Case summary: Investigation into the death of Taran Morrison

Official title: Board of Investigation into the Death of an inmate which occurred at Millhaven Institution (maximum) on February 4, 2024

Description of the incident

On February 4, 2024, at approximately 1542 hours in [redacted] at Millhaven Institution, Taran Morrison was observed to be unresponsive in his cell by a Social Programs Officer (SPO). The SPO remained at the cell trying to elicit a response from Mr. Morrison and immediately alerted the Correctional Manager (CM) conducting a range walk. The CM radioed for additional staff members to attend the unit and requested the control post to open the cell door.

On approach to Mr. Morrison in the cell, the CM was still unable to get any response and requested a nurse to attend. With support from the other Correctional Officers who had arrived to assist, the CM laid Mr. Morrison on the floor from the seated position in which he was found, to initiate cardiopulmonary resuscitation. Nursing staff arrived and together with correctional staff, continued emergency life-saving measures until paramedics arrived on site around 1600 hours to take over emergency care.

At approximately 1618 hours, a paramedic announced the declaration of death by a physician from Kingston General Hospital. The Ontario Provincial Police (OPP) and Coroner were both notified of the death in custody.

At the time of the incident, Mr. Morrison was a 41-year-old man serving an aggregate sentence of three years, five months and 27 days for robbery, break and enter, mischief, and carry a concealed weapon. He was sentenced on January 19, 2021. He was [redacted] at Millhaven Institution on [redacted] where he resided until his death.

Incident investigation process

The Correctional Service Canada (CSC) is required by law to investigate incidents where an inmate under their care and custody dies or suffers serious bodily injury. On March 6, 2024, CSC convened a Board of Investigation (BOI) comprised of three members, that included a National Investigator (NI) and Psychologist with extensive experience in mental health as Chairperson, a CM, from Port-Cartier Institution, Québec Region, and an experienced community member as BOI members. An Independent Observer (IO), with extensive work experience within provincial corrections and municipal government in key areas of human resources, labour relations, and administration, was also appointed to ensure thoroughness, impartiality, and integrity of the investigation process; the IO has submitted their report for publication by the CSC. The investigation was found to be consistent with the parameters set out in the Convening Order and that the findings and recommendations were supported by the evidence reviewed by the BOI. Further, the IO concluded that there was not prejudice or bias in the findings; were guided solely based on evidence and ensured a thorough investigation.

During the investigation, the BOI interviewed 12 staff members from Millhaven Institution and consulted with internal CSC stakeholders. Policy instruments were reviewed, in addition to all relevant file information specific to the operational unit, the incident, and the inmate involved. Both the audio and closed circuit television recordings were also analyzed. Further, pictures and a video recording of the operational unit and location of the incident were examined.

The BOI considered the following areas of investigation:

• The existence of pre-incident indicators, precipitating events or contributing factors to the incident
• The security classification of the inmate involved in the incident [redacted] at Millhaven Institution
• The care, treatment, and monitoring of the inmate prior to the incident
• The staff presence in the area where the incident occurred, including the monitoring of inmate activities; and
• The staff response to the incident, including but not limited to, the interventions and medical care provided to the inmate following the incident.

Investigation results

Key findings

The BOI identified key findings in the following areas: health/mental health assessment and classification, consultation with the case management team for input into the transfer decision, and documentation of the engagement of the inmate in the first-day health assessment in the [redacted].

The BOI noted a potential pre-incident indicator as per evidence retrieved by the OPP, which staff were not aware of until after the incident. No precipitating events were identified. Contributing risk factors identified by the BOI were documented in the inmate file and staff were aware of the areas of vulnerability prior to the incident. The BOI noted that there was an omission in the completion of assessment and the activation of an alert in the Offender Management System (OMS) because some Health Services employees did not have access to the system. The BOI made a recommendation to address this gap in policy.

[redacted] to appropriately manage the level of risk and needs, were completed in accordance with policy and within required timeframes. The BOI noted that the case management team was not consulted to explore other potential alternatives prior to his [redacted] at Millhaven Institution on [redacted].

Regarding the care and monitoring of Mr. Morrison, the BOI noted that following the [redacted] the steps to further engage Mr. Morrison in these assessments were not documented on the relevant forms.

The BOI noted issues relating to security patrols and stand-to counts in the week prior to the incident that included quality, timing, and predictability, Security patrols were noted to be of insufficient quality to confirm the presence of a live, breathing body, late, not staggered to avoid predictability. For Stand-to counts, inmates were not being asked by staff to stand. A recommendation from several previous BOIs to ensure an efficient quality control mechanism to monitor the quality of security patrols has been addressed through revisions to policy, which was promulgated in March 2025.

Upon discovery of the incident, staff intervened quickly and provided the appropriate medical care in every effort to preserve life, and in accordance with policy.

Recommendations and action plans

The BOI made a recommendation aimed at addressing the Board’s identification of a gap in policy, to improve operational practices, and prevent similar occurrences in the future. Correctional Service Canada has developed an action plan to address the following recommendation:

1. That the Assistant Commissioner, Health Services provide directions on the procedure to follow when relevant health-related Alerts/Flags/Needs should be activated in OMS by health care professionals who do not possess an OMS account.

Action plan for recommendation 1

Health Services will reinforce in relevant policies that health-related Alerts/Flags/Needs must be activated by a health care professional in the OMS. Direction will be provided that all Managers of Health Care Rehabilitation Programs and Services, Chiefs of Health Services, and Chiefs of Mental Health must have an active OMS account. Health Care professionals without an OMS account will alert the above when an Alert/Flag/Need needs to be activated in the OMS. Each site will also be required to have a documented process in place regarding the roles and responsibilities regarding the activation of relevant health related Alerts/Flags/Needs in the OMS.