in institutions and in the community” and “efficient and effective management practices that reflect values-based leadership in a changing environment.” The audit links to CSC’s corporate risk that “CSC will not be able to maintain required levels of operational safety and security in the institutions and in the community.” Footnote 5
CSC is focused on ensuring that federal correctional institutions provide a safe and secure environment that is conducive to inmate rehabilitation, and staff and public safety. In order to maintain safety and security within institutions, CSC has established emergency response teams (ERT) to provide an emergency response capability beyond what could be provided by regular line staff. Footnote 6 This capability requires the provision of specialized training and equipment designed specifically for emergencies to which the ERT could respond.
It is essential that CSC has an adequate and effective management framework in place to ensure that situations are managed within the scope of the law, including the Corrections and Conditional Release Act (CCRA), the Corrections and Conditional Release Regulations (CCRR), and the Criminal Code of Canada (Criminal Code); and that CSC guidance limits the ERT interventions to what is necessary and proportionate.
Emergency Response Teams
CSC has established ERTs to provide for a specialized response capability at medium, maximum and multi-level institutions. As per Commissioner’s Directive (CD) 600 Management of Emergencies in Operational Units, ERT membership is voluntary and teams are generally comprised of staff from the correctional officer/primary worker, and staff training officer groups. While the ERT at male offender intuitions can be comprised of male and female staff, the ERT at women offender institutions must be comprised of female staff only.
ERTs are managed at the institutional level. As per CD 600, deployment of the ERT is pre-planned and carried out pursuant to the Situation, Mission, Execution, Administration, and Communications Action Plan (SMEAC). The SMEAC outlines the plan for how the ERT will respond to a situation, including the weapons, equipment, and tactics authorized for use. A crisis manager must approve the SMEAC in order to deploy the ERT.
As outlined in the table below, ERTs are trained to respond to situations that fall under levels one and two. Situations that fall under level three are considered extreme and have a low probability of occurring, therefore CSC has established Memorandums of Understanding (MOUs) with other agencies (e.g., Royal Canadian Mounted Police (RCMP), local police agencies, and Department of National Defence) to assist with a response to these situations. Footnote 7
TABLE 1 – ERT Situation Breakdown Footmote 8
Level 1 Situations | Level 2 Situations | Level 3 Situations |
---|---|---|
|
|
|
1.2 Legislative and Policy Framework
Legislation
Criminal Code of Canada
The way in which security incidents are managed at CSC is governed by the Criminal Code sections: 25 to 27, 34, 35, 37, 67 to 69, 92, 117.07, 494, and 495. These sections, while covering different situations, focus on the reasonableness of the force applied and how the force must match the potential outcome of not applying force. Section 26 specifically states, “Everyone who is authorized by law to use force is criminally responsible for any excess thereof according to the nature and quality of the act that constitutes the excess.”
Corrections and Conditional Release Act
The CCRA establishes the purpose of the federal correctional system as contributing to the maintenance of a just, peaceful and safe society with the protection of society as its paramount concern. The following sections of the CCRA relate to ERTs and the management of situations at CSC: 3, 3.1, 4, 31 to 44, 68, and 97. Section 4 is the most relevant as it limits the measures that CSC may use to only what is “necessary and proportionate to attain the purposes of this Act.”
Corrections and Conditional Release Regulations
The CCRR lays out the regulations to support the CCRA and includes the delegation of authorities to staff members to carry out requirements within CDs. The following sections of the CCRR apply to ERTs and the management of situations at CSC: 3, 4, 19 to 41, and 73.
CSC Policy Framework
There are 12 CDs and guidelines that prescribe requirements and processes that are related or applicable to the ERTs. Refer to Annex C for a complete list.
1.3 CSC Organization
National Headquarters (NHQ)
The Assistant Commissioner, Correctional Operations and Programs is responsible for the development, implementation, maintenance and evaluation of interventions, and for ensuring that any issues or deficiencies arising from security policies or procedures are addressed in a timely manner. Additionally, the Assistant Commissioner, Correctional Operations and Programs is to ensure that national training and certification standards for staff are developed in collaboration with the Director General, Learning and Development (L&D). Footnote 9
The Director General, Security is responsible for establishing operational standards and requirements for the management of emergencies in operational units, and ensuring that contingency plans are reviewed at the national level in accordance with the contingency plan content requirements. Footnote 10
The Human Resources Management Sector is responsible for coordinating all of CSC’s training initiatives and courses, and for advising CSC on all labour relations concerns, including occupational health and safety issues.Footnote 11
Regional Headquarters (RHQ)
The Assistant Deputy Commissioner, Correctional Operations is responsible for communicating policies and providing support to operational units as well as conducting operational reviews of policy implementation on a regular basis. Additionally, the Assistant Deputy Commissioner, Correctional Operations is to report any issues or deficiencies arising from security policies/procedures or their implementation to the Director General, Security in a timely manner. Footnote 12
Institutions
The institutional head is responsible for ensuring that the ERT is established, equipped and trained to National Training Standard (NTS) requirements; any planned ERT intervention is authorized through a SMEAC; and contingency plans are developed that include unique ERT requirements for women offender institutions. Footnote 13
The crisis manager, typically the institutional head, is responsible for the overall management of emergencies including approving the deployment of the ERT. Footnote 14
The Assistant Warden, Operations is responsible for the coordination of all activities related to emergency planning to ensure an appropriate response capacity. Footnote 15
The ERT team leader is responsible for assessing a situation, developing the SMEAC, liaising with the crisis manager, and coordinating and leading an ERT response. Footnote 16 In addition, they are responsible for assisting with the recruitment of ERT team members. Footnote 17
The Security Maintenance Officer (SMO) is responsible for managing the ERT equipment inventory. Footnote 18
Institutional health services staff are responsible for communicating physical and mental health information to the ERT during development of the SMEAC, and the provision of health services to inmates and CSC staff during and after a security response. Footnote 19
Staff, which includes members of the ERT, are responsible for ensuring that they know and understand the applicable law, policies and procedures and consider cultural, physical health, mental health and gender issues in their interventions; demonstrate fairness, judgement and professionalism when returning the institution to a safe and secure environment; to not consent to or take part in any cruel, inhumane or degrading treatment or punishment of an inmate; and report any such behaviour or treatment if witnessed. Footnote 20
1.4 Risk Assessment
This Audit of Emergency Response Teams was identified as a high audit priority and an area of high risk to CSC in the 2018-2020 RBAP. The audit team completed an engagement-level risk assessment using the results of interviews, research, and knowledge obtained through previous audits to assist in determining areas that the audit should cover. Overall, the assessment identified key risks associated with the framework in place to support ERTs as well as with the implementation of key controls. These controls were assessed through the audit to determine if risk mitigation strategies were sufficient.
2.0 Objectives and Scope
2.1 Audit Objectives
The objectives of this audit were to provide assurance that:
- The management framework in place supports the efficient and effective achievement of objectives; and
- ERTs are being managed efficiently and effectively.
Specific criteria have been established to assess these objectives and are included in Annex A.
2.2 Audit Scope
The audit was national in scope and included the framework and processes in place at the national, regional, and institutional levels. File review focused on a sample of ERT deployments that occurred between January 1, 2017 and November 1, 2018.
The audit did not include stand-alone minimum-security institutions, healing lodges, community-based residential facilities, community correctional centers, or parole offices, as they do not have ERTs.
The Audit of the Framework and Implementation of Situation Management at CSC, completed in 2017, previously examined several areas related to this audit, including post use of force medical assessments and treatment, timeliness of completion of use of force reviews, and the associated nature and effectiveness of corrective action taken to address the deficiencies identified. Analysis of these areas were not included in this audit.
3.0 Audit Findings and Recommendations
3.1 Management Framework
The first objective for this audit was to provide assurance that the management framework in place supports the efficient and effective achievement of objectives.
The management framework was examined from four perspectives: CSC guidance; roles and responsibilities; training; and monitoring and reporting. Annex A provides general results for all audit criteria.
3.1.1 Guidance, and Roles and Responsibilities
We expected to find that CSC guidance is complete, clear, aligns with legislation, and that roles and responsibilities are defined, documented, communicated and understood.
The following areas met the audit expectations for this criterion:
- CSC guidance aligns with the CCRA, CCRR, and Criminal Code;
- Guidance generally reflects current practices;
- Roles and responsibilities are generally defined and documented in CSC guidance and training material; and
- Roles and responsibilities are communicated through policy, training and on the job direction.
As described below, there are two areas related to guidance, and roles and responsibilities that warrant further consideration by management.
CSC guidance does not clearly define what constitutes assistive or therapeutic touch.
In December 2018, the revised CD 567-1 Use of Force was promulgated. Under the previous version of this CD, all physical handling was considered a use of force; however, exceptions have been made in the revised CD for physical handling that is considered an assistive or therapeutic touch. Through interviews with ERT members, it became clear that the meaning of this revised definition was not always well understood. For example, we were informed of a situation where the ERT had used a shield to ‘guide’ an inmate during a medical injection, and that this was not reported as a use of force due to the belief that it constituted a therapeutic touch. Through interviews with management at NHQ, we were informed that this interpretation is not accurate, and that they were aware of similar situations where this definition has been misinterpreted. Further, a review of CSC’s national guidance revealed that assistive or therapeutic touch is not defined.
The absence of clarity around what constitutes an assistive or therapeutic touch increases the risk that a use of force during an intervention is not accurately identified and reported. This could result in post use of force requirements not being implemented (e.g., use of force review, medical assessment, etc.), which in some cases could lead to non-compliance with legislative requirements.
CSC guidance for the consideration of offender health information is inconsistent.
As outlined in CD 567-1, consultation with a health care professional will occur during the development of a SMEAC to ensure the physical and mental health of an offender is considered. However, when a health care professional is not on-site after hours, any known source of information, such as needs/flags/alerts in OMS or RADAR will be accessed by non-health care personnel in order to seek pertinent offender health related information. Therefore, the manner in which the offender’s health information is obtained, and the nature and extent of the information considered is dependant on when the ERT intervention occurs.
3.1.2 Training
We expected to find that CSC provides training to support the discharge of responsibilities.
The following areas met the audit expectations for this criterion:
- A national committee is in place and meets on a regular basis to help ensure the adequacy and effectiveness of ERT training;
- A formal process to establish a national training structure is in place to help ensure the consistency of training delivered across the country;
- Gaps in training, identified through the national review completed by L&D in 2013, have been addressed;
- ERT team leaders and members receive NTS training to support the discharge of responsibilities;
- ERT training generally covers the situations that the ERT is expected to respond to; and
- Women offender institution ERTs receive training scenarios specific to women offender institutions.
As described below, there is one area related to training that warrants further consideration by management.
Crisis manager training does not fully support the discharge of responsibilities.
Crisis managers at an institution are typically the Warden, Deputy Warden and the Assistant Warden of Operations. NTS training has been developed and all crisis managers are required to complete this training before discharging their ERT related duties. Interviews with crisis managers revealed that they do not always feel that the training they receive is sufficient to effectively review and approve a SMEAC. The most common issues that were raised include a lack of refresher training (especially for individuals who had taken the training many years ago, or those who do not have a lot of experience with the ERT), and lack of direction around the weapons and type of tactical response to use given the situation. As a result, crisis managers feel that they are not always able to adequately challenge the SMEAC put forward by the ERT team leader. This increases the risk that crisis managers may not approve the appropriate weapons or tactics, which could result in a response with a greater potential for a negative outcome.
3.1.3 Monitoring and Reporting
We expected to find that monitoring is conducted on a regular basis and results are reported to the required management level.
The following area met the audit expectations for this criterion:
- ERT use of force responses are reviewed to ensure compliance with law and policy;
- Use of force reviews are completed for ERT uses of force; and
- Results of ERT use of force reviews are analyzed to identify trends, results reported to the appropriate management level, and corrective action is identified and taken when required.
As described below, there is one area related to monitoring and reporting that warrants further consideration by management.
Monitoring and analysis of ERT deployments is insufficient.
Management at the national and regional levels have not established key performance metrics for ERT deployments. As a result, we found that current monitoring activities are limited to ERT deployments where force was used, and do not include an overall assessment of ERT activities. For example, the total number of ERT deployments per institution, region, and security level, the reason for the deployment (e.g., cell extraction, medical injection, etc.), and the tactics and equipment utilized by the ERT during the response are not being assessed. One of the key issues identified through this audit was the inconsistent use of the ERTs across the country; however, the monitoring information currently compiled does not include the data that would enable management to assess whether or not ERTs are being used consistently and in accordance with expectations. In addition, we identified significant differences in ERT equipment in terms of variety, capability, and condition (some personal safety equipment was heavily worn) across institutions. Funding for ERT equipment is sourced from each institution’s general security budget, which has resulted in inconsistent levels of expenditure on the ERT across the country. These purchases are not specifically coded to the ERT, which impedes CSC’s ability to conduct analysis of the cost of maintaining an ERT and ultimately limits its ability to make strategic decisions around funding for ERT equipment.
Overall, the limited monitoring and analysis impedes NHQ management’s ability to make strategic decisions for the ERT portfolio.
Conclusion
With respect to the first objective, we found that a management framework is generally in place; however, a few improvements are required to help ensure that the framework supports the efficient and effective achievement of ERT objectives. Specifically, CSC guidance does not include a definition for what constitutes assistive or therapeutic touch, and is inconsistent with respect to the consideration of offender health information during the development of the SMEAC. In addition, crisis manager training does not fully support the discharge of responsibilities, and the lack of monitoring and analysis has impeded CSC’s ability to make strategic decisions for the ERT portfolio.
3.2 Management of Emergency Response Teams
The second objective of this audit was to provide assurance that ERTs are being managed efficiently and effectively.
The management and deployment of ERTs was examined from four perspectives: recruitment and retention; equipment; scheduling and deployment; and compliance with requirements. Annex A provides general results for all audit criteria.
3.2.1 Recruitment and Retention
We expected to find that CSC has the necessary mechanisms and processes in place to recruit and retain its ERT members.
The following areas met the audit expectations for this criterion:
- ERT team sizes were compliant with CD 600 at 100% (19/19) of the institutions visited;
- ERTs are comprised of all female staff at 100% (5/5) of the women offender institutions visited; and
- Wardens generally feel that the voluntary recruitment model and the number of members on their ERT meets their needs.
As described below, there are three areas related to recruitment and retention that warrant further consideration by management.
Institutional management does not always lead the ERT recruitment process.
We expected to find that CSC has the necessary mechanisms and processes in place to recruit its ERTs. We found that institutions generally utilize a formal process to recruit its ERT members; and while these processes are not defined, they typically include a call out to staff, an interview, a physical test, and a candidate suitability check. Institutional staff that we interviewed felt that these processes were fair and inclusive, and results of our file review indicate that ERTs are able to perform their assigned tasks in accordance with requirements. In addition, institutional management did not raise concerns over the ability of their ERTs to perform assigned tasks. However, we did note that not all institutions ensure that management runs the recruitment process. Specifically, we found that some ERTs vet the candidates before management is able to conduct an assessment, which could lead to the potential for preferential treatment and interference during the recruitment process.
ERT membership letters of agreement are generally not signed and/or on file.
As required by CD 600, each new ERT member will sign a membership letter of agreement. The letter outlines the terms of the agreement for membership on the ERT and is to be signed prior to commencing the initial member training. We found that only 18% (51/276) of the ERT members at the institutions we visited had signed member agreements that could be located. In general, there was significant uncertainty and variation across institutions over how the agreements are managed. For example, management and staff at some institutions believed the agreements were signed at the ERT initial training, but did not know where they were maintained, while at other institutions the team leaders would manage the agreements. Having ERT members carry out their assigned tasks without having signed an agreement could create difficulties enforcing the terms that are not otherwise outlined in legislation and/or CDs (e.g., resignation).
The ERT member agreement establishes the requirements for resigning from the ERT, specifically, that the acceptance of a resignation will depend on “the current complement of members and the requirement to seek and train a new member.” Given that membership on the ERT is voluntary, the requirement for a member to remain on the ERT until a replacement is found, with no identified period of time within which this must be completed, would likely not withstand a challenge as it contradicts the nature of the volunteer model. As a result, even if member agreements were signed, CSC may not be able to enforce the terms for resignation from the ERT.
Overall, these issues increase the risk that institutions will not be able to maintain the necessary capacity to respond to emergencies, which is further exacerbated by the fact that many institutions do not have MOUs in place with police agencies (refer to 3.2.4 for more details), another mitigating control for the voluntary ERT model.
Correctional managers are ERT team members.
As outlined in CD 600, “new membership on the ERT will be selected from the correctional officer/primary worker and staff training officer groups.” We completed a review of the composition of ERTs and found that at least one correctional manager (CM) is a member (not a team leader) on the ERT at 50% (9/18) of the institutions included in the audit. This could result in situations where a CM would be taking direction from a team leader who is in a junior position (many team leaders are CX-1s and CX-2s), which presents a number of challenges. For example, if the CM was the crisis manager at the time of the emergency, the ERT team leader would be presenting the SMEAC to a team member for approval. Further, a team leader could have to determine whether to recruit his day-to-day manager should that individual apply for the ERT, or assess the performance of their manager if they were a member of the team.
3.2.2 Equipment
We expected to find that CSC has the necessary equipment in place to support its ERTs.
The following areas met the audit expectations for this criterion:
- A security equipment manual (SEM) is in place that provides direction to institutions over the equipment and weapons that are approved for purchase and use;
- Weapons and equipment (e.g., breaching tools, surveillance equipment, etc.) being used by institutions generally comply with the SEM; and
- 100% (237/237) of the firearms (e.g., launchers, handguns, shotguns, etc.) sampled from the national inventory were found on-site at the institutions visited.
As described below, there is one area related to equipment that warrants further consideration by management.
Inventory management practices are insufficient.
CSC’s National Security Equipment Inventory “was created to streamline the recording and reporting of security equipment and to standardize this process nationally. It further serves as a real time database for what equipment is available during a major incident and will assist with the coordination of equipment if needed.” Footnote 21 Interviews with SMOs revealed that the national inventory is not updated on a regular basis as many institutions maintain informal records (e.g., Microsoft Excel spreadsheets) to track inventory and then use this information to update the national inventory. In addition, we found that the ERT team leaders at some institutions have been assigned the responsibility for tracking ERT equipment (e.g., breaching tools, personal safety equipment, etc.). The team leaders often indicated that they do not have time to regularly manage and update their inventory, and that equipment assigned to ERT members is often not documented. We also found that physical access to the armouries were not always well controlled. SMOs indicated that various individuals (e.g., staff training officers, ERT team leaders, CMs, etc.) have access to the armoury and will remove items such as ammunition and gas munitions without accounting for it, making it difficult to keep accurate records. The impact of the poor inventory controls was evident as we found that the physical inventory of gas munitions, ammunition, and ERT equipment (e.g., breaching tools, surveillance equipment, etc.) matched the national inventory at only 33% (5/15) of the institutions visited. As well, many institutions had excessive amounts of expired gas munitions and equipment that was unaccounted for in their inventory. We were also unable to verify if all personal equipment (e.g., boots, gloves, etc.) assigned to individual ERT members was available due to a lack of an audit trail.
Insufficient inventory control increases the risk of lost or stolen equipment, and impedes CSC’s ability to ensure that required equipment is available when needed. Further, it can result in inefficient procurement, increased costs, and limits CSC’s ability to monitor and assess the overall cost of the ERT portfolio.
3.2.3 Scheduling and Deployment
We expected to find that CSC schedules its ERT members and deploys its ERTs in an efficient and effective manner.
The following areas met the audit expectations for this criterion:
- We did not identify any issues with ERT response times and no issues were raised by Wardens or ERT members;
- The majority of institutions maintained a readily available list of ERT members, including their home phone numbers and addresses in case members had to be called in to respond; and
- A crisis manager who had completed the required NTS training approved the SMEAC in 99% (74/75) of the files reviewed.
As described below, there is one area related to scheduling and deployment that warrants further consideration by management.
Deployment of ERTs is not consistent across institutions.
The current ERT model assigns responsibility for determining when to deploy the ERT to the crisis manager, and this determination is based on a risk assessment of the situation. Through file reviews and interviews with institutional management and staff, we found inconsistency in the types of situations for which the ERTs are utilized across institutions with the same security level. While crisis manager training outlines the situations for which ERTs are trained to respond, we found that CSC guidance does not provide any additional clarity as to when to use the ERT versus line staff for these situations. For example, we found that cell extractions are generally completed using line staff at some institutions; while at others, they are completed using the ERT. Further, we found that culture within institutions has played a large role in these decisions as past situations where the ERT has been deployed has created expectations amongst staff that similar situations that arise in the future should also require response from the ERT.
Inconsistent deployment across institutions could lead line staff to believe that it is not their role to respond to situations that the ERT is utilized for at other institutions, thus allowing institutional culture to influence decisions around when to deploy the ERT. Over time, this could lead to unnecessary use of the ERT and increased costs (ERT allowance, overtime, etc.). In addition, it could be called into question whether or not line staff should receive the ERT allowance and/or additional training in order to prepare them for the performance of interventions that are led by ERTs at other institutions.
3.2.4 Compliance with Requirements
We expected to find that key activities have been implemented in compliance with requirements.
The following areas met the audit expectations for this criterion:
- A consultation occurred with a health care professional to consider the offenders physical and mental health needs during the development of the SMEAC for 96% (52/54) Footnote 22 of the files reviewed;
- The response (tactics) utilized by the ERT matched what was approved on the SMEAC for 96% (73/75) of the files reviewed; and
- The weapons and equipment used by the ERT matched what was approved on the SMEAC for 96% (73/75) of the files reviewed.
As described below, there is one area related to compliance that warrants further consideration by management.
MOUs with police agencies are not always in place as required by CD 600.
As required by CD 600, a national MOU is in place with the RCMP that outlines the type of support that could be provided to CSC during an emergency. Further, CSC institutional jurisdictions that are not served by the RCMP are required to establish an MOU with the police service of jurisdiction. We found that only 17% (2/12) of institutions that are not served by the RCMP have an MOU in place with the police service of jurisdiction. Management at the non-compliant institutions generally believed that it was the role of RHQ to establish these MOUs; however, CD 600 clearly indicates that this is the responsibility of the institutional head. Further, we found that some institutions only had draft MOUs in place, which had yet to be finalized. The absence of MOUs increases the risk that institutions would not have the necessary capacity to respond to emergencies when assistance is required from outside of the institution. This in turn increases the risk of potential negative outcomes if an emergency were to arise.
Conclusion
With respect to the second objective, we found that the ERTs are generally well managed; however, some improvements could be made to help ensure compliance with requirements. Specifically, we found that ERT membership letters of agreement are generally not signed and/or on file, CMs are often ERT team members, and MOUs with police agencies are not always in place. In addition, we found that inventory management practices are insufficient, and ERTs are not consistently deployed across the country.
Recommendation 1
The Assistant Commissioner, Correctional Operations and Programs should:
- Revise guidance to define what constitutes assistive and therapeutic touch; and
- Establish and implement a monitoring and reporting framework for the ERT portfolio that includes developing key performance indicators, and monitoring and reporting requirements.
Management Response
The ACCOP will revise CD 567-1 Use of Force to further define assistive and therapeutic touch.
Further, the ACCOP will work in collaboration with the ACP to ensure that a monitoring framework is developed that includes key performance indicators to monitor performance results and trends and operational reports to enhance reporting abilities related to use of force interventions including ERT interventions.
In terms of the individual incident review, currently there is an established and implemented monitoring and reporting framework embedded within CD 567-1, which outlines the review requirements for the use of force interventions at the institutional, regional, and national levels within OMS’ Use of Force Module. These monitoring requirements are inclusive of ERT interventions and 100% of interventions are reviewed at the institutional level to ensure responses are consistent with relevant legislations and policy. A number of factors, like the mental health flags in OMS, influence if an intervention would be subject to further review in the region or nationally. Given the commitment above to develop a monitoring framework, CSC will be able to better report on ERT interventions.
Recommendation 2
The Assistant Commissioner, Health Services, in collaboration with the Assistant Commissioner, Correctional Operations and Programs should review the role of health care professionals in the development of the SMEAC and update guidance as necessary.
Management Response
ACHS supports this recommendation and by April 2021 will have completed a review of policies where Health Services is named in use of force procedures.
Recommendation 3
The Assistant Commissioner, Correctional Operations and Programs and the Assistant Commissioner, Human Resources Management should:
- Revise NTS training for crisis managers to ensure that it provides direction around the weapons, equipment, and tactics used by the ERT;
- Revise NTS to include refresher training for crisis managers; and
- Revise the ERT member letter of agreement to ensure that the terms of membership can be enforced.
Management Response
The NTS training for crisis managers will be reviewed in order to determine if training content should be revised, and to determine whether a refresher NTS training should be developed. Further, the ERT letter of agreement will be revised to create a letter of agreement that is enforceable.
Recommendation 4
The Regional Deputy Commissioners should:
- Conduct periodic reviews of the rationale for correctional managers to be members of the ERTs within their region; and
- Direct the institutional heads in their regions to establish formal processes to help ensure that:
- ERT members sign the membership letter of agreement;
- MOUs are established with the police force of jurisdiction in accordance with the requirements in CD 600; and
- The national security equipment inventory is updated on a regular basis to ensure that it accurately reflects all weapons and equipment available at their institution.
Management Response
We agree with this recommendation and plan for implementation by September 30, 2020.
4.0 OConclusion
With respect to the first objective, we found that a management framework is generally in place; however, a few improvements are required to help ensure that the framework supports the efficient and effective achievement of ERT objectives. Specifically, CSC guidance does not include a definition for what constitutes assistive or therapeutic touch, and is inconsistent with respect to the consideration of offender health information during the development of the SMEAC. In addition, crisis manager training does not fully support the discharge of responsibilities, and the lack of monitoring and analysis has impeded CSC’s ability to make strategic decisions for the ERT portfolio.
With respect to the second objective, we found that the ERTs are generally well managed; however, improvements could be made to help ensure compliance with requirements. Specifically, we found that ERT membership letters of agreement are generally not signed and/or on file, CMs are often ERT team members, and MOUs with police agencies are not always in place. In addition, we found that inventory management practices are insufficient, and ERTs are not consistently deployed across the country.
Recommendations have been issued in the report based on areas where improvements are required.
5.0 Management Response
Management agrees with the audit findings and recommendations as presented in the audit report. Management has prepared a detailed Management Action Plan to address the issues raised in the audit and associated recommendations. The Management Action Plan is scheduled for full implementation by September 30, 2021.
6.0 About the Audit
6.1 Approach and Methodology
Audit evidence was gathered using the following methods:
Interviews
Interviews were conducted with senior management and staff at NHQ, RHQ and the local levels. Interviews took place in person, by teleconference, and by videoconference.
Review of Documentation
Documentation that was reviewed included: applicable legislation, CSC policy instruments, and corporate documents such as guidelines, security equipment manual, SMO reference guide, training manuals, SMEACs, and videos and documents available in the OMS use of force module.
File Review
A sample of ERT deployments was selected and associated documentation and video footage was reviewed in relation to the criteria on scheduling and deployment, and compliance with legislation, policy, and guidance.
Observation
Observations were completed of a sample of weapons and equipment selected from the national inventory to verify their existence.
Analytical Review
Analytical review was completed in relation to the criteria on guidance, training, and recruitment and retention.
Sampling Strategy
A non-statistical judgemental sample of 75 SMEACs was selected to ensure adequate coverage of ERT deployments involving offenders with elevated mental health needs, and women offenders.
6.2 Past Audits and other reviews/reports on Emergency Response Teams
The following past CSC internal audits and external assurance work were used to assist in scoping the audit work.
- Audit of National Emergency Preparedness
- Audit on Management of Security Incidents
- Audit of the Framework and Implementation of Situation Management
- Review of ERT Training completed by CSC Learning and Development
6.3 Statement of Conformance
In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with management. The opinion is applicable only to the area examined.
The audit conforms to the Internal Auditing Standards for Government of Canada, as supported by the results of the quality assurance and improvement program. The evidence gathered was sufficient to provide senior management with proof of the opinion derived from the internal audit.
Christian D’Auray, CPA, CA
Chief Audit Executive
Annex A: Audit Criteria
The following table outlines the audit criteria developed to meet the stated audit objective and audit scope.
Objective | Audit Criteria | Met/ Met with Exceptions/ Partially Met/ Not Met |
---|---|---|
To provide assurance that the management framework in place supports the efficient and effective achievement of objectives. | 1.1 Guidance - CSC guidance is complete, clear, and aligns with legislation. | Met with exceptions |
1.2 Roles and Responsibilities – Roles and responsibilities are defined, documented, communicated, and understood. | Met | |
1.3. Training – CSC provides training to support the discharge of responsibilities. | Met with exceptions | |
1.4 Monitoring and Reporting – Monitoring is conducted on a regular basis and results are reported to the required management level. | Met with exceptions | |
To provide assurance that emergency response teams are being managed efficiently and effectively. | 2.1 Recruitment and Retention – CSC has the necessary mechanisms and processes in place to recruit and retain its emergency response team members. | Met with exceptions |
2.2 Equipment - CSC has the necessary equipment in place to support its emergency response teams. | Partially met | |
2.3 Scheduling and Deployment – CSC schedules its Emergency Response Team members and deploys its Emergency Response Teams in an efficient and effective manner. | Met with exceptions | |
2.4 Compliance – Key activities have been implemented in compliance with requirements. | Met with Exceptions |
Annex B: Site Selection
The following institutions were selected based on a number of data points including: volume of ERT usage (both high and low usage), labour relations official complaints (127.1s and 128s), and the number of ERT deployments as a percentage of all security incidents at the institution.
Region | Institution |
---|---|
Atlantic | Atlantic Institution |
Quebec | Joliette Institution* |
Ontario | Collins Bay Institution |
Prairie | Edmonton Institution |
Pacific | Fraser Valley Institution |
NHQ | Various sectors |
*The audit team did not visit these institutions and conducted its testing remotely.
Annex C: CDs and Guidelines
- CD 566-6 Security Escorts
- CD 566-7 Searching of Offenders
- CD 567 Management of Incidents
- CD 567-1 Use of Force
- CD 567-2 Use of and Responding to Alarms
- CD 567-3 Use of Restraint Equipment for Security Purposes
- CD 567-4 Use of Chemical and Inflammatory Agents
- CD 567-5 Use of Firearms
- CD 568-1 Recording and Reporting of Security Incidents
- CD 577 Staff Protocol in Women Offender Institutions
- CD 600 Management of Emergencies in Operational Units
- GL 005-1 Institutional Management Structure
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