Case Summary: Investigation into the Death of Stéphane Bissonnette

Official title: Investigation into the death of an inmate at the Regional Treatment Centre-Millhaven Institution (multi-level), on December 17, 2021

Description of the incident

At the time of the incident, Stéphane Bissonnette was a 39-year-old [redacted] male classified as a maximum-security inmate and serving his first federal (aggregate) sentence of 12 years. Mr. Bissonnette was not known to be affiliated with any Security Threat Groups. He had a history of [redacted] mental health needs. This history, coupled with frequent suicidal/self-harm ideation and behaviour, required that he receive health care in Treatment Centres and on Modified or High Watch, or in the Pinel Restraint System (PRS).

Mr. Bissonnette had been residing at the Regional Treatment Centre (RTC) Millhaven Institution (MI) since June 13, 2021. At approximately 0500 hours on December 17, 2021, a Correctional Officer (CO) responsible for observing Modified Watch via Closed Circuit Television (CCTV) at the RTC asked another CO to check on Mr. Bissonnette’s wellbeing, as he had not been seen moving for a long period of time. As directed, the CO proceeded to begin the count and arrived at Mr. Bissonnette’s cell at approximately 0505 hours. The CO could not observe Mr. Bissonnette breathing and attempted to elicit a response by turning on and off his flashlight, pointing it in the cell, and knocking on the door with his hand. A Nurse, conducting a Health Services Walk, arrived at Mr. Bissonnette’s cell at approximately 0507 hours, followed by 2 other Nurses 1 minute later. The CO left the cell to continue the count on the lower range, and then on the upper range, while the 3 Nurses stayed at Mr. Bissonnette’s cell door to observe him.

When the CO came back from the upper range, at approximately 0510 hours, the Nurses requested access to the cell to assess Mr. Bissonnette, as they could not observe signs of life. The CO left the range to inform the Sector Coordinator (SC) that there was a need to enter the cell. The SC opened Mr. Bissonnette’s cell and entered it at approximately 0512 hours. A Nurse left the cell to retrieve medical equipment. Mr. Bissonnette was observed to be unresponsive [redacted]. At approximately 0514 hours, a fourth Nurse entered the cell, ordered an ambulance to be called, briefly examined Mr. Bissonnette, and ordered cardiopulmonary resuscitation (CPR) to start. Mr. Bissonnette was turned [redacted] to assist in medical intervention, at which time it was observed that [redacted].

The Automated External Defibrillator (AED) was activated at approximately 0517 hours and conducted an analysis. No shocks were recommended at that time, nor with any subsequent analyses. The CPR maneuvers continued with staff rotating positions until approximately 0535 hours, when 2 paramedics arrived at the cell, and ordered CPR to cease.
Mr. Bissonnette was pronounced deceased at approximately 0536 hours. Ontario Provincial Police and the Coroner attended the Institution later that morning. As per the Coroner’s report, the cause of death could not be ascertained.

Incident investigation process

The Correctional Service Canada (CSC) is required by law to investigate incidents where an inmate under its care and custody, dies or suffers serious bodily injury. On June 16, 2022, CSC convened a Board of Investigation (BOI) that was comprised of 4 members, including a CSC Psychologist and National Investigator (NI) as Chair, a Nursing Project Officer, Health Services, NHQ, as Board Member, another NI with extensive operational experience, as Board Member, and an experienced community member, as Board Member. An Independent Observer (IO), a university Professor, was also appointed to ensure thoroughness, impartiality, and the integrity of the investigation process, as recommended by the 5th Independent Review Committee (IRC) into Non-natural Deaths in Custody.

During the investigation, the BOI interviewed 43 staff members from Millhaven Institution and the RTC, 2 members of Mr. Bissonnette’s family and a family friend, a friend of Mr. Bissonnette at the RTC, and an RTC patient. The principal policy instruments were reviewed, as was the incident and inmate file information. The BOI was provided with audio, CCTV, and telephone recordings. The BOI also consulted the Police and relevant CSC sectors with respect to recommendations.

The BOI examined the following areas:

• the existence of pre-incident indicators, precipitating events and contributing factors to the incident
• Mr. Bissonnette’s security classification and subsequently his admission to the RTC
• the monitoring of inmate activities on the range and the staff response to self-harm incidents in the days preceding the incident
• a review of Mr. Bissonnette’s mental health management plan and the care provided while at the RTC
• the factors related to the environment and operations at the RTC
• Mr. Bissonnette’s allegations of mistreatment at the RTC
• the effectiveness of the National Drug Strategy and the application of the Canadian Drugs and Substances Strategy at the RTC; and
• the process through which the next of kin was notified

Results of the investigation

Key findings

The BOI identified some key findings in the following areas: information sharing, security patrols and monitoring, staff response to the incident, training and awareness of roles and responsibilities, and physical infrastructure.

The BOI highlighted that communication both within sectors and across sectors could be improved. For example, the BOI found that information sharing among the health services staff could have included more communication using established mechanisms such as the nursing logbook, Offender Health Information System – Electronic Medical Record (OHIS-EMR), Offender Management System (OMS), and shift briefings. Additionally, communication between sectors such as health services and security was also identified as an area for improvement, where information sharing across sectors could have improved the staff response in the overall management of Mr. Bissonnette’s file.

Security patrols and monitoring were also brought forward by the BOI as areas for improvement. More specifically, to be of good quality, security patrols are to be staggered to avoid predictability, directly observe inmates to confirm the presence of a live, breathing body, and adhere to a specific schedule. Further, limited distractions from the presence of additional COs are required to ensure that direct observation is conducted according to policy. Silver Guard Electronic Recording Devices also need to be available and in full working order to effectively monitor security patrols and counts.

The BOI identified some areas with respect to staff response that could be improved. Some of the BOI findings related to a need for additional training and awareness on roles and responsibilities, both during the response and in the management of inmates on an enhanced level of monitoring (for example, Modified Watch or High Watch). Clear roles and responsibilities need to be established in the case of a medical emergency for an efficient and coordinated response. In addition, the BOI noted that the responsibility and authority to pronounce death during a medical intervention (such as, Nurse, institutional physician, paramedics) needs to be clearly articulated.

Further, the BOI noted that support following the incident, including Critical Incident Stress Management (CISM), and the assistance of Inmate Representatives, Chaplains, and Indigenous Elders to provide inmate support could have been more readily available and offered. A routine refresher training on CISM and intervention following an incident would be beneficial to support CISM team members in fulfilling their role.

A key finding that the BOI identified as limiting was with respect to the physical infrastructure of the institution itself. More specifically, the physical design and layout (including office space and yards) of the RTC, was considered by the BOI to be restrictive in terms of institutional routine, clinical interventions, time outside of the cell, and leisure activities, in addition to hindering the overall mental health care and quality of life of the inmates.

Recommendations and action plans

In total, the BOI made 10 recommendations aimed at improving operational practices and addressing the findings of the BOI, to prevent similar incidents from occurring in the future. CSC has action plans to address each one of these recommendations:

1. The Warden, MI, establish an Action Plan to address the issue of MI staff members who were introducing their cell phones into the institution without authorization.

2. That CSC review its policies to include specific quality assurance protocol procedures which demonstrate due diligence (including reviews of CCTV footage and/or by another efficient means to ensure that COs consistently look for a sufficient amount of time in cells to confirm that inmates are breathing and are not in medical distress) and documentation to ensure that the quality of counts and security patrols is assured.

3. That CSC Health Services define the parameters by which the Health Services Walks must be conducted in an inpatient setting at the Regional Treatment Centre – Millhaven Institution, or in any Correctional Service Canada federal institution.

4. That the Warden of MI, establish an action plan to address the issue of Silver Guard Electronic Recording Devices (SGERD) malfunctioning or potentially being tampered with.

5. That CSC Health Services address the minimum amount of time outside of a cell for leisure, exercise, and Significant Social Contact for inmates/patients under High Suicide Watch or Modified Suicide Watch that should be offered per day (taking into consideration the risk-based assessment from a Health Care (HC) professional.

6. That CSC Health Services review relevant policies to identify a specific staff member position responsible for ensuring that the conditions of the Modified Suicide Watch or High Suicide Watch are respected (including receiving only authorized items in the observation cell).

7. That CSC Health Services, include ‘pronouncement of death’ in policy to ensure Nurses are aware of their professional standards of practice in relation to the pronouncement of death.

8. That CSC Health Services implement a national nursing orientation program on which a site-specific structured orientation framework could be based.

9. That CSC develop specific training for Correctional Officers related to working in a psychiatric facility with patients with mental health needs.

10. That CSC provide interim guidance to be aligned with current approaches to address drugs and substances issues in Correctional Service Canada.

Related links

• Independent Observer’s report
• CSC response to recommendations from Independent Observer