Independent Observer’s Report: Death of Stéphane Bissonnette

Official title: Independent Observer’s Report: National Board of Investigation into the death of an inmate at Regional Treatment Centre - Millhaven Institution (multi-level) on December 17, 2021

On this page

• Summary
• Introduction
• Independent Observer's methodology/approach
• Independent Observer's assessment
• Main observations and recommendations
• Other comments (if any)
• Conclusion
• References
• Annex A (Terms of Reference)

Summary

Highlights

On June 16, 2022, the Correctional Service of Canada (CSC) convened a Board of Investigation (BOI) into the Death of an Inmate at Millhaven Institution’s Regional Treatment Centre (Millhaven RTC) on December 17, 2021, to ensure responsibility, accountability and transparency, and to enhance its ability to contribute to the safety of the public, staff and offenders.

This BOI included Mike McPHERSON, National Investigator, Incident Investigations Branch (IIB), National Headquarters, Joanne BARTON, Nursing Project Officer, Health Services, National Headquarters, as board members, Kim BRISSON, as community board member, and Yvan TURCOTTE, National Investigator, IIB, National Headquarters as chairperson. Serge BROCHU acted as an Independent Observer (IO).

The IO’s work started on June 27, 2022. As the board's work was already underway, he had access to all the interviews conducted at the time. The IO’s work continued right up to the exceptional National Investigations Meeting (NIM) and the tabling of the final report, i.e., on August 16, 2023.

After observing live and recorded interviews, viewing Closed-Circuit Television recordings of the inmate's cell or range, reviewing relevant documents, witnessing exchanges between board members, attending pre-briefing and debriefing meetings, and comparing the various versions of the report, the IO can attest to the thoroughness and impartiality of the investigation process into the death of Mr. BISSONNETTE and the professionalism of each member of the national BOI.

The IO has, however, noted a number of areas for improvement to ensure that the work of the national BOIs is optimized. In this regard, here are 4 recommendations:

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 lapse of time 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.
2. The deceased's preferred language 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 BOI 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.
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.
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.

Furthermore, the members of the BOI did not have access to the coroner's report (nor to the cause of death) until February 2, 2023, or the police report (February 22, 2023), well after the interviews had ended. It seems crucial to us that the members of the national BOI have access to all relevant information and, of course, this includes the cause of death. We understand that the work of the coroner or the police is not the CSC's responsibility, but we urge them to exert pressure to make their reports available much more quickly.

Introduction

On December 17, 2021, at approximately 0505 hours, a Correctional Officer (CO) entered sector 1 of the Millhaven RTC, walked over to Mr. BISSONNETTE’s cell window, looked into the cell with a flashlight and knocked on the cell window in an attempt to get a response, but was unable to get one. At approximately 0506 hours, a health services staff member entered the range and began a wellness assessment. At approximately 0507 hours, the health services staff member arrived in Mr. BISSONNETTE's cell, accompanied by the CO who continued to try to get a response from the offender. At approximately 0512 hours, the door to Mr. BISSONNETTE'S cell was opened and they entered. Mr. BISSONNETTE [redacted]. A call was made for an ambulance at approximately 0514 hours, and cardiopulmonary resuscitation was initiated at approximately 0516 hours. The paramedics arrived and resuscitation measures were stopped at 0535 hours. It should be noted that, on December 16, 2021, at approximately 1030 hours, Mr. BISSONNETTE was treated for [redacted] placed in an cell on modified suicide watch. Mr. BISSONNETTE began exhibiting unusual behavior throughout the day and at approximately 1641 hours, he appeared to be in [redacted]. Mr. BISSONNETTE’s last movements were observed on the closed-circuit television recording at approximately 1206 hours on December 17, 2021.

In response to this incident, the Commissioner of the CSC, pursuant to sections 19 and 20 of the Corrections and Conditional Release Act (CCRA), ordered a national investigation.

Given the seriousness of the incident and the public interest in the investigation, the CSC appointed an IO to ensure the thoroughness, impartiality, integrity and professionalism of the investigation process.

In order to achieve the objectives defined in this mandate, the IO was granted full and unrestricted access to documents, interviews, locations and information related to the BOI.

The IO had direct access to board members and obtained their full cooperation. All his requests were promptly and appropriately answered. The board chairman even adopted a proactive approach to keep the IO adequately informed of the relevant elements and stages of the investigation. All interviews and meetings that the IO was unable to attend were recorded, so that he could be aware of what was said.

A complete description of the mandate provided to the IO regarding Mr. BISSONNETTE’s case can be found in Annex A (Terms of Reference).

Independent Observer's methodology/approach

In order to fulfill the IO’s terms of reference, the following tasks were carried out:

1. Viewing of the camera recordings of Mr. BISSONNETTE’s cell and the range where his cell was located on the day of his death
2. Viewing of the board members’ preliminary meeting held on June 10, 2022
3. Viewing of the initial meeting with the various employee representatives and the initial meeting with the managers involved, both held on June 22, 2022
4. Viewing of the meetings with 49 interviewees. For the majority of them, this involved direct observation via Microsoft Teams (camera and microphone closed, after a short introduction). However, interviews conducted before the contract was signed (3) and during scheduling conflicts (4) had to be viewed as recordings
5. Participation in post-interview debriefing meetings
6. Visiting the Millhaven RTC and consulting Mr. BISSONNETTE’s institutional files on September 27, 2022
7. Observing the working meeting for the drafting of recommendations, on September 28, 2022 (live) and October 21 (recorded)
8. Reading of all email exchanges between board members or in connection with the drafting of the board's report
9. Reading of changes made to the report throughout the various iterations
10. Participating (camera and microphone closed) in the debriefing meeting with local managers involved (November 18, 2022), and the pre-debriefing meeting (February 7, 2023)
11. Viewing of the meeting with managers to discuss recommendations (December 21, 2022)
12. Reading of all email exchanges with stakeholders relating to the report's recommendations
13. Reading of laws, regulations and commissioner's directives relevant to the investigation
14. Reading the Warden’s Situation Report – Institutional Incidents
15. Reading other relevant documents (see the reference list)
16. Participating (camera and microphone closed) in the pre-debriefing meeting (April 12, 2023) with the IIB team
17. Viewing the national debriefing meeting (April 26, 2023)
18. Viewing the national post-debriefing meeting (April 26, 2023)
19. Participating in the exceptional NIM (August 16, 2023); and
20. Comparing the various versions of the investigation repor

Independent Observer's assessment

To begin with, it should be noted that our observations allow us to affirm that the interviews conducted by the national BOI were carried out in accordance with the CSC’s statement of values (CD 001). Thus, we can affirm that they were conducted with respect, fairness and professionalism. We'll come back to these aspects later, when we look more specifically at the thoroughness, impartiality and integrity of the process.

Our assessment of the investigation process is based primarily on CD 041 and the internal guidelines and standards of the IIB and the Professional Standards Section (PSS).

As a reminder, the purpose of CD 041 is to:

To ensure that the CSC takes appropriate action following an incident;

To ensure that the review of investigation reports and organizational practices where appropriate, and significant findings/recommendations from these reports are shared in order to prevent similar incidents from occurring in the future; and

To ensure that quality of care reviews are conducted when an inmate dies from natural causes in a CSC facility, excluding in community correctional centres.

Thoroughness of the BOI’s process

The thoroughness of the investigation process is defined in CD 041 (Incident Investigations).

At the outset, it should be noted that the BOI’s composition complies with sections 21 to 29 of CD 041.

BOI members had extensive experience with CSC, and their expertise covered all the important aspects, giving them a good grasp of the issues involved in this mandate. All the members had significant experience as investigators. The chairperson, a Psychologist, worked at the Regional Mental Health Centre in the Quebec Region (Centre régional de santé mentale de la région du Québec) (in accordance with section 26 of CD 041). Mrs. BARTON, a Nurse, worked at Millhaven and NHQ (in accordance with section 26 of CD 041), and enabled the board to identify, locate and understand important documents for the board's work. Mr. McPHERSON has extensive experience in operations and as a manager at the CSC; he is very knowledgeable of the elements and issues related to safety and operations. Mrs. Kim BRISSON, a member of the community (section 24 of CD 041), has extensive field experience with offenders and is very knowledgeable of the issues that may be raised by the community. The board members were very familiar with the CSC, its procedures, policies, culture and dynamics. Among other things, they had a good understanding of the issues involved in assessing risk levels and managing offenders. All in all, they knew and understood very well the organization they were investigating.

Mr. TURCOTTE and Mrs. BRISSON are perfectly bilingual. Mrs. BARTON understands and speaks a little French, while Mr. MCPHERSON neither understands nor speaks French. The board’s composition therefore complies with the directives in section 22 of CD 041 stipulating that:

When preparing for an investigation to be convened in bilingual designated regions, at least one member of the Board of Investigation will be bilingual. All efforts will be made to have two bilingual Board members.

Board members were relieved of their usual duties for the time needed to conduct the investigation and draft the report (section 29 of CD 041). The CSC provided the board with sufficient resources for the investigation.

It is our understanding that the board members were well-informed and aware of the scope of their investigation mandate, and the board's work was conducted within the parameters set out in this mandate. Each of the nine aspects mentioned in the convening order was carefully analyzed and is the subject of this report. The chairman and board members identified, gathered and analyzed the elements relevant to the investigation. They identified, contacted and met all known persons who might hold information relevant to the investigation. The board members asked appropriate, legitimate and adequate questions to the interviewees.

The recommendations in the board's report are well supported by facts/evidence gathered during the work and presented in a clear manner. These facts were based on interviews conducted or documents consulted. All changes made to the report were approved by all members.

Although the investigation process was lengthy, all board members remained highly committed to their role throughout its development. Each member was committed to improving the way the CSC operates, so that a situation similar to the one that led to Mr. BISSONNETTE's death never reoccurs.

In short, the IO can testify to the seriousness and thoroughness of the investigation. The BOI took into account all the evidence brought to its attention. The board members worked thoroughly and cooperatively to analyze the case assigned to them from every angle.

Impartiality of the investigation process

Impartiality refers to the absence of prejudice and bias.

The board members, with the exception of the community member, were CSC employees. However, none of the members had any real or apparent conflict of interest beyond their employment relationship. In the circumstances, we attest that the investigation was conducted as independently as possible.

The board members had extensive experience related to the case under investigation. They were thus able to identify and analyze all points relevant to the investigation. They were open-minded throughout the process. The investigation was not conducted in such a way as to obtain predetermined results. The recommendations were based solely on the evidence/facts, without overlooking any. To our knowledge, nothing was systematically concealed.

The members of the BOI were not subject to any undue influence brought to the attention of the IO for the purpose of modifying or changing their supporting facts or recommendations. Of course, those likely to be affected by the board's recommendations had the opportunity to comment on them before they were drafted in their final form - to do otherwise would have been unfair to them - but this did not hinder the impartiality of the process.

We can therefore affirm that the investigation process was carried out in accordance with the IIB's quality control standards. It was carried out fairly and equitably, impartially, without bias or prejudice.

Professionalism and integrity of the board of investigation process

a) Professionalism of the BOI process

All interviews and interactions/communications with interested parties and stakeholders, both verbal and written, were conducted in a courteous, respectful and timely manner, given that the mandate was only given to the national BOI in June 2022, almost six months after the events.

All persons interviewed in the course of this investigation were informed by the BOI’s chairman of the protection granted to them under section 13 of the Inquiries Act (paragraph 33[a] of CD 041).

The members and the chairman worked together in a collegial spirit of openness, honesty and transparency.

In the IO’s opinion, all BOI members complied with the Values and Ethics Code for the Public Sector. The board members always interacted respectfully and fairly with CSC staff and the community. Among other things, each member, especially the chairman, demonstrated a caring attitude towards interviewees. He said he understood that the situation under investigation had been a difficult one, and that questions from the board members might revive unease. He stated that employee assistance services were available to them, should the need arise. Each member was very attentive to what the interviewees had to say. All in all, the IO can testify to the professionalism of each board member and the professional nature of the investigation process.

b) Integrity of the investigation process

Integrity refers to the state of something that remains intact, whole.

Before submitting its final report, the BOI organized debriefing meetings at local, regional and national levels in accordance with section 44 of CD 041.

The report was also carefully reviewed by the IIB’s staff prior to submission to regional and national authorities. Comments from the IIB’s staff were shared and discussed with the board’s chairman at a pre-briefing meeting. We attended this pre-briefing meeting (camera and microphone closed). The comments generally consisted of requests or suggestions for clarification, which in no way altered the nature of the observations or recommendations. Nevertheless, one recommendation (no. 2 – patrol quality) in the report was the subject of more lively discussion. This discussion focussed on the best way to word this recommendation, so that it could be accepted by the CSC's senior management and implemented. In this case, and for all observations or recommendations, the chairman and board members remained free to accept or reject the suggestions for modifications put forward by the IIB’s staff. The director was very clear: the BOI had full discretion to decide whether or not to leave the wording of their recommendations as originally formulated.

The national debriefing meeting (April 26) gave CSC senior management the opportunity to ask questions for clarification, to have discussions with the BOI members and to present their reactions to the report as well as their points of view, sometimes disagreeing with certain recommendations. Once again, recommendation no. 2 (patrol quality) was discussed at length. These discussions focused, among other things, on the definition of a patrol’s quality and the indicators to measure it. Also, some participants felt that this was more of a compliance issue than a policy gap. Some members of management seemed to disagree with the wording of this recommendation and provided alternative passages, but the chairman maintained consistency throughout his statements in order to maintain the intrinsic message, the intent of the board's recommendation. He nevertheless agreed to revise recommendation 2 in light of the discussion.

Recommendation no. 5 was also discussed at length. Once again, the chairman listened to the arguments presented, agreed to modify the wording of the recommendation if necessary, while maintaining the essential message of the recommendation. Other recommendations were less extensively discussed. The recommendations that sparked the most reaction seemed to be those calling for changes to national policies (commissioner’s directives).

A post-debriefing meeting with the board members was held on April 26, 2023, at the end of the national debriefing meeting. All the members supported the positions taken by the chairman at the previous meeting. In the days that followed, the chairman reworked certain parts of the report, including recommendation no. 2, and the changes made (in follow-up to modifications) were accepted by all the members. In the IO’s opinion, the change in wording in no way affects the original message.

In response to the national debriefing meeting, one recommendation was withdrawn (initial recommendation 7), as it overlapped with two previous recommendations (recommendations 5 and 6), but the facts supporting this recommendation remained in the report to show them clearly.

In short, the discussions at the national debriefing meeting, while giving rise to a few opinions on the part of CSC's senior management, did not threaten the integrity of the board's recommendations. When changes were made to the wording of a recommendation (very few), this was done with a view to preserving its essence and without diluting it, and with the agreement of all board members. In this sense, we can affirm that the CSC’s senior management did not exert undue pressure to modify the recommendations or observations contained in the report.

We can therefore affirm that the entire investigation process was carried out with integrity.

Main observations and recommendations

Now that the thoroughness, impartiality and professionalism of the BOI's work have been established, let's take a few moments to analyze the ways in which the process could be improved.

Start and duration of work

The IO protocol established by Lafontaine (2016) states that celerity is an important indicator of the consistent application of a thorough investigation process. In fact, over time, memories become less precise or may become confused. Documents may be harder to identify or locate (misplaced, corrupted or overwritten). Staff members may have resigned. Fellow inmates may have been released and may be difficult to find. It was not until June 16, 2022, that the CSC convened the BOI, i.e. six months after Mr. BISSONNETTE’s death, and the final report was tabled at the exceptional NIM on August 16, 2023, once it had been discussed at the debriefing meeting with all parties involved and reviewed at the NIM, i.e. 20 months following the event. For the start of the work, we understand that it is preferable for the national investigation to take place after the disciplinary investigation, so as not to contaminate the two processes. However, it seems to us that the time allowed is very long and does not meet the criterion of celerity stated earlier.

Sections 11 and 12 of CD 041 cover timelines, stating that national investigations:

… should be completed and prepared for review by the Executive Committee within six months from the date of the convening order. However, in the case of more complex investigations… the Senior Deputy Commissioner may extend the time to investigate beyond the established timeframe. P. 5

It is understandable that the current investigation could be considered to be a complex investigation (e.g. a high profile incident), but with a delay of more than a year between the date of the convening order and the date of submission of the report at the exceptional NIM, it is clear that the prescribed deadline has been largely exceeded. Several reasons may explain this long delay.

Among other things, a summer break interfered with the board's work. Any long break entails risks (including difficulty in clearly recalling the content of the meetings held prior to the break). It is recommended that interviews be carried out in one period, with no break lasting more than a week.

Finally, it is important to mention that, following the submission of a first version of the report, a lengthy process of exchanges with stakeholders and managers, quality control and debriefing took place. While we understand the necessity of each of these steps, it seems to us that the process as a whole is far too long, and should be shortened to allow recommendations to be implemented within a reasonable timeframe.

Furthermore, sections 11 and 12 of CD 041 provide no indication of when the board's work is to begin. We recommend adding a section on the maximum timeframe for issuing the convening order. In our opinion, this period should not exceed three months.

Bilingualism of board members

It was mentioned earlier that one member of the board had difficulty understanding and expressing themselves in French, while another could neither understand nor express themselves in French. However, the composition of the board complied with section 22 of CD 041.

The board chairman always asked interviewees to choose their preferred language for the interview (section 30 of CD 041). However, when interviewees indicated that they preferred to express themselves in French, some members were unable to follow the conversation (for example, the interview with the [redacted]). In other circumstances (meeting with a friend of the deceased), the interview began in French, but after realizing that some members might have difficulty understanding French, the interviewee preferred to speak in English in order to be clearly understood by all board members. During the interview with the [redacted], the board chairman asked him, as he did in all interviews, in which language he wanted the meeting to take place. This person, a Francophone, then asked if all board members understood French well. When he was informed that they did not, he said he preferred to speak in English so that all members could understand him. Since his English was not very good, he alternated between French and broken English. On one occasion, the chairman felt it necessary to summarize the conversation in French to ensure that he had understood what the interviewee had said in English. One board member asked to repeat one of the explanations in French, as she had misunderstood certain elements that seemed important to her.        

We feel it is very important that all persons approached by a national BOI feel heard and understood by all board members in the Canadian official languages of their choice. In fact, this is the underlying principle of section 30 of CD 041.

For obvious reasons, the necessity to express oneself in one of the two official languages that one does not master, in order to try to make oneself understood by all the board members, is a problem. It is not normal in Canada for some people to feel it necessary to express themselves in one of the two official languages which is not their own and which they do not master well.

The CSC must now go one step further to ensure that all board members are able to understand what the interviewees are saying. Thus, we recommend that section 22 of CD 041 be amended in order that the CSC be required to ensure that all board members are able to understand English when an investigation involves an anglophone and all board members are able to understand French when the investigation involves a francophone. When not all members are able to understand what is being said in a language other than their own, a translation service should be provided.

Recurrence of the national BOIs’ recommendations

One of the aims of CD 041 (Incident Investigations) is:

To ensure that the review and analysis of investigation reports influence organizational policy and practices where appropriate, and significant findings/recommendations from these reports are shared in order to prevent similar incidents from occurring in the future.

Cormier, Jones and Leonardi (2019) wrote in their report entitled Fifth Independent Review Committee on Non-natural Deaths in Custody that:

…but we are concerned that the numerous findings of non-compliance not be lost in the process. These cases illustrate the need to review reoccurring Compliance Issues and gather them across BOIs to conduct analyses to inform the organization of possible systemic issues. This would allow the organization to learn from the BOIs collectively and take appropriate action and, in this way, better meet its accountability in this critical area of non-natural deaths in custody. p.135

The authors go on to say:

Repeated lack of compliance begins to move toward a systemic issue and serves to reduce the trust placed in CSC as a whole, and in the IIB to conduct independent and impartial investigations. p.144

It seems to us that references to non-compliance and recommendations similar to those in the report on the death of Mr. BISSONNETTE (among others, on the quality of security patrols) have already been made on several occasions by previous boards, without any real convincing follow-up. Such repeated observations/recommendations without convincing follow-up could produce a cognitive bias among members of an investigation board or IIB staff. In fact, they may deem it unnecessary to repeat the same non-compliance observations or recommendation for the umpteenth time, become complacent or water down a recommendation so that it becomes "acceptable" to an institution’s senior management.

We encourage the CSC to carry out a meta-analysis of non-compliance observations and recommendations in national BOI reports for incidents over the past ten years in order to highlight recurrences, analyze the possible presence of systemic issues, and measure the extent to which effective solutions have been implemented to ensure that the objectives set out in CD 041 are fully met.

In this regard, we support recommendation 30 in the report entitled Fifth Independent Review Committee on Non-natural Deaths in Custody:

That the Incident Investigations Branch 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. Based on the outcome of this review, it may be appropriate to include this topic as a Term of Reference for a future Independent Review Committee. p.145

Access to all relevant information

The members of the BOI did not have access to the coroner’s report until February 2, 2023, i.e. long after the interviews had been completed. In addition, the report did not indicate the cause of death. The board members were therefore unable to ask specific questions related to the precise cause of Mr. BISSONNETTE’s death. Board members, including the chairman, made repeated requests to receive the coroner’s report.

Similarly, the police report was not received in time (received on February 22, 2023) to be used in the interviews. That said, the report indicated that there were no criminal elements suspected in connection with this death.

In this case, it does not appear that the death was due to an overdose or other criminal event, and reading the conclusions of the coroner's report or the police report would not have changed the course of the interviews. However, in other circumstances where, for example, the cause of death could have been related to a proven synergistic effect between psychotropic drugs and illicit substances, the questions to certain interviewees might have been different.

We feel it essential that the members of the national BOI have access to all relevant information, and the cause of death is obviously one of them. We are well aware that the work and deadlines of the coroner or the police services are not the CSC’s responsibility, but we urge them to press for their reports to be made available much more quickly.

In addition, the IO received no introduction or formal training before taking up his new position. He himself had to find out which documents were relevant and where they could be found in order to consult them. However, he received excellent support from the board’s chairman, who made himself available to answer all his questions, and from IIB staff. In order to fulfill their mandate, and to do so optimally, without wasting time, the IOs should be able to benefit from an orientation guide on:

1. Tools available at the CSC for document retrieval
2. Stages in the CSC investigation process
3. CD 041
4. Internal guidelines and standards specific to the IIB; and
5. The fundamental principles and directives that are communicated to the members of national BOIs

Other comments (if any)

One interview took place in a room where it was very difficult to hear what the interviewee was saying. What's more, one of the board members expressed doubts about the confidentiality of what could be said in that room. The CSC must pay particular attention to maintaining the confidentiality of comments made during its investigation meetings. Among other things, it should ensure that interview rooms are sufficiently soundproofed and protected from prying eyes.

Conclusion

After viewing the closed-circuit camera recordings of the inmate's cell and range on the day of his death, attending the BOI’s live and recorded interviews, reading the relevant documents and attending the pre-debriefing and debriefing meetings, the IO can attest to the thoroughness and impartiality of the process, and the professionalism of each member of the national BOI into Mr. BISSONNETTE’s death.

In fact, the members of the BOI had extensive experience within the CSC, and their expertise covered all the key areas required to fully understand the issues associated with their mandate. The nine aspects specified in the convening order were each carefully analyzed and are the subject of this report. Board members identified, contacted and met with all known persons who might have information relevant to the investigation. Members asked relevant, legitimate and appropriate questions to the interviewees. The board's recommendations were well supported by the facts gathered during the work, and carefully presented.

The IO can attest to the absence of bias on the part of the BOI members, the BOI support team and the IIB. The board members, with the exception of the community member, were CSC employees. However, there was no real or apparent conflict of interest for any member, other than their employment relationship. The investigation was not conducted in such a way as to obtain predetermined results. The recommendations were based solely on the evidence/facts, without overlooking any.

All interviews and interactions/communications with interested parties and stakeholders, both verbal and written, were conducted in a respectful manner. In the opinion of the IO, all the members of the BOI complied with the Values and Ethics Code for the Public Sector. Among other things, each board member always dealt respectfully and fairly with CSC staff and the community. Board members and the chairman worked together in a collegial spirit of openness, honesty and transparency.

Finally, despite the fact that some of the CSC’s senior management mentioned their perplexity about certain recommendations during the national debriefing, they did not exert undue pressure on the board members to modify their report, and the recommendations were not modified in such a way as to compromise their intent or diminish them.

The IO did, however, note a number of areas where improvements could be made to optimize the board's work. With this in mind, here are four recommendations:

1. The event under investigation took place on December 17, 2021, but it was not until June 16, 2022, that the board was established. The board's work was suspended for part of the summer. Communications with stakeholders and managers took place in the fall of 2022. The quality control process comments were submitted in winter 2023, and the national debriefing meeting took place on April 26, 2023, a few months before final submission in August 2023. It is recommended that the national BOI be established more quickly (three months after the event), to avoid work interruptions lasting more than a week, and to accelerate the steps leading to the national debriefing. This is to ensure the most truthful picture possible of the situation under investigation, and the implementation of concrete actions to prevent similar situations from recurring
2. The deceased's mother tongue was French. Not all board members understood French well. We feel that it is very important for all board members to be able to understand and express themselves in the interviewees’ language. Of course, it may be difficult to ensure that all members of national assessment boards are 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, translation services should be provided
3. With respect to the recurrence of certain recommendations, we encourage the CSC to carry out a meta-analysis of the recommendations of the national BOI reports of the last ten years, in order to identify recurring observations, analyze the possible presence of systemic issues and measure the extent to which effective solutions have been implemented, in order to ensure that the objectives of CD 041 are fully met
4. Finally, we understand the need for IOs to remain independent and, in this sense, not to conform to specific instructions from the CSC. However, in order to make their work more efficient, we feel it is necessary to provide IOs with 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 contents of CD 041, the internal guidelines and standards specific to the IIB, and the fundamental principles and directives that are communicated to the national BOI members

We would also like to acknowledge the IIB staff’s excellent collaboration with the IO throughout the process, which demonstrated their great professionalism.

References

Cormier, R., Jones, G., Leonardi, L. (2019). Fifth Independent Review Committee on Non-natural Deaths in Custody. Ottawa: CSC.

Commissioner's Directive 001 (2018). Mission, Values and Ethics Framework of the Correctional Service of Canada.

Commissioner's Directive 041 (2020). Incident Investigations.

Commissioner's Directive 048 (2019). Information Sharing and Provision of Support Services Associated with Coroner’s/Medical Examiner's Death Investigations or Inquests/Inquiries.

Commissioner's Directive 060 (2019). Code of discipline.

Commissioner's Directive 568-1 (2016). Recording and Reporting of Security Incidents.

SOR/92-620 dated October 29, 1992. Corrections and Conditional Release Regulations (CCRR) (amended November 30, 2019).

Lafontaine, F. (2016). Évaluation de l’intégrité et de l’impartialité des enquêtes du SPVM sur des allégations d’actes criminels visant des policiers de la SQ à l’encontre des femmes autochtones de Val-D’Or et d’ailleurs. Rapport de l’observatrice civile indépendante. (translation: Assessment of the integrity and impartiality of Montréal police (Service de police de la Ville de Montréal - SPVM) investigations into allegations of criminal acts committed by Sûreté du Québec (SQ) police officers against Indigenous women from Val-D'Or and elsewhere. Independent Civilian Observer’s Report.] Montréal.

S.C. 1992. Corrections and Conditional Release Act (amended June 23, 2022).

R.S.C. 1985. Inquiries Act. (amended April 1, 2005)

R.S.C. 1985. Privacy Act. (amended October 1, 2022)

Annex A (Terms of reference)

Terms of reference for the Independent Observer

National Board of Investigation into the death of an offender at the Millhaven Institution’s Regional Treatment Centre on December 17, 2021.

General information

On December 17, 2021, at approximately 5:05 a.m., a correctional officer (CO) entered sector 1 of the Millhaven Institution’s Regional Treatment Centre (Millhaven RTC), walked over to Mr. BISSONNETTE’s cell window, looked into the cell with a flashlight and knocked on the cell window in an attempt to get a response, but did not get one. At approximately 5:06 a.m., a health services staff member entered the range and began a wellness assessment. At approximately 5:07 a.m., the health services staff member arrived in Mr. BISSONNETTE's cell, accompanied by the CO who continued to try to get a response from the offender. At approximately 5:12 a.m., the door to Mr. BISSONNETTE’s cell was opened and staff entered. Mr. BISSONNETTE [redacted]. A call was made for an ambulance, and cardiopulmonary resuscitation was initiated. The paramedics arrived, and resuscitation measures were stopped at 5:35 a.m. It should be noted that, on December 16, 2021, at approximately 10:30 a.m., Mr. BISSONNETTE was treated for [redacted] and placed in an cell on modified suicide watch. Mr. BISSONNETTE began exhibiting unusual behavior throughout the day and at approximately 4:41 p.m., he appeared to be in [redacted]. Mr. BISSONNETTE’s last movements were observed on the closed-circuit television recording at approximately 12:06 a.m. on December 17, 2021.
In response to this incident, the Commissioner of the Correctional Service of Canada (CSC), pursuant to sections 19 and 20 of the Corrections and Conditional Release Act (CCRA), ordered a national investigation.
Given the seriousness of the incident and the public interest in the investigation, the CSC appointed an Independent Observer (IO) to ensure the thoroughness, impartiality, integrity and professionalism of the investigation process.

Investigation terms of reference^{Footnote 1} 

1. The IO will assess whether the work of the Board of Investigation (BOI) is thorough, impartial and professional
   1. Thorough will be understood as the adherence to the parameters set out in the Convening Order, as well as the consistent application of a rigourous established investigation process, as defined under Commissioner’s Directive 041 as well as the Incident Investigations Branch’s own internal guidelines and standards
   2. Impartiality will be understood as an absence of prejudice or bias, actual or perceived, in the outcome of the investigation that will be guided solely by the evidence; and
   3. Professional will be understood as assessing that all interviews, verbal and written interactions/communications with involved parties and stakeholders, are carried out in a respectful and timely manner
2. Throughout the course of all activities, the IO is expected to make observations and/or recommendations on any issues related to their mandate. The observations and recommendations may be made to the BOI or, in the event the observations and recommendations relate to the BOI or at the preference of the IO, to the CSC Senior Deputy Commissioner (SDC). This includes identifying potential concerns and proposing solutions for resolution of such concerns
3. Following the conclusion of the investigation process, the IO will provide a final report of their observations and conclusions, which will be at latest on Friday, December 16, 2022. The format of such a report shall be determined by the IO and the report shall be made public by the CSC
4. The IO will liaise with the chair of the BOI to obtain access to all the information and documents deemed necessary
5. The IO will also liaise with the Director General of the IIB, and their office for assistance regarding any procedural or administrative matter related to the conduct of the investigation
6. The CSC shall provide the IO office supplies and material (such as a CSC laptop) upon request
7. The IO shall maintain document security, including respecting the need to know principle, as provided by the Government of Canada Security Policy
8. The IO will comply with the provisions of the Privacy Act
9. The IO will inform the SDC of any media or government requests for commitment
10. The IO will be reimbursed for any necessary travel and disbursements in accordance with Government of Canada policy

In consideration of the foregoing and in accordance with the Terms of Reference set out above, I agree to act as the Independent Observer in this matter.
Assented to this …… day of…… (month) ……(year) at Montréal, Quebec.
Name