Case Summary: Investigation into the Death of Robert Pickton

Official title: Board of Investigation into the assault of an inmate on May 19, 2024, at Port-Cartier institution, resulting in their death in hospital on May 31, 2024

At the time of the incident, Robert PICKTON was a 74-year-old man who had been serving a life sentence since 2007 for 6 counts of second-degree murder. 20 additional counts of first-degree murder led to a stay of proceedings in 2010. Mr. PICKTON’s crimes received extensive media coverage across the country and around the world. His security level had been maintained at maximum since his intake assessment in 2008. He had been incarcerated at Port-Cartier Institution (PCI) since 2018.

On Sunday, May 19, 2024, at approximately 1716 hours, when medication was being distributed in the unit, Mr. PICKTON was assaulted by another inmate. When the assault started, the Correctional Officer (CO) assigned to the control post requested the assistance of other COs, who quickly intervened and were able to convince the aggressor to stop the assault.

At approximately 1718 hours, the aggressor then grabbed a broomstick, broke the handle, and thrust it into the face of Mr. PICKTON . Correctional Officers again intervened, managed to gain his compliance and handcuffed the aggressor, then escorted him to the Structured Intervention Unit. Mr. PICKTON was transported by ambulance to the Centre de santé et de services sociaux de Sept-Îles under escort around 1757 hours. Given his critical condition, he was transported via air ambulance to the Hôpital Enfant-Jésus in Québec City the next day, where he was admitted to intensive care. On May 31, 2024, Mr. PICKTON was pronounced deceased.

The Crimes Against the Person Investigation Unit of the Sûreté du Québec (SQ) began a police investigation. No criminal charge has yet been laid in this case^{Footnote 1} . Correctional Service Canada (CSC) has not yet received any reports from the Quebec Coroner’s Office^{Footnote 2} .

CSC is required by law to investigate incidents where an inmate under their care and custody dies or suffers serious bodily injury. On July 5, 2024, CSC convened a Board of Investigation (BOI) comprised of 4 members, including a National Investigator (NI) with vast operational experience as Chairperson, a Senior Project Advisor, from the Preventive Security and Intelligence Branch, National Headquarters, and an experienced community member as BOI members. An Independent Observer (IO), a retired public servant with more than 30 years of experience in the field of national security and security intelligence, was also appointed to ensure the thoroughness, impartiality, and integrity of the investigation process; the IO has submitted their report for publication by CSC.

During this investigation, the BOI interviewed 35 staff members mainly from PCI, but also from Donnacona Institution, and from the Special Handling Unit. The BOI also consulted the Sergeant Investigator of the SQ in charge of the police investigation, as well as staff from relevant sectors at both Regional Headquarters and National Headquarters. Policy instruments were reviewed, as well as the information on file regarding the specific operational unit, the incident, and the inmates involved. The audio and closed circuit television recordings from the day of the incident were also analyzed. The BOI virtually visited the operational unit and location of the incident, and used virtual tools to obtain file documentation and to conduct interviews.

The BOI considered the following areas of investigation:

• The existence of pre-incident indicators, precipitating events or contributing risk factors to the incident
• The security classification of the inmates involved in this incident and their placement at Port-Cartier Institution
• The staff presence in the area where the incident occurred, including the monitoring of activities and the management inmate movement; and
• The staff response to the incident, including but not limited, to the interventions and the interventions and medical care provided to the inmates following the incident, as well as the process through which the inmate’s Next of Kin was notified

The BOI made a number of key findings in the following areas: accessibility of items that could compromise the security of the institution, CO training on their obligations related to the assessment of inmate progress, and the collection and sharing of information with the Next of Kin.

Though the staff presence in the area where the incident occurred was consistent with current practice standards, the BOI identified an underlying issue regarding access to wooden handles from mops and brooms (the weapon used in the incident). The BOI was informed that inmates had free access to cleaning items and that there were no functional locking cabinets that could be used to store the brooms or mops on the range, nor was there an inventory of these items at the time of the incident. During consultations, at the time of the writing of the report, the BOI was able to confirm that the management team at PCI was open to reviewing access to cleaning supplies, and that there were projects in progress with Technical Services to find solutions.

The BOI analyzed the casework records in the Offender Management System (OMS) for the 2 inmates involved for the 6 months prior to the incident. The structured 45-day casework records for both inmates involved in the incident were not in compliance with policy, despite their importance in the assessment of inmate progress, raising concern with the BOI regarding the required follow-ups done with respect to these, by the managers and management at PCI. The information collected in interviews and consultations revealed that there is a need to review training that currently exists for COs to carry out tasks such as structured casework records. As a result, the BOI recommended that CSC ensure that correctional officers (appointed and acting) are equipped with tools so they can fulfill their obligations in accordance with policy.

Finally, the Board of Investigation raised concerns about information collection and sharing practices following a situation that arose from a call made to the inmate's Next of Kin. Mr. PICKTON’s Next of Kin, who had been documented as such in the OMS since 2011, was notified of the inmate’s death on the same day. However, a few days later, PCI staff discovered that the individual who had initially been contacted regarding the death was not the correct Next of Kin. The BOI was unable to determine whether Mr. PICKTON was aware that his Next of Kin had changed their contact information, as this information was not documented in the OMS, and staff had not been informed of a change. The BOI was also unable to determine whether the erroneous information about the Next of Kin provided by CSC to the hospital had any impact on this case. Currently, the reminder to update this information is found in the 45-day structured casework record, which as previously indicated, has been the subject of non-compliance. Given the risks associated with the collection and sharing of this information, the BOI made a recommendation to address the issue.

The BOI made a total of 3 recommendations aimed at improving operational practices and addressing the Board’s findings, to prevent similar incidents from occurring in the future. CSC has developed action plans to follow up on each recommendation:

1. That Port-Cartier Institution establish an action plan to reduce accessibility to items that are used or transformed for purposes that jeopardize the security of the institution.

   Action plan: A project is underway to secure the doors of the cleaners’ storerooms in unit common rooms to better control access to cleaning supplies. Furthermore, a reminder has been issued for special monitoring on the night shift, of materials in unit common rooms. Finally, there is an inventory of the items in every common room at the Port-Cartier Institution

2. That the Correctional Operations and Programs Sector ensure that correctional officers II are provided with tools so they can fulfill their obligations associated with the evaluation process of assessing inmates’ progress.

   Action plan: The Security Operations Division team, with the support of the Inmate Accountability Working Group, has made changes to the OMS to increase and improve the sharing of information on offenders within the case management team and to strengthen performance indicators by providing the required data. Changes were made to the structured casework records screen in the OMS to integrate policy requirements into the system and to guide COs in writing them. Correctional Officer IIs will also be required to add text in order to save the record. As such, a Security Bulletin has been written and is now available on the Hub. Furthermore, as set out in the Intervention Responsibility Matrix Guidelines, Correctional Managers are responsible for performing quality control on the documents completed by CO-IIs, including 45-day structured casework records

3. That the Policy Sector assess the organizational risk that CSC is exposed to under the current practices of collecting and sharing information to an inmate’s Next of Kin.

   Action plan: The Policy Sector, together with Correctional Operations and Programs Sector, will review current practices with respect to how institutions collect and share information about and with inmates’ Next of Kin to determine their compliance with the requirements set out in the Privacy Act, the Treasury Board Secretariat Directive on Privacy Practices, and in Commissioner’s Directives. Based on the findings of this review, any necessary changes will be made to the applicable Commissioner’s Directives to correct and/or mitigate the risks identified and the changes will be communicated to the affected employees