Response to recommendations of the Independent Observer
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Official title: Response from Correctional Service Canada to recommendations of the Independent Observer of the Board of Investigation into the death of Mr. Bissonnette
Recommendation 1
The event which is the subject of this investigation took place on December 17, 2021, but it was only on June 16, 2022, that the board was set up and that work could begin. The board's work was suspended for part of the summer, and it was not until August 16, 2023, that the final version of the report was submitted to the exceptional NIM, once it had been discussed at a debriefing meeting with all the parties involved and reviewed at the NIM. In order to reduce the time lapse between the occurrence of the event and the submission of the final report, it is recommended that the national BOI be set up more quickly (less than six months after the event), to avoid work interruptions of more than a week, and to speed up the processes leading up to the submission of the final report, without sacrificing the quality of the work. This is to ensure that we obtain the most accurate picture possible of the situation under investigation, and that the board's recommendations can be acted upon rapidly.
CSC Response
The Incident Investigations Branch (IIB) reviewed its entire investigation process and several steps and procedures that caused delays were identified and modified. The IIB also mapped out the entire incident investigation process, and created a digital tool that identifies each step in the process and indicates the maximum number of days that each step should take to complete. This tool will assist IIB in planning and managing Boards of Investigation (BOIs) moving forward. The IIB also implemented the following procedures to generate efficiencies and decrease the time to complete investigations, including:
- Combining multiple incidents into a grouped BOI with a larger scope to focus on and identify key systemic issues emerging, particularly in response to the increase of incidents of assault across sites.
- Launched a new process for Local investigations, which includes a ‘BRIEF’ process to review incidents that do not include any concerns with mental health, staff response, or any other areas of systemic concern, to expedite the review of incidents in a more timely manner. The primary goal of the streamlined process for local investigations is to reduce resources required to conduct these investigations and to maintain a strategic focus on National level investigations (such as the Bissonnette case).
Recommendation 2
The deceased's mother tongue was French. Not all board members understood French well. Although the constitution of the board respected the parameters set out in the Commissioner’s Directive 041 (CD 041), we feel it is very important that all board members be able to understand and express themselves in the language of the interviewees. Of course, it may be difficult to ensure that every member of a national assessment board is bilingual, but we recommend that the CSC ensure that all board members are able to understand English when an investigation involves an anglophone, and that all board members are able to understand French when an investigation involves a francophone. If not, the CSC should ensure that a translation service is made available to interviewees.
CSC Response
The IIB takes into consideration the composition of the Board members’ ability to communicate in both official languages at the outset of each investigation, often based on the region and the preferred language of the inmate(s) and/or offender(s) involved in the incident(s). Since the formulation of this recommendation, IIB has and will continue to actively recruit and increase the number of fluently bilingual National Investigators and Community Board Members that are fully capable of working in both official languages, and there will be increased focus on ensuring there are no barriers in communications during the investigation process.
Recommendation 3
In connection with the recurrence of certain recommendations of the national BOIs, we encourage the CSC to carry out a meta-analysis of the recommendations of the National BOI reports for incidents over the past ten years in order to identify recurring observations (systemic problems) and to measure the extent to which these recommendations have been implemented.
CSC Response
The IIB has created a database that contains BOI findings (i.e., non-compliance, policy gaps, underlying issues, best practices), recommendations, and the resulting responses and corrective actions from Offices of Primary Interest. This database contains data from all BOIs completed and finalized at the quarterly National Investigations Meetings, from fiscal year 2013/2014 to present. This database is updated on a quarterly basis, to ensure all finalized BOIs are entered and accessible for searching and retrieval.
Since June 2024, National Investigators have been able to access information from this database to assist them in substantiating findings flowing from Boards of Investigation. The IIB will also undertake various analyses of this data in order to provide metrics to CSC senior management, and will explore how best to measure the extent to which BOI recommendations have been implemented by CSC.
Recommendation 4
Finally, in order to carry out its mandate properly and optimally, without wasting time, we believe that IOs should be able to benefit from an orientation guide informing them of the tools available at the CSC to find documents, the stages of an investigation process at the CSC, the content of CD 041, the internal guidelines and standards specific to the IIB, and the fundamental principles and directives that are communicated to national BOI members.
CSC Response
The IIB has developed a new Orientation Package for new Independent Observers which encompasses the elements identified in the above recommendation. The primary purpose of the Orientation Package is to facilitate the onboarding of new Independent Observers who are appointed to Boards of Investigation when required. The Orientation Package contains an Independent Observer Manual that articulates the roles and responsibilities for the Independent Observer, the composition of the board based on the level of investigation, as well as the important role of IIB operations staff who provide a primary function in support of investigation teams as the primary point of contact. Also included in the Orientation Package is the Statement of Work and Terms of Reference related to the work of the Independent Observer, investigations and security policies, IIB report templates, incident type checklists, and Questions and Answers for reference on the investigations process.