ARCHIVED - ANNUAL REPORT OF THE OFFICE OF THE CORRECTIONAL INVESTIGATOR 2008-2009

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June 29, 2009


The Honourable Peter Van Loan
Minister of Public Safety
House of Commons
Ottawa, Ontario

Dear Minister,
In accordance with section 192 of the Corrections and Conditional Release Act, it is my privilege and duty to submit to you the 36th Annual Report of the
Correctional Investigator.

Yours respectfully,

 

Howard Sapers
Correctional Investigator


Table of Contents


Correctional Investigator's Message

Review of Areas of Key Concern

  1. Mental Health
  2. Addressing Incidents of Self-harm
  3. Health Services Review
  4. Correctional Programs and Case Preparation
  5. Deaths in Custody
  6. Aboriginal Offenders
  7. Federally Sentenced Women
  8. Gaps in Dynamic Security
  9. Segregation By Any Other Name

Correctional Investigator's Outlook for 2009/10

Annex A: Statistics

Annex B: Summary of Recommendations

Response of the Correctional Service of Canada

 

Correctional Investigator's Message

At the core of nearly every individual complaint there is usually a more general or systemic issue relating to the interpretation or application of correctional law and policy.

The frequent reader of my Office's Annual Reports will notice an addition to our 2008/09 report: the incorporation of individual case summaries. Drawn from more than 6,000 offender complaints submitted to our Office this past year, the cases illustrate the connection between an individual complaint and systemic areas of concern. They also highlight my primary mandate, which is to objectively and fairly address offender complaints in a timely fashion. At the core of nearly every individual complaint there is usually a more general or systemic issue relating to the interpretation or application of correctional law and policy. My Office's review and investigations go to the fairness of those decisions.

 

This year's Annual Report, my sixth, reviews nine areas of key concern. Those readers who followed the public release of our report into the tragic death of Ashley Smith (A Preventable Death) will not be surprised to find that this year's report leads off with a review of mental health concerns, closely followed by related sections on self-injury and self-harm in prisons, and commentary on the Correctional Service of Canada's (CSC's) essential health services review exercise. My decision to present and organize my report this way was deliberate, as I have come to the conclusion that mental health care delivery and related services and supports in federal corrections are perhaps the most serious and pressing issues facing the Service today.

The volume of all health care-related complaints to this Office, both this year and in previous years, confirms the importance of this issue. Federal correctional mental health care services are under extreme duress—there are deficiencies in terms of capacity, quality, standards and responsiveness of care. Criminalizing and then warehousing the mentally ill burdens our justice system and does nothing to improve public safety. The demands in this area of corrections are increasing dramatically; the unmet needs are immediate and troubling.

Leading off with my concerns about mental health does not mean that other areas of corrections are less deserving of public scrutiny and attention. In fact, this year's report once more illuminates the spectrum of issues facing Aboriginal and women offenders under federal sentence. And, once again, I point to the need for more direct and visible leadership and accountability in these two areas. In my view, it is not enough to simply aspire to reduce the gap in correctional outcomes between Aboriginal and non-Aboriginal offenders—we must, in fact, work toward innovative solutions and practices that will meaningfully address and, in the longer term, reverse the failure that Aboriginal overrepresentation in our correctional facilities represents. Similarly, for federally sentenced women, whose annual population growth has been a constant in recent years, it is disconcerting that there has not been more forward movement. As I make clear, the so-called Management Protocol for women offenders is anything but progressive or effective corrections. In fact, it is a step in the wrong direction.

As an Ombudsman, my mandate is to investigate the problems of offenders related to decisions, recommendations, acts or omissions of the Correctional Service that are contrary to law or policy, or that otherwise negatively affect offenders, either individually or as a group. By necessity, the work of my Office involves documenting errors, deficiencies and failures, and recommending corrective actions. The Service generally only hears from my Office when there is a problem or we identify an issue that demands to be fixed.

Indeed, in my work, there is not usually much opportunity to give praise for a job well done, recognition for a life saved, or commendation for going above and beyond the call of duty. In fact, there are any number of national initiatives deserving of recognition, including, for example, the Report of the Policy Review Task Force (2008), which recommends strengthening the Service's policy capacity and governance structure. I am also encouraged by the Service's initial response to my Office's recent work addressing preventable deaths in custody and its commitment to detailed follow-up.

I personally have tremendous and enduring respect for the men and women who work on the front lines of our federal correctional system. Exercising humanity, compassion and restraint in assisting the most vulnerable, isolated and deprived members of our society is not only a job; it is also a vocation. The nature of correctional work is that it is carried out in difficult, stressful and challenging circumstances. By and large, the commitment and dedication to public safety, public service and the changing of lives is praiseworthy. Along with other Canadians, I want to extend my Office's best wishes to CSC as we celebrate the 30th anniversary of its creation.

Given my oversight role and mandate, I accept there will be some degree of "creative" tension and constructive debate between my Office and CSC. That is a normal and healthy state of affairs inherent in any ombudsman arrangement and function. For the most part, the relationship between our two organizations is conducted with respect, courtesy and professionalism. We may agree to disagree on some challenging issues in corrections, but at the end of the day we share the same commitment to public safety, to the principles of fair and humane treatment of offenders, and to the safe return of offenders to the community as law-abiding citizens.

The number and frequency of staff visits to federal institutions across the country is down this year. Credibility, legitimacy and access are core elements of the Ombudsman function. While services provided by my Office were used less often than in previous years, I note that that is primarily the result of decreased presence within institutions. There was simply too much demand being placed upon too few people, who were called upon to manage multiple competing priorities. Some of these priorities, as explained below, kept investigative staff away from institutions and focused instead on a few complex and demanding reviews.

Two very thorough and detailed investigations were particularly resource intensive this past year. We publicly released our findings and recommendations in reports on two disturbing death-in-custody cases— A Failure to Respond (May 2008) and A Preventable Death (March 2009)—because there was a compelling public interest reason to do so. Both deaths were preventable, and both were the product of systemic and individual failures. To conduct these investigations and detailed follow-up required a redistribution of workload and a reorganization of priorities within our Office.

On a personal note, I was very pleased to have received news of my reappointment, effective April 1, 2009, to a three-year term as Correctional Investigator. A renewal of mandate is always a good time to take stock, make new commitments and move forward. It is therefore with renewed conviction, energy and optimism that I present my 2008/09 Annual Report.

Howard Sapers
Correctional Investigator of Canada

 

Review of Areas of Key Concern

Mental Health

The case of Ashley Smith is not unique ... She suffered from a mental illness, and the truth is that a complex web of disjointed services, antiquated policies, squandered opportunities and crippling stigma presentedan impermeable barrier to her recovery ... Both youth and adult institutions were incapable of recognizing Smith's mental health problems for what they were and repeatedly punished her rather than offering a helping hand. She was confined to segregation cells, slapped with additional criminal charges, assaulted, marginalized and transferred 11 times in less than a year. She never received comprehensive treatment for the mental health problems that wereburied beneath her disruptive behaviours.

Press Release, Provincial Centre of Excellence for Child and Youth Mental Health at the Children's Hospital of Eastern Ontario, March 3, 2009.

In an appearance before the Standing Committee on Public Safety and National Security on April 2, 2009, the Minister of Public Safety made some significant remarks on the issue of mentally ill offenders and whether prisons are the most appropriate place to treat their needs. The Minister noted that over the past three decades, we have progressively moved toward a community and outpatient system of "de-institutionalizing" the mentally ill from provincial facilities, only to discover that we are "re-institutionalizing" them as prisoners. The Minister stated the problem succinctly by suggesting that we are, in effect, "criminalizing the mentally ill." His remarks make it clear that addressing the problem will be a major challenge requiring far-reaching reforms of the health care, criminal justice and correctional systems.

The plight of offenders with mental disorders in prisons has become a major focus and priority of my Office. We know that the prevalence of offenders with significant mental health issues upon admission has doubled in the past five years. At admission, 11% of federal offenders have a significant mental health diagnosis and over 20% are taking a prescribed medication for a psychiatric condition; just over 6% were receiving outpatient services prior to admission. Female offenders are twice as likely as male offenders to have a mental health diagnosis at admission—over 30% of female offenders had previously been hospitalized for psychiatric reasons. [1] A recent file review of health records in the Ontario region suggests that 39% of inmates in that region have been diagnosed with a mental illness, have a current medication order in effect, or are receiving ongoing psychiatric evaluation or psychological intervention. Preliminary results for a newly implemented mental health screening system suggest one in four offenders has some degree of mental illness at admission.

While the precise numbers and definitions might be in some dispute, it is increasingly clear that we are confronted with a very sizeable, vulnerable and distressed population. Federal prisons are housing the largest psychiatric populations in the country. Yet, despite the need, the capacity of the federal correctional system to respond to and treat mental illness is largely reserved for the most acute or seriously chronic cases—those receiving psychiatric treatment in one of the five Regional Treatment Centres (RTCs). Most other mental health problems are either untreated or receive limited clinical attention. Even in the wider community, mental illness is often difficult to detect and treat. This problem is compounded in the prison setting.

 

We also know that most offenders with mental health issues do not progress well in conventional correctional programs and settings for a variety of reasons, including cognitive delays or impairments, yet most of these offenders do not currently have an integrated clinical treatment and management plan. Continuity and quality of mental health care are also major problems, especially considering that there are insufficient resources for necessary mental health services in most federal institutions across the country, whether at maximum, medium or minimum security levels.

Enhancing the capacity of the Correctional Service to address mental health needs of offenders is a key corporate priority. My Office endorsed the launch of CSC's Mental Health Strategy in 2004, as well as the accompanying Community Mental Health (2005) and Institutional Mental Health (2007) initiatives. We acknowledge and welcome the new resources committed to enhancing primary care capacity in regular institutions through these and other initiatives. We have, moreover, called for and supported an interdisciplinary approach to treating mentally ill offenders, an approach that integrates various elements and disciplines (psychologists, psychiatrists, social workers, nurses, behavioural counsellors) with case management and security. These are vital components in better addressing the mental health needs of federal offenders.

More recently, there has been positive movement in the following areas: implementation of a new mental health training package for front-line staff; rollout of a mental health screening system at intake; and discharge/reintegration planning. All of that said, I continue to be disappointed by the very slow pace of change and by the lack of real, demonstrable improvements in the delivery and quality of care and services available to offenders with mental disorders. As I have noted before, the problem is not one of poor intentions, but rather capacity of the system to respond, adapt and adjust. The overall situation of offenders with mental health disorders has not significantly improved since my Office first reported on this troubling situation back in 2004.

I would suggest that this is, in part, a problem of priority and focus. For example, except for the psychologists involved in the Institutional Mental Health Initiative, a typical psychologist within CSC spends most of his or her day conducting risk assessments—such as conditional release reviews, segregation reviews and security reclassifications— rather than treating or determining the extent of an offender's mental health needs. The prioritization of risk in managing challenging behaviours associated with mental health problems typically gives rise to responses that are focused on security and control rather than on treatment and intervention. Unfortunately, a distinct division has been drawn between risk, security and vulnerability assessments, and clinical treatment and intervention practices. Offenders requiring the latter are often caught in the middle or neglected altogether.

Case Summary: The mental health of a maximum security inmate placed on high suicide watch two days earlier deteriorated rapidly, culminating in acts of self-harm and a suicide attempt. An Institutional Emergency Response Team physically extracted him from his dissociation (segregation) cell, placed him in six-point restraints and transferred him, on an emergency basis, to the Regional Treatment Centre (RTC). Less than 24 hours later, while still in physical restraints, the inmate was discharged from the RTC and placed back in the same dissociation cell with no clinical management plan in place. My Office continues its investigation of this case.

Recommendation #1

The Service should bolster its recruitment and hiring of clinical mental health professionals, giving priority to existing vacancies in underserviced institutions, and should establish permanent recruiting and training budgets for these professionals.

Although offenders with acute needs, or those requiring specialized intervention, may be sent to a Regional Treatment Centre (RTC), they are typically returned to the referring institution after a short period of "stabilization." Overwhelmed by volume, the RTCs have become revolving doors of referrals, admissions and discharges. Almost no intermediate mental health care services are currently available to bridge the transition between the therapeutic and clinical interventions offered at the RTCs and the return to regular institutional routines. Except for two proposed regional pilots, there are no halfway measures or services for offenders attempting to return to regular prison life. Segregation too often becomes the default option.

The vast majority of offenders with mental disorders do not generally meet the acute criteria that would allow them to benefit from services provided in the RTCs; less than 10% of offenders are ever admitted to or treated in the therapeutic environment of the RTCs. Instead, offenders stay in the general institutional population, where psychological resources are strained. If they are assessed at all, their issues are often portrayed as a behavioural problem, not a mental health disorder per se. Within corrections, mental health issues need to be viewed as needs in their own right, distinct and separate from other security, risk and control concerns.

 

An overall lack of accessible mental health services means offenders with an identified need for these services remain in settings ill-prepared to respond to their symptoms and behaviours. In far too many cases, their mental health problems deteriorate to the point where they result in violations of institutional rules, altercations with staff and other offenders, and, often, self-harm. In too many instances, these offenders are placed in segregation or protective custody for their personal safety. Too many complaints to this Office dealing with segregation placements, transfers to higher security and use of force interventions can be traced to behaviours rooted in unmet mental health needs.

Recommendation #2

Consistent with CSC's approved mental health strategy, the Service should immediately implement intermediate mental health care units in each region.

During the past year, the Service has piloted a Mobile Interdisciplinary Treatment Assessment and Consultation Team (MTAC). A deployable unit consisting of national headquarters staff, resourced by the Health Services sector, MTAC was initially developed to support regional women's facilities upon request by a warden. A central feature of MTAC is the clinical management plan (CMP), described in an internal working paper as a "portable document developed by and for the institutional case management team" that "pulls together case management, security and clinical interventions."[2]

While the initiative is still in the pilot and development stages, it is encouraging that the Service understands the need to start integrating a range of clinical, security and case management interventions to better manage offenders with mental health needs. (That was, after all, a central component of the 2002 proposed Mental Health Strategy for Women Offenders.) The challenge in moving toward national implementation will be to ensure institutions have adequate resources and capacity to provide the level of continuity and comprehensiveness of care that CMPs require. Without institutional capacity, MTAC will amount to nothing more than a short-term "band-aid" for a very pressing and challenging issue.

Recommendation #3

Clinical management plans to treat offenders with mental disorders should be developed and implemented on a priority basis and should be managed by interdisciplinary teams of mental health, security and case management personnel working together.

As documented extensively in our investigation of the death of Ashley Smith, I am increasingly concerned about the persistent and pervasive use of segregation to manage mentally ill offenders in federal penitentiaries. In the correctional environment, offenders with mental disorders do not always comprehend, conform to or adjust properly to the rules of institutional life. They often suffer from personality disorders, illogical thinking, cognitive impairments, delusions, paranoia, or severe mood or emotional swings. Irrational, impulsive and compulsive behaviours associated with their disorders can result in verbal or physical confrontations with staff or other inmates, which often lead to institutional charges and long periods in administrative or disciplinary segregation.

It is the view of my Office that prolonged periods of deprivation of human contact adversely affect mental health and are counterproductive to rehabilitation. Far from treating mental illness, the conditions of deprivation in most segregation units and dissociation cells too often exacerbate the "acting out" or challenging behaviours they are supposed to manage. After investigating, my Office often discovers that inmates are placed in such units and cells due to disruptive behaviour arising from a prevailing mental health condition. It is a classic catch-22 scenario.

The practice of confining offenders with mental disorders to prolonged periods of isolation and deprivation must end. It is not safe, nor is it humane. In light of the fact that segregation is not conducive to treating mental illness, I recommended three key actions in my report, A Preventable Death:

  • regional managers, including health care managers, should review all long-term segregation placements after 60 days of segregation;
  • psychological review of an inmate's current mental health status, with a special emphasis on the evaluation of the risk of self-harm, should be completed within 24 hours of an inmate's placement in segregation; and
  • segregation placements of inmates with mental health concerns should be independently adjudicated.

The Service has responded by introducing a National Population Management Committee to provide national monitoring of the use of administrative segregation. It has also committed to piloting an independent review of long-term segregation cases in the upcoming year. To ensure public accountability and credibility, I recommend the following.

Recommendation #4

The Service should conduct an independent review of long-term segregation cases on an expeditious basis, and submit the review process to an external validation and evaluation exercise.

 

Addressing Incidents of Self-harm

Case Summaries:

1 // The instigator attempted suicide by hanging in his segregation cell.

2 // The instigator advised staff that he had ingested all of his medication.

3 // The instigator inflicted injuries to his arm with a piece of glass, refusing verbal orders to stop. Staff used physical handling to prevent further self-injury. The instigator was placed in the Pinel restraint system and assessed by health care workers.

Source: CSC's daily internal situation reporting system (SITREP).

The issue of self-injurious behaviour, especially repeated or chronic self-harm, is a matter of ongoing concern and priority for my Office. It requires the sustained focus of the Service. In the past year, I was alarmed by the number and frequency of self-harm incidents, especially chronic cases, appearing in the Service's internal situation reporting (SITREP) system. There is reason for concern. A recent CSC study suggests that the rate of reported self-harm incidents has increased gradually but substantially. In the six-month period between April and September 2008, there were 184 self-harm incidents reported in SITREP, more than double the number recorded over the same period in 2006.[3]

In my 2006/07 Annual Report, I recommended that the Correctional Service establish a framework for systematically reporting and reviewing the circumstances of attempted suicides, self-inflicted injuries and overdoses. My purpose in making this recommendation was two-fold: to encourage the Service to take corrective actions to prevent the recurrence of self-harm incidents, and to ensure difficult cases are appropriately assessed and subject to effective treatment and management plans.

The Service is conducting research to better understand and assess the extent of the problem. This work will build on a recent internal study of reported self-harm incidents in order to establish baseline data, clarify the dynamics and reasons behind self-harming, and develop a profile of individuals who engage in such acts, including an inventory of clinical intervention strategies. As the internal study mentioned earlier suggests, most acts of self-mutilation are not intended to end life. In fact, most offenders who self-harm are very open about their acts. It follows that front-line staff need to be diligent and vigilant—for example, they should exercise the principles of dynamic security. They must also learn to recognize the early indicators of self-harming and respond appropriately.

It is my view that the issue of self-harming in prisons needs to be understood and treated first and foremost as a mental health issue, and not predominantly or exclusively as a security or behavioural problem (for instance, it should not be labelled as "acting out" or "attention-seeking" behaviour). In too many instances, self-harm incidents result in a use of force that is at times disproportionate to the risk presented, inconsistent with the "least restrictive" principle or inappropriate from a clinical perspective. In some instances, the use of force actually escalates an already difficult and distressing medical or mental health emergency.

Over the past year, my Office has corresponded several times with senior managers at National Headquarters (NHQ) to recommend their active involvement and direction in ensuring that appropriate clinical management and intervention plans are in place for offenders who are repeat self-harmers. The Service has responded to my repeated inquiries by stating that NHQ's role in cases of self-injury is limited to offering "assistance and support" upon request by the warden or regional authorities who have direct line authority over inmates. At the same time, on the front lines, psychiatrists and psychologists inform our Office that despite NHQ's efforts to define the components of a clinical management plan (CMP), the field does not yet fully understand what exactly a CMP should be and who is responsible for creating it.

If local resources are insufficient and critical elements of a strategy to manage incidents of chronic self-harm are not in place, then it makes very little material difference whether or not regional authorities ask NHQ for assistance or support. Even when the advice is both sought and received, the capacity to act on the advice is lacking.

It is, in fact, the position of my Office that cases involving repeated incidents of self-injurious behaviour should be referred to the Assistant Commissioner of Health Services at NHQ, as well as the Deputy Commissioner for Women in cases of women offenders. In turn, NHQ's responsibility and accountability would be to ensure that CMPs are in place at the institutional level and that regional and national teams regularly monitor case management progress. As much as I support the need for more research to better understand the dynamics, characteristics and needs of this growing population, it is important for the Service to move forward in building a cohesive national strategy that incorporates front-end research and analysis in conjunction with appropriate clinical treatment and staff intervention measures, prevention strategies, and oversight by NHQ.

It is in that regard that I make the following set of recommendations.

Recommendation #5

A national strategy for managing chronic self-harming behaviours and incidents should be developed and shared with my office. The protocol should include clear national, regional, and institutional authorities and accountabilities to ensure ongoing management and monitoring of these cases occurs, as well as staff training requirements regarding the early recognition of self-harming behaviour.

Recommendation #6

Clinical management plans—which would include prevention, intervention and treatment measures—should be put in place to manage offenders who chronically self-harm.

Recommendation #7

As a matter of priority, an inventory of "best practices" in the treatment and prevention of self-harm should be developed and distributed widely throughout the Service.

Recommendation #8

Specialized and dedicated units should be immediately created in each region, as required, to manage chronically self-harming offenders.

 

Health Services Review

Case Summary:

A 47-year-old male suffering from complications related to cardiovascular disease died in a maximum security penitentiary. While the exact cause of death remains unknown, CSC's own board of investigation identified numerous deficiencies pertaining to the quality and standards of care he received prior to his death. For example, six weeks prior to his death, the attending institutional physician requested that the inmate's blood work and blood pressure be verified twice a week. This work was never completed. On the night of his death, the inmate was found lying unresponsive on his cell floor during a security round. Policy clearly states that when a medical emergency occurs, staff members should immediately request assistance and begin cardiopulmonary resuscitation, but that did not occur. Our Office continues to investigate the immediate events and contributing circumstances surrounding this death.

Despite an annual health services funding envelope in excess of $180 million,[4]the Service meets the health needs of inmates in a highly variable way, depending on prevailing local or site-specific conditions. While individual health professionals may provide high-quality care, that is often more reflective of local health networks than CSC policy. Several factors add to the number of health services-related complaints that my Office handles annually, including a lack of consistency in clinical standards of practice from one institution to another; recent changes to the way essential health services are defined and provided, including what is covered and why; and the lack of direct line authority over the attending physicians, nurses, dentists and psychologists under contract or employed by CSC. Another factor is that while CSC is a federal entity, it employs and contracts with health professionals subject to provincial and territorial licensing and practice guidelines. This situation can lead to inconsistent treatment, role conflicts, and professional and inmate frustration. CSC has engaged Accreditation Canada in an effort to provide more consistency in health services from one site to the other, and to ensure the delivery of health services in accordance with professionally accepted standards. It bears noting, however, that the accreditation process was initiated almost a decade ago.

According to internal CSC data, federal offenders submitted 2,289 health services complaints and grievances in fiscal 2007/08. A total of 361, or approximately 16%, of all submitted complaints and grievances were completely upheld or partially upheld. Of those, the most frequently grieved categories included the following:

  • medication and prescriptions (28%);
  • staff competency (18%);
  • wait times (17%);
  • delays in treatment and diagnosis (13%); and
  • communication (7%).

I can confirm these statistics insofar as health care remains the single most frequent area of offender complaint to my Office each year. Where there is some discrepancy between the figures cited by CSC [5] and our own interventions, it is in the area of access to health care.

It is not surprising that concerns about health care elicit a strong reaction from the offender population. Physical health is one of the few areas in which offenders exercise some degree of control and autonomy—they still "own" their health, despite incarceration. However, inmates have very little practical choice over who attends to their needs, how the care is administered or what is defined as essential. Unlike most of us when we need medical care, inmates in federal institutions are offenders first and patients second. They must simply take what they can get, when they can get it.

Case Summary:

An inmate contacted the Office claiming that his prescribed treatment was no longer covered under the new Drug Formulary rules. Being an elderly offender who was no longer able to perform prison work, the inmate claimed that the change made it impossible for him to purchase the topical ointment from his own funds and his daily allowance of $2.50. He was informed that the institutional physician could make an "exceptional" service request for relief to be approved by the Regional Manager of Clinical Services. The request was completed by the attending physician but was denied at the regional level. A review at the national level is "pending."

Recent changes to CSC's Drug Formulary have not yet resulted in many complaints involving lack of services per se. Instead, complaints have surfaced regarding cancellation of or changes to medications or a prescribed method of treatment. As indicated above, institutional life is predicated on rules and routines. Changing the rules in such an environment is never an easy thing, particularly for aging and elderly offenders. In that light, the Service may want to consider increased consultation with inmates, to better communicate the implications of and rationale for changes to formerly prescribed treatments, diagnostics and services. In particular, offenders should be informed of the "exception" provisions under the new Essential Health Care Services Framework,[6] and tight timeframes for this process should be established and respected.

For the most part, the health services review exercise has been conducted in house. While a National Advisory Committee on Essential Health Services has been established, it appears that there is little external professional representation on this committee. The first phase of the review has focused on identifying and approving a list of services, equipment and supplies (including the Drug Formulary) to be covered under the framework. We question the relative weighting of the criteria that have thus far been developed and used—such as cost, safety and efficacy—to assess which services or treatments are essential and why. In its next phase, the review is scheduled to shift its focus to other essential areas, including mental health, public health, dentistry and diagnostics.

 

The Service is reminded of its legal requirement to provide offenders with essential health care that conforms to professionally accepted standards of practice. A system of centrally managed health care must strive for national consistency while still being responsive and flexible enough to meet individual and local health care needs. Fundamentally, the future and quality of correctional health services will be decided on questions of governance, credibility and accountability - who decides what is essential, for whom, by what standards, on whose professional judgement and authority? Like all governance questions, these are extremely vital issues, and they go to the very core of the ongoing health services review. Just as our national public health system is the subject of intense debate and scrutiny, I suggest that it is time to bring matters of health care governance within the Service out in the open. The questions are too big and the stakes too high to think that all the answers can come from within the correctional community.

Recommendation #9

The national essential health services framework should be submitted to a peer review process conducted by an external, independent and expert panel that is empowered to report annually and publicly over the next three years on the Service's implementation of the framework.

 

Correctional Programs and Case Preparation

Case Summary:

An inmate in medium security complained that his correctional plan required him to complete a certain program in order to be considered for conditional release. Staff advised him that the institution was not intending to run his required program due to a lack of referrals, as well as low program staffing levels. On the guidance of this Office, the inmate applied for a transfer to another institution where the program was being offered. He was advised that his request for a voluntary transfer was "pending" due to a lack of bed space at the receiving institution. The inmate missed his day parole eligibility date as he awaited transfer.

The law requires CSC to provide programs and interventions that address factors related to an offender's risk of re-offending. From a series of evaluation reports, we know that correctional programs contribute to public safety and represent good value for money. Offenders who complete their programs are significantly more likely to be granted a discretionary release and are less likely to re-offend following their release. In terms of value, internal CSC evaluation documentation suggests that the vast majority of correctional programs evaluated were cost effective as, on average, every dollar spent on programming resulted in a return of one to eight dollars (due to earlier community releases or extended stays in the community).

Of major concern is the fact that CSC allocates only 2% of its total annual budget to offender programming. Currently, the Service spends $37 million annually on all its core correctional programs, including those for women and Aboriginal people. The program funding envelope, which has remained stable over the last decade, includes training, quality control, management and administrative costs. This Office does not think 2% of an approximately $2.2 billion annual budget is the right balance. (We note that annual expenditures on overtime are approximately double the funding allocation for core correctional programs). We are encouraged by the fact that the Service plans to make significant program reinvestments as part of its $48.8-million Strategic Review reallocations. We look forward to seeing more programs being provided to more offenders earlier in their sentences as the new funding is rolled out.

 

Over the past year, my Office has intervened in a number of program bottleneck issues. These bottlenecks often result in parole waivers, adjournments and postponements, because inmates cannot complete required programs. In many respects, programming is the key to safe reintegration, but its availability is too often reduced by a series of factors within the control of the correctional authority, including the following:

  • long wait lists for correctional programs;
  • overdue security reclassifications resulting in offenders being accommodated at higher than necessary security levels;
  • outstanding voluntary transfer requests;
  • an insufficient number of trained program workers;
  • "pending" applications for access to community supports, such as private family visits, temporary absences and work releases; and
  • overdue casework reports and records.

Other bottlenecks in the system also affect program availability, access to programs and case preparation. For instance, most maximum security institutions are operating at or above their rated capacity. At the same time, minimum security facilities are generally operating below capacity. Consequently, more offenders are being released directly from medium security institutions, often without the benefit of a series of discretionary releases behind them. Given that minimum security institutions are running below capacity, it is not surprising to find that temporary absences, work releases and day parole grant rates are now at their lowest level of this decade. Offenders released on statutory release now account for over 53% of all releases.[7]

By its own assessment, the Service recognizes that it needs to augment program capacity in a number of areas. These areas include programs and interventions for offenders with education and learning deficits, for those with mental health needs, and for those serving short sentences in higher security facilities.[8] The Service has responded by providing some programming during the intake assessment process, which helps offenders serving short sentences complete their correctional programming before they are released or transferred to their placement institutions. Although that is a good endeavour, it is worth noting that close to 80% of offenders have not completed high school. That has implications for program involvement and success, as a functional Grade 8 literacy level is a minimum requirement for participation in most programs.[9]

Access to and availability of programs for offenders serving shorter sentences (under four years) in maximum security institutions is particularly problematic. As it is, programming is severely limited at most maximum security institutions. Lockdowns, searches, and limits on movement and association place additional practical restrictions on programming in these facilities. Moreover, excessive and unreasonably long delays are occurring in reclassifying maximum security offenders serving life and indeterminate sentences down to lower security levels, because there are not enough resources to conduct the psychological assessments required under CSC policy.

Program uptake and completion rates are also increasingly determined by sentence length. It bears noting that sentences under three years remain the most common federal sentence length. Over the last decade, sentences shorter than three years have actually grown from 35% of all warrant of committal admissions to 55%. The trend toward shorter sentences means there is very limited time to prepare offenders for their parole eligibility dates. In too many cases, programs are not offered until an offender is close to his or her statutory release date. In these cases, the Service is not preparing offenders for timely and safe reintegration.

It is interesting to note that preliminary findings of a joint CSC-National Parole Board (NPB) research study indicate that approximately 25% of all offenders never appear before the NPB to be considered for conditional release. Offenders typically decide to waive or postpone parole hearings because they have not completed their programs. Another common reason is the belief that their parole officers will not recommend them for early release. Significantly, close to 40% of offenders self-report a limited understanding of the parole review process; their main source of information about the process is other inmates, not CSC or NPB.

The previously referenced program evaluation report found that short sentence length or lack of time to complete programs, lack of available programs, timing of program delivery at the institution and long wait lists are some of the main reasons behind low program participation rates.[10] While there may be some discrepancy between staff members' and offenders' perceptions of program availability and program participation, there is clearly room for improvement in better preparing offenders for their eventual safe and timely return to the community. Offender programming is a key component of the Service's mandate to ensure every reasonable effort is made to prepare offenders to live a law-abiding life upon their reintegration to the community.

Recommendation #10

With respect to correctional programming, i recommend that in the coming year, the correctional service make significant progress in addressing the following areas, consistent with the least restrictive principle and effective corrections:

  • reduce program wait lists;
  • increase use of temporary absences and work releases as means to promote and improve an offender's likelihood of being positively prepared and recommended for parole;
  • increase access to programs and programming opportunities in maximum security institutions;
  • increase program interventions and improve outcomes for special needs offenders, including older offenders, offenders with learning delays or disabilities, and offenders with mental health problems; and
  • improve inmate communication and understanding of the parole review process.

Recommendation #11

The Service should review the rationale, criteria and average waiting time for psychological assessments required for security reclassifications of offenders serving life and indeterminate sentences.

 

Deaths in Custody

Case Summary:

This death can only be described as tragic. The inmate was a First Nations federal offender in the care and custody of the Correctional Service of Canada. While in his cell, he self-inflicted a life-threatening wound to his left arm and, subsequently, called for help by pressing his cell emergency button. Help came but fell short of what must be expected... Employees responding to the medical emergency failed to administer first aid, failed to determine the nature and extent of the wound, failed to remain with the subject for most of the 30 minutes prior to the arrival of the ambulance attendants, failed to respond in a manner that might have preserved life, and, subsequently, inconsistently reported critical information related to the death.

A Failure to Respond, May 2008, Office of the Correctional Investigator

In 2008/09, my Office continued its review of and focus on deaths in custody. Following the earlier release of our Deaths in Custody Study (February 2007), in May 2008 my Office released A Failure to Respond, a report on the death of a federal Aboriginal offender. This report concluded that "the concerns related to the failures by staff to respond to a medical emergency in this case are strikingly consistent with the concerns that have been raised in the past with the Correctional Service by its own National Board of Investigations, Provincial Coroners and the OCI, including the Deaths in Custody Study."

In March 2009, I publicly released our report into the death of Ashley Smith, a young woman from New Brunswick who spent five years in the youth justice system before being transferred to the care and custody of CSC in October 2006, at age 18. My report was originally submitted to the Minister of Public Safety and the Commissioner of Corrections on June 24, 2008. It contains 16 recommendations focused on preventing deaths in custody and identifies systemic compliance issues related to segregation, transfers, processing of offender grievances and use of force interventions.

The release of these reports attracted significant media scrutiny and public commentary, including a number of ministerial and parliamentary interventions. The important point is that these deaths were not isolated occurrences. Our investigations reveal that some deaths in custody could be averted through improved risk assessments, more vigorous preventive measures, and more competent and timely responses by attending institutional staff.

Case Summary:

On October 19, 2007, at the age of 19, Ashley Smith was pronounced dead in a Kitchener, Ontario, hospital. She had been an inmate at the Grand Valley Institution for Women (GVI), where she had been kept in a segregation cell, at times with no clothing other than a smock, no shoes, no mattress and no blanket. During the last weeks of her life, she often slept on the floor of her segregation cell, from which the tiles had been removed. In the hours just prior to her death, she spoke to a primary worker of her strong desire to end her life. She then wrapped a ligature tightly around her neck, cutting off her air flow. Correctional staff failed to respond immediately to this medical emergency, and this failure cost Ms. Smith her life.

A Preventable Death, June 2008, Office of the Correctional Investigator

It is indeed troubling to note that my Office continues to review and investigate deaths in custody where the initial staff response was neither appropriate nor timely. As our reports recommend, intervention should be immediate and decisive whenever life is at risk. The Service continues to have serious compliance issues with respect to responding to situations of medical distress. It bears noting that coverage, delivery, quality and availability of professional health care services in federal institutions, especially during the critical hours between 11:00 p.m. and 7:00 a.m., is inconsistent across regions, as well as among facilities of different security classifications.

The Service has committed to a number of corrective measures to improve its response and capacity to prevent deaths in custody. I am encouraged by the fact that the Service has agreed to publicize, on its website, its commitments and undertakings regarding recommendations from my Office's Deaths in Custody Study and A Preventable Death. That is an important and necessary public accountability measure that my Office strongly endorses. I very much look forward to reviewing the Service's implementation progress over the coming year. I will be looking for signs of improvement in, among other things, staff training, use of segregation, timeliness of assessments, dynamic security and the use of clinical interventions. In particular, I am hopeful that we will see some positive movement on the recommendation that is specifically addressed to the Minister of Public Safety—namely, the development of a national strategy that would ensure better coordination among federal, provincial and territorial correctional and mental health systems.

 

Aboriginal Offenders

It is distressing to note that despite many wellintentioned efforts and reforms to address the plight of Aboriginal people in the criminal justice system, the incarceration rate for Aboriginal people has increased from 815 per 100,000 in 2001/02 to 983 per 100,000 in 2005/06.[11] Aboriginal rates of incarceration are now almost nine times the national average. One in five federally incarcerated offenders is a person of Aboriginal ancestry. Among women offenders, the overrepresentation is even more dramatic—an astounding 32% of women in federal penitentiaries are Aboriginal.

As this Office has reported too many times before, once Aboriginal people are inside a federal penitentiary, their outcomes lag significantly behind those of non-Aboriginal offenders on nearly every indicator: for example, they have higher risk, needs and security classifications; higher rates of recidivism; lower parole grant rates; a greater proportion of sentences spent in institutions before first release; higher rates of statutory release; and overrepresentation in segregation populations. Over the years, my Office has made a series of findings and recommendations to challenge the Service's thinking and its resolve to make significant and sustainable progress in the area of Aboriginal corrections. Many of our recommendations have yet to be fully implemented. As a consequence, the gap between Aboriginal and non-Aboriginal offenders continues to widen, the situation for Aboriginal people under federal sentence deteriorates, and the Service revises and updates frameworks and strategies without apparent results.

There is no shortage of recommendations that could be made to improve outcomes for Aboriginal offenders. With specific reference to Aboriginal programming, a "top 10" list might include the following:

  • a greater range and variety of Aboriginal-specific programming;
  • more Aboriginal context in existing programs;
  • more resources and contacts with Elders and Aboriginal liaison officers;
  • more staff sensitivity and awareness training on Aboriginal culture;
  • greater use of healing plans and Elder assessments;
  • more extensive use of section 81 and 84 provisions of the Corrections and Conditional Release Act;
  • accreditation of Aboriginal programs;
  • Aboriginal anti-gang programming initiatives in institutions;
  • an Aboriginal-sensitive classification assessment instrument; and the extension of Gladue principles[12] to all areas of correctional decision-making that significantly affect the liberty of Aboriginal offenders, including segregation placement, security classification, intake assessment and transfers.

In the year ahead, we will be reviewing these and other issues as we look to complete a comprehensive progress report on federal Aboriginal corrections initiatives.

Meantime, the Service is finalizing its review and revision of its Aboriginal Corrections Accountability Framework, which is intended to operationalize its 2006 Strategic Plan for Aboriginal Corrections.[13] Although that is a promising development, it is increasingly apparent to me that governance of and accountability for Aboriginal issues within the Service requires dedicated and focused leadership at the very highest levels of the organization. For the benefit of Aboriginal people who come into conflict with the law and the communities they come from, the correctional gap must not be allowed to widen any further.

Attaching responsibility for Aboriginal corrections to the Senior Deputy Commissioner's already large portfolio, as is currently the case, does not do justice to the scope of the problem and the prominence that these issues demand.

It is in that light that I feel compelled to breathe new life into a recommendation that has been languishing for far too long.

Recommendation #12

The minister of public safety should immediately direct that CSC appoint a deputy commissioner for aboriginal corrections.

 

Federally Sentenced Women

Over the past decade, there have been many positive developments in women's corrections in Canada.[14] I am specifically encouraged by the Service's recent focus and efforts in the areas of security reclassification of women offenders and mental health training for front-line staff at regional women's facilities. However, as the Expert Committee Review report noted, despite considerable progress, there is still a great deal of work to be done to move forward in women's corrections over the next decade. I highlight the following areas of challenge:

  • inadequate programming and mental health services for women offenders with acute psychological and psychiatric needs;
  • lack of culturally specific custody rating scales for Aboriginal women offenders;
  • limited community reintegration options, including access to unescorted temporary absences, work releases and integrated discharge planning from regional women's facilities;
  • inappropriate and overly security-focused strategies for and responses to non-compliant women offenders, particularly repeat self-harmers;
  • repeated and prolonged use of segregation to manage a very small number of high-risk and high-need women offenders;
  • lack of development of integrated clinical management plans for this group of offenders; and
  • fatigued, stressed and under-trained front-line staff working in overcrowded facilities.

Although all of these issues are worthy of further comment, there is one area in particular that demands fuller public accounting and scrutiny: the Management Protocol for women offenders. The Management Protocol is not a Commissioner's Directive per se; however, it has nonetheless been a formal approach since the approval of the Secure Unit Operational Plan in 2003. Since it was formalized, seven women offenders have been placed on the Protocol following incidents at regional women's facilities.

A woman offender can be placed on the Management Protocol if she is involved in an incident that has caused serious harm to others or that seriously jeopardizes the safety of others and cannot be managed within the regular maximum security population. Strikingly familiar in purpose to the ultra-secure Special Handling Unit (SHU) for men, the Protocol is in fact meant to address concerns regarding a handful of challenging and distressed women offenders at regional women's facilities. The Management Protocol is a security-driven approach to managing these difficult women offenders. It is not a formal placement per se (as with male offenders placed in the SHU) but, rather, a "status." There are specific phases and steps involved in applying the Protocol, but in all cases movement and association are extremely structured and regulated—more so than in any of the men's facilities. For example, movement outside the secure unit requires the presence of three staff members and typically includes application of physical restraints— handcuffs and leg irons, or both. Women in the initial phases of the Protocol have no contact with other women offenders, for months at a time.

It is noteworthy that the standards of behaviour offenders must meet to be moved down the sliding scales of the Protocol are almost always security focused, and extremely difficult to assess or meet. There are few to no correctional programs or leisure activities available to women on the Protocol. This is counterproductive, given that these women require intensive assistance and support. Indeed, I note that the application of the Protocol tends toward the punitive as opposed to the corrective—a situation that is inconsistent with the Service's guiding philosophy for women offenders as outlined in Creating Choices.

It is particularly troublesome that, as of March 31, 2009, four out of the five women offenders on the Protocol were Aboriginal and the other woman was a member of a visible minority. In addition, only one woman offender has been able to work herself off the Protocol. Time on the Protocol is measured in months, not days. I have very serious concerns about the impact of this form of harsh and punitive confinement on the mental health and emotional well-being of these women. They need intervention and treatment, not deprivation. I think most Canadians would agree that in the 21st century there must be safer and more humane ways for our correctional system to assist a handful of high-needs women offenders.

To conclude this section of the Annual Report, I make three substantive recommendations in the area of women's corrections. The first speaks to the need for clear and direct lines of authority, responsibility and accountability for the governance of women's prisons. Currently, the position of Deputy Commissioner for Women at National Headquarters has "functional" authority for women's corrections, but little substantive authority to provide national oversight and direction in terms of monitoring policy compliance or challenging operational decisions at the institutional and regional levels that may be inconsistent with policy or law. Although we are aware of the Service's position on this matter, we think the Deputy Commissioner for Women's role and office should be strengthened, consistent with the analysis and recommendation put forward in A Preventable Death.

Recommendation #13

The deputy commissioner for women should have full and direct line authority—and, therefore, accountability—for all matters concerning federally sentenced women.

Second, in respect to the Management Protocol, I recommend the following:

Recommendation #14

The management protocol for women offenders should be immediately rescinded pending further review by an external expert in women's corrections.

And third, although I acknowledge that the Mobile Interdisciplinary Treatment Assessment and Consultation Team (MTAC) pilot is in place to assist regional women's institutions in managing a small group of women offenders with severe mental health or behavioural difficulties, there is a clear need to strengthen capacities at the local level. As we understand it, independent psychological assessments for the highest need and highest risk women offenders have been completed. However, it is not clear how these assessments have been used to inform treatment and intervention measures in regional facilities. Accordingly, I recommend the following:

Recommendation #15

Clinical management plans for high-needs and high-risk women should be immediately completed and implemented, and the necessary resources and services, both internal and external, should be made available to the institutions.

 

Gaps in Dynamic Security

Case Summary:

During a visit to a maximum security institution, an investigator noted several compliance issues regarding physical conditions of confinement:

  • cell lock-up of inmates not attending programs or work;
  • meals confined to cells;
  • lengthy lock-downs of entire ranges to facilitate population movement through the institution;
  • a high number of "exceptional" searches;
  • no association between inmates from different living ranges;
  • restricted access to the recreation yard, gym and daily fresh air exercise;
  • excessive restrictions on visits;
  • unclean and noisy common areas, including the gym, showers and yard; and
  • a high number of overdue complaints and grievances.

The report indicated serious concern about the overall mood, health and culture of the institution, deeming the environment stressful, restless, tense and unsafe for both inmates and staff.

Many on-site visits this year confirmed that the physical conditions of confinement have been significantly hardened, especially at the higher security levels. Some maximum security institutions appear to have responded to ongoing issues—including gang affiliation, non-compliant behaviour and drug use— with a regime of increasingly restricted inmate movement and association. Several informal sanctions—including cell confinement, limits on yard or gym time, restrictions on visits, delivery of programs in cells and lock-downs—and incentives for good behaviour have been introduced, which largely fall beyond the scrutiny of the Corrections and Conditional Release Act and its regulations. At some maximum security facilities, the inmate yard is being replaced by small exercise pods at the extremities of individual cell ranges, allowing staff to tightly control movement and mixing of populations. While these measures may provide an enhanced sense of security, they do little to promote pro-social behaviour or to reduce the underlying causes of tension within institutions.

While such measures are partly practical responses to the more challenging federal offender profile, it is difficult to escape the conclusion that they also reflect a gradual, but perceptible, decrease in the quality and practices of dynamic security, an approach to corrections that relies on front-line staff to be alert, engaged, and interacting closely and constructively with inmates. There has been a proliferation of static 8 // GAPS IN DYNAMIC SECURITY security measures and technologies, including electronically controlled locks and physical barriers, armed perimeter and control posts, ion scanners and drug detection dogs at entry checkpoints, and closedcircuit cameras. Front-line officers have been equipped with a new kit of personal safety items that includes stab-proof vests, first aid (CPR) masks and personal portable alarms. Firearms are being carried for outside escorts of offenders at higher security levels, and requirements for reporting the use and display of firearms have been reduced. Designed to exercise both control and surveillance over the inmate population, the cumulative effect of these measures has been to increase the physical separation between the "keeper" and the "kept."

The problem, of course, is that a more punitive and restrictive environment is not one that is likely to promote rehabilitation of inmates. On the contrary, the evidence indicates that overusing sanctions, punishment and displays of force does not produce sustained behavioural change, nor do such practices make for safer institutions. In point of fact, it is more productive to create a living and working environment for staff and inmates that offers positive incentives, programming, and meaningful and regular engagement and interaction than one that adopts punitive attitudes that reinforce an "us-versus-them" mentality. Educational, self-improvement and treatment programs can help reduce the tension, deprivation and stress that are inherent in the incarceration experience. Well-run institutions are facilities that emphasize care, custody and control in a safe, reasonable and humane manner. The degree of control and response exercised by correctional authorities should be proportionate to the risk and exercised within the limits of the "least restrictive" principle. Inmates who are engaged constructively with staff on a regular basis are more likely to adopt the kinds of pro-social behaviours that will foster their rehabilitation and eventual reintegration. In short, dynamic security is preventive security; a living environment that is unsafe for offenders is a working environment that is unsafe for staff.

 

These are not new observations by any means, but the lessons they hold for correctional authorities bear repeating from time to time. As the Service looks toward fully implementing its Transformation Agenda, I believe this is one of those times.

Recommendation #16

I recommend that the correctional service refresh and reinforce the principles and practices of dynamic security in the following areas:

  • strengthen its dynamic security training module for all new recruits so that the significance and benefits of this correctional approach are clearly understood;
  • develop and implement a dynamic security refresher training module for all staff to be delivered as soon as is practical;
  • identify specific accountabilities for correctional managers to ensure every inmate is seen and engaged on a regular basis; and
  • ensure regular rounds and counts are verified and conducted according to policy.

I further recommend:

Recommendation #17

The Service should conduct an internal audit of maximum security institutions across the country to ensure the prison regime conforms to the "least restrictive" principle and dynamic security practices. this review should incorporate the following areas: access to yards and recreation, visits, programs, daily outdoor exercise, association and movement.

Recommendation #18

The display of a firearm should continue to be considered a reportable use of force.

 

Segregation By Any Other Name

My Office continues to be concerned about the excessive number of offenders on long-term segregation status (60 days and over). By policy, the Service is required to regularly review each case and ensure an alternative plan is in place for segregated offenders. Placing an offender in administrative segregation solely due to population management pressures is contrary to law and policy. It is not good correctional practice. In many of these cases, my Office finds that the correctional authority has failed or seriously erred in its application of the "least restrictive" principle or the duty to act fairly.

A particularly troublesome development in this area of corrections is the proliferation of so-called "transition," "secure," "structured" and "enhanced" living units at higher security facilities. These units effectively operate as if they were segregation units but without any of the substantive procedural safeguards and entitlements of the law. For instance, they do not require written documentation outlining why the offender is being transferred to the unit, or details of what the offender must do, in terms of behaviour, to be removed from it. Minimally above the standards of segregation facilities, these units appear to be the unfortunate outcome of the tension between the security needs of the institution and the reintegration needs of the offender.

These issues are not unknown to the Service. As I have made clear before, the concept of "transitional" units is meant to denote a temporary and less restrictive alternative to administrative segregation. Unfortunately, too many of these temporary units, which typically offer a limited regime of earned privileges and incentives for good behaviour, have become permanent fixtures on the correctional landscape. This means of population management within the Service is fast becoming untenable and unreasonable. I am therefore compelled to restate the following recommendation from earlier Annual Reports:

Recommendation #19

The Service should implement procedural safeguards and ensure legal compliance with offender rights, entitlements and access to programs for all forms of "segregation by any other name," consistent with its legal and policy requirements.

 

Correctional Investigator's Outlook for 2009-2010

With the appointment of a new Executive Director, my Office has initiated a strategic planning exercise. As part of this exercise, we are renewing our Investigative Policies and Procedures Manual, with which we intend to build a more streamlined organizational structure that will allow us to align and better allocate resources to address areas of priority and systemic concern. In the year ahead, we intend to carry out a comprehensive review of the Correctional Service's mental health and Aboriginal corrections portfolios.

With respect to mental health, I particularly welcome the initiative of the Standing Committee on Public Safety and National Security to review mental health and addictions in the correctional context. In my view, the focus and scrutiny of parliamentarians in this area of corrections is both timely and appropriate.

As the Service moves forward to consolidate its accountability and governance framework for Aboriginal corrections, my Office will conduct its own parallel review to assess CSC's progress in meeting its commitments aimed at achieving better results for Aboriginal offenders. Our report will better inform our interventions to influence the Service's thinking and resolve in this critical area of corrections.

As a matter of priority and focus, my Office will remain engaged in the Correctional Service's follow-up actions and public commitments resulting from our recent reports on deaths in custody. I am encouraged by the Service's involvement in the development of a Forum on Custody Deaths in Canada—a roundtable of experts with an interest in promoting education, awareness and research, as well as exchanging best practices in the prevention of in-custody deaths in correctional, policing and psychiatric facilities. I also look forward to a public accounting of the Service's response to my report on the death of Ashley Smith, A Preventable Death. That said, it is with some degree of unease that I report that my Office is currently investigating the circumstances of two other very troubling deaths in custody.

We have furthermore identified concerns regarding the Service's direction and obligations with respect to reviewing deaths by natural causes. Over the next fiscal year, we will review the Service's Mortality Review process, focusing on whether this alternative process appropriately identifies gaps in compliance and points out necessary corrective actions.

The Service is clearly committed to moving forward with its Transformation Agenda in line with the Review Panel report of December 2007, A Roadmap to Strengthening Public Safety. The Service received new funding to start implementing recommendations from one of the five themes of the Roadmap: eliminating drugs in prisons. Many of the more difficult and contentious reforms—such as eliminating statutory release, emphasizing increased offender responsibility and accountability, and carrying out large-scale physical infrastructure reform—are still in the planning and development stages. They will require significant legislative changes, policy refinements, program enhancements, realignment of efforts and targeted investments. My Office looks forward to learning how the government and the Service intend to move forward in defining the priorities and focus of federal corrections for decades to come. We owe it to Canadians to get it right. In my opinion, public consultations with Canadians, concerned stakeholders and parliamentarians are essential, given the scope and gravity of the changes under consideration.

Also on the horizon, several criminal justice-related issues and reforms are making their way through the system. They will have downstream impacts on federal corrections, particularly with respect to anticipated population increases. An increase in the prison population will add to the pressures in a system that is already having difficulty fulfilling its mandate to provide safe and humane custody, and to reintegrate offenders into their communities in a timely fashion.

As I conclude my 2008/09 annual report, it is only proper and fitting that I should offer my sincere thanks and appreciation to my staff members, who approach their work with exemplary integrity, professionalism and commitment. It is indeed a genuine pleasure to serve alongside such dedicated public servants.

 

ANNEX A: STATISTICS

TABLE A: COMPLAINTS(1) BY CATEGORY
  ACTION
CATEGORY I/R (2) INV(3) TOTAL
 
Administrative Segregation
Conditions 22 85 107
Placement/Review 77 239 316
Total 99 324 423
 
Case Preparation
Conditional Release 71 69 140
Post Suspension 24 11 35
Temporary Absence 7 30 37
Transfer 27 18 45
Total 129 128 257
 
Cell Effects 185 231 416
Cell Placement 1 42 43
 
Claims Against the Crown
Decisions 12 11 23
Processing 14 28 42
Total 26 39 65
 
Community Programs/Supervision 10 8 18
Conditions of Confinement 151 222 373
Correspondence 51 54 105
Death or Serious Injury 6 11 17
Decisions (General) - Implementation 58 55 113
 
Diet
Medical 5 13 18
Religious 9 14 23
Total 14 27 41
 
Discipline
ICP Decisions 6 5 11
Minor Court Decisions 7 2 9
Procedures 9 15 24
Total 22 22 44
 
Discrimination 8 4 12
Employment 41 60 101
 
File Information
Access - Disclosure 74 78 152
Correction 61 40 101
Total 135 118 253
 
Financial Matters
Access 45 46 91
Pay 20 29 49
Total 65 75 140
 
Food Services 24 39 63
Grievance Procedure 67 142 209
Harassment 28 25 53
Health and Safety - Worksite 4 5 9
Ion Scan/Drug Dog 4 1 5
 
Health Care
Access 143 374 517
Decisions 73 200 273
Dental 19 42 61
Total 235 616 851
 
Mental Health
Access 9 40 49
Programs 6 7 13
Total 15 47 62
 
Methadone 11 25 36
Official Languages 6 7 13
Operation/Decisions of the OCI 17 8 25
 
Programs
Access/Services 66 120 186
Release Procedures 43 50 94
Safety/Security of Offender(s) 39 126 165
Search and Seizure 12 17 29
Security Classification 62 76 138
Sentence Administration 20 15 35
Staff Performance 187 170 357
Telephone 72 123 195
Temporary Absence Decision 32 42 74
 
Transfer
Implementation 38 87 125
Involuntary 47 106 153
Pen Placement 27 37 64
Voluntary 35 70 105
Total 147 300 447
 
Urinalysis 8 6 14
Use of Force 11 40 51
 
Visits
General 86 139 225
Private Family Visits 22 64 86
Total 108 203 311
 
Outside Terms of Reference
Parole Process/Decisions 81 80 161
Other Issues 34 21 55
 
Grand Total 2334 3725 6059

Complaints - see Glossary (1)
Internal Response - see Glossary (2)
Investigation - see Glossary (3)

GLOSSARY

Complaint:  Complaints may be made by an offender or a third party on behalf of an offender by telephone, facsimile, letter or during interviews held by the OCI's investigative staff at federal correctional facilities. 

The legislation also allows the OCI to commence an investigation at the request of the Minister or on the OCI's own initiative.

Internal Response:  A response provided to a complainant that does not require consultation with any sources of information outside the OCI.

Investigation:  A complaint where an inquiry is made with the Correctional Service and/or documentation is reviewed/analyzed by the OCI's investigative staff before the information or assistance sought by the offender is provided.

Investigations vary considerably in terms of their scope, complexity, duration and resources required. While some issues may be addressed relatively quickly, others require a comprehensive review of documentation, numerous interviews and extensive correspondence with the various levels of management at the Correctional Service of Canada prior to being finalized.

(*) Includes 97 complaints from federal offenders in the community and 10 complaints from federal offenders in provincial institutions

 

TABLE B: COMPLAINTS BY INSTITUTION
REGION/INSTITUTION Number of Complaints Number of Interviews Number of Days Spent in Institution
 
WOMEN'S FACILITIES
Edmonton Women's Facility 52 12 3
Fraser Valley 49 7 1.5
Grand Valley 113 31 7
Isabel McNeill House 0 0 0
Joliette 136 34 6
Nova 156 36 3.5
Okimaw Ohci Healing Lodge 11 1 1
Regional Psychiatric Centre 1 0 0
Region Total 518 121 22
 
ATLANTIC
Atlantic 140 26 6
Dorchester 211 30 8
Shepody Healing Centre 29 2 0.5
Springhill 143 38 7
Westmorland 25 2 0.5
Region Total 548 98 22
 
ONTARIO
Bath 63 11 2
Beaver Creek 34 11 1.5
Collins Bay 64 9 3
Fenbrook 106 27 8
Frontenac 26 0 0
Joyceville 92 13 4
Kingston Penitentiary 372 84 14.5
Millhaven 199 24 6
Pittsburgh 23 0  
Regional Treatment Centre 29 0 1
Warkworth 286 63 7
Region Total 1294 242 47
 
PACIFIC
Ferndale 32 11 2
Kent 198 47 4
Kwikwèxwelhp 2 0 0
Matsqui 76 6 3
Mission 117 14 4
Mountain 200 63 6
Pacific 84 48 6
Regional Treatment Centre 85 0 0
William Head 19 0 0
Region Total 813 189 25
 
PRAIRIE
Bowden 283 65 10
Drumheller 109 32 8
Edmonton 425 98 11.5
Grande Cache 100 23 4
Grieson Centre 5 0 0
Ochichakkosipi 0 0 0
Pê Sˆkˆstêw 17 0 0
Riverbend 6 0 0
Rockwood 22 2 0.5
Regional Psychiatric Centre 69 1 0
Saskatchewan Penitentiary 247 6 3
Stan Daniels Centre 5 0 0
Stony Mountain 123 25 4.5
Willow Cree 1 0 0
Region Total 1412 252 41.5
 
QUEBEC
Archambault 135 25 5
Centre Régional Santé Mentale 23 8 0
Cowansville 83 28 3
Donnacona 214 50 6
Drummond 91 23 3
Federal Training Centre 35 0 0
La Macaza 130 53 6
Leclerc 192 15 2
Montée St-François 18 0 0
Port Cartier 291 109 13.5
Regional Reception Centre 111 21 3
Special Handling Unit 58 11 5.5
Ste-Anne des Plaines 27 6  
Waseskun 5 1 1
Region Total 1413 350 48
GRAND TOTAL (*)5998 1252 205.5

(*) Excludes 50 complaints from federal offenders in the community and 11 complaints from federal offenders in provincial institutions.

 

TABLE C: COMPLAINTS AND INMATE POPULATION - BY REGION
REGION Total Number of Complaints (*) Inmate Population (**)
Atlantic 548 1294
Quebec 1413 3270
Ontario 1294 3767
Prairie 1412 3402
Pacific 813 1927
Women's Facilities 518 503
TOTAL 5998 14163

(*) Excludes: 50 complaints from federal offenders in the community and 11 complaints from federal offenders in provincial institutions.

(**) Excludes: As of June 2008, according to the Correctional Service of Canada's Reporting System.

 

TABLE D: DISPOSITION OF COMPLAINTS BY ACTION
ACTION DISPOSITION Number of Complaints
Internal Response Information given 1372
Not supported   80
Pending   50
Referral   323
Withdrawn   420
Total   22450
 
Investigation Information given 932
Not supported   250
Pending   181
Referral   729
Recommendation/Resolution Facilitated   1614
Withdrawn   108
Total   3814
 
GRAND TOTAL   (*) 6059

(*) Includes 50 complaints from federal offenders in the community and 11 complaints from federal offenders in provincial institutions.

 

TABLE E: AREAS OF CONCERN MOST FREQUENTLY IDENTIFIED BY OFFENDERS
 
TOTAL OFFENDER POPULATION
 
Health Care 851
Transfer 447
Administrative Segregation 423
Cell Effects 416
Conditions of Confinement 373
Staff Performance 357
Visits 311
Case Preparation 257
Information - Access and Correction 253
Grievance Procedure 209
 
ABORIGINAL OFFENDERS
 
Health Care 66
Transfer 55
Staff Performance 34
Administrative Segregation 32
Grievance Procedure 30
Program - Access 28
Case Preparation 28
Visits 27
Cell Effects 26
Information - Access and Correction 24
 
WOMEN OFFENDERS
 
Health Care 32
Conditions of Confinement 21
Safety/Security of Offender 21
Case Preparation 21
Administrative Segregation 20
Staff Performance 15
Parole process/decision 15
Visits 15
Program - Access 12
Temporary Absence Decision 12

 

ANNEX B: SUMMARY OF RECOMMENDATIONS

1. The Service should bolster its recruitment and hiring of clinical mental health professionals, giving priority to existing vacancies in underserviced institutions, and should establish permanent recruiting and training budgets for these professionals.

2. Consistent with CSC's approved mental health strategy, the Service should immediately implement intermediate mental health care units in each region.

3. Clinical management plans to treat offenders with mental disorders should be developed and implemented on a priority basis and should be managed by interdisciplinary teams of mental health, security and case management personnel working together.

4. The Service should conduct an independent review of long-term segregation cases on an expeditious basis, and submit the review process to an external validation and evaluation exercise.

5. A national strategy for managing chronic self-harming behaviours and incidents should be developed and shared with my office. The protocol should include clear national, regional, and institutional authorities and accountabilities to ensure ongoing management and monitoring of these cases occurs, as well as staff training requirements regarding the early recognition of self-harming behaviour.

6. Clinical management plans—which would include prevention, intervention and treatment measures—should be put in place to manage offenders who chronically self-harm.

7. As a matter of priority, an inventory of "best practices" in the treatment and prevention of self-harm should be developed and distributed widely throughout the Service.

8. Specialized and dedicated units should be immediately created in each region, as required, to manage chronically self-harming offenders.

9. The national essential health services framework should be submitted to a peer review process conducted by an external, independent and expert panel that is empowered to report annually and publicly over the next three years on the Service's implementation of the framework.

10. With respect to correctional programming, i recommend that in the coming year, the correctional service make significant progress in addressing the following areas, consistent with the least restrictive principle and effective corrections:

  • reduce program wait lists;
  • increase use of temporary absences and work releases as means to promote and improve an offender's likelihood of being positively prepared and recommended for parole;
  • increase access to programs and programming opportunities in maximum security institutions;
  • increase program interventions and improve outcomes for special needs offenders, including older offenders, offenders with learning delays or disabilities, and offenders with mental health problems; and
  • improve inmate communication and understanding of the parole review process.

11. The Service should review the rationale, criteria and average waiting time for psychological assessments required for security reclassifications of offenders serving life and indeterminate sentences.

12. The minister of public safety should immediately direct that CSC appoint a deputy commissioner for aboriginal corrections.

13. The deputy commissioner for women should have full and direct line authority—and, therefore, accountability—for all matters concerning federally sentenced women.

14. The management protocol for women offenders should be immediately rescinded pending further review by an external expert in women's corrections.

15. Clinical management plans for high-needs and high-risk women should be immediately completed and implemented, and the necessary resources and services, both internal and external, should be made available to the institutions.

16. I recommend that the correctional service refresh and reinforce the principles and practices of dynamic security in the following areas:

  • strengthen its dynamic security training module for all new recruits so that the significance and benefits of this correctional approach are clearly understood;
  • develop and implement a dynamic security refresher training module for all staff to be delivered as soon as is practical;
  • identify specific accountabilities for correctional managers to ensure every inmate is seen and engaged on a regular basis; and
  • ensure regular rounds and counts are verified and conducted according to policy.

17. The Service should conduct an internal audit of maximum security institutions across the country to ensure the prison regime conforms to the "least restrictive" principle and dynamic security practices. this review should incorporate the following areas: access to yards and recreation, visits, programs, daily outdoor exercise, association and movement.

18. The display of a firearm should continue to be considered a reportable use of force.

19. The Service should implement procedural safeguards and ensure legal compliance with offender rights, entitlements and access to programs for all forms of "segregation by any other name," consistent with its legal and policy requirements.



[1] Public Safety Canada, Corrections and Conditional Release Statistical Overview: Annual Report 2008, December 2008.

[2] Correctional Service of Canada, Mobile Interdisciplinary Treatment Assessment and Consultation Team (MTAC) Frequently Asked Questions, internal paper, undated.

[3] Correctional Service of Canada, A Study of Reported Self-Harm Incidents in CSC, February 2009.

[4] This total includes funding for the Regional Treatment Centres.

[5] Correctional Service of Canada, Health Services, Report on Health Services Grievances 2007-2008, March 2009.

[6] Correctional Service of Canada, National Essential Health Services Framework, March 31, 2009.

[7] National Parole Board, Performance Monitoring Report 2007-08, July 2008.

[8] Correctional Service of Canada, Evaluation Report: Correctional Programs, January 2009.

[9] Programming for female offenders does not have a minimum education requirement for program participation.

[10] Correctional Service of Canada, Evaluation Report: Correctional Programs, January 2009.

[11] Statistics Canada, Adult Correctional Services in Canada, 2005/2006, June 2008.

[12] Gladue principles arise from the seminal Supreme Court of Canada decision that concluded that the unique systemic and background circumstances of Aboriginal offenders, including a social history of disadvantage and discrimination, should be considered in ameliorating the problem of overrepresentation of Aboriginal people in federal prisons.

[13]Correctional Service of Canada, Strategic Plan for Aboriginal Corrections, Innovation, Learning and Adjustment, 2006-07 to 2010-11, undated.

[14] See, for example, Moving Forward with Women's Corrections: Expert Committee Review of the Correctional Service of Canada's Ten-Year Status Report on Women's Corrections, 1996-2006, undated.

 


Response of the

CORRECTIONAL SERVICE OF CANADA

to the

36th ANNUAL REPORT
of the
CORRECTIONAL INVESTIGATOR
2008-2009

 

Introduction

The Correctional Service of Canada (CSC) contributes to public safety by administering courtimposed sentences of two years or more. Federal custody involves managing institutions of various security levels and supervising offenders on different forms of conditional release, while assisting them to become law-abiding citizens. CSC also administers post-sentence supervision of offenders with Long Term Supervision Orders for up to 10 years.

On an average day during the 2008-09 fiscal year, CSC was responsible for approximately 13,000 federally incarcerated offenders and 9,000 offenders in the community. However, over the course of the year, including all admissions and releases, CSC managed 19,959 incarcerated offenders and 16,744 supervised offenders in the community. CSC manages 57 institutions including four (4) Aboriginal Healing Lodges, five (5) regional institutions for women and five (5) regional treatment/psychiatric facilities; 16 community correctional centres and; and 84 parole offices and sub-offices.

CSC continues to face significant challenges in balancing the multiple needs of offenders and delivering effective correctional services which lead to public safety results for Canadians. Offenders arrive at federal institutions with criminal histories involving violent offending, mental health problems, substance abuse problems, cognitive behavioural problems, education and employment skills deficiencies, gang and organized crime affiliations, and higher rates of health issues such as infectious disease.

CSC Transformation Agenda

CSC has been actively pursuing its transformation agenda over the last year in five (5) key areas: increasing offender accountability; eliminating drugs from penitentiaries; developing employability/employment skills of offenders; renewing the physical infrastructure of our penitentiaries; and, strengthening our community corrections capacity.

The 2008 and 2009 Budgets are allowing CSC to address some of its current and longstanding challenges; better support its current priorities; and provide CSC with an opportunity to integrate transformation initiatives in a way that will contribute to improved public safety results for Canadians.

The focus of the first year of the Transformation Agenda was on strengthening CSC's existing operational and programming base by enhancing key correctional processes related to safety and security; building community capacity; building partnerships with service deliverers (e.g. mental health treatment); and strengthening human resource management and training. Increased funding allowed the Service to strengthen its capacity to eliminate drugs in institutions (e.g. increasing detector dog teams and security intelligence capacity) and developing enhancements to ensure more integrated and responsive correctional interventions. For example, a compressed offender intake assessment process was developed for offenders with shorter sentences, which also includes the introduction of programs at Intake Units and computerized mental health and employment assessment tools.

In the second year of the Transformation Agenda, CSC is continuing to pursue initiatives that will create additional opportunities for offenders to participate in correctional programs and initiatives that enhance public safety results. The following provides some examples of the many areas on which CSC is focusing.

Safety and Security - The focus will be on ensuring the full integration of CSC's policies and processes supporting its efforts to integrate the drug interdiction, gang management, security intelligence, physical security initiatives and security technology strategies.

Assessment and Correctional Interventions - Development of a new integrated correctional program model that will provide for earlier and more appropriate program referral, and a continuous intake process to increase offender participation in programs.

Education - CSC will continue to enhance offender education levels and the development of work skills. Focus is being placed on literacy, as well as on the relationship between education and employability training in job readiness initiatives.

Employment (CORCAN) - CSC is developing a revitalized employment and employability strategy for offenders, with a specific focus on Aboriginal and women offenders.

Aboriginal Offenders - An Integrated Strategy for Aboriginal Corrections Accountability Framework will be implemented in all CSC regions.

Staffing - Aboriginal Recruitment Teams have been put in place at the national and regional levels to ensure that a greater number of Aboriginal candidates are referred to the CSC recruitment process. As well, CSC is placing significant emphasis on the recruitment, development and retention of visible minority staff to meet the needs of an ethno-culturally diverse offender population across the country.

Mental Health - Initiatives have been undertaken to implement key components of the Institutional and Community Mental Health Strategies, such as continued implementation of the mental health screening at intake sites (COMHISS), primary care in regular institutions, the provision of mental health training for staff, piloting of Dialectical Behaviour Therapy for women offenders, and the implementation of the Community Mental Health Initiative.

Ultimately, improving public safety is the overall goal of the Correctional Service of Canada's plans to fundamentally transform federal corrections. Through these and other initiatives, such improvements can be achieved over the coming months and years.

Strategic Review

In 2008, CSC participated in the Governmentmandated "Strategic Review" (a review of its program spending) which provided an opportunity to further align its budget, programs and priorities with the new vision for federal corrections in Canada and the Government's overall priorities. In particular, CSC is reallocating a portion of its expenditure base to activities that can accelerate the implementation of its Transformation Agenda and enhance its abilities to deliver on its key corporate priorities.

The reallocations will focus on six (6) key areas within CSC: clinical health care; offender case management; accommodation services, including institutional services; CORCAN employment and employability; intelligence and supervision services; and internal services. Some of the specific reallocations include the following:

  • CSC will implement a more cost-effective approach to offender case management by focusing psychological and specialized assessment resources on the highest-needs offenders. ese measures will result in greater efficiencies, while ensuring that those offenders requiring full and comprehensive assessments continue to receive them in a timely manner;
  • CSC will be gradually adopting a service-based delivery model for institutional services - facility maintenance and engineering services. e proposed local service delivery model will allow institutional heads to focus more on core operational issues while having a more effective model for addressing physical infrastructure needs.
  • In recognition of the need to provide offenders with marketable employment skills for today's employment reality, CSC will gradually phase out the six CoRCAn farm operations. CoRCAn will be looking towards developing alternative training opportunities that will provide more relevant and practical employability skills for offenders for the current job market.

In addition to these measures, CSC is making a number of reinvestments, with the objective of:

  • increasing capacity to address the program requirements of higher-needs offenders who are serving shorter sentences (less than four years);
  • creating capacity to begin program interventions during the intake assessment period;
  • increasing the capacity to deliver violence prevention interventions in both institutions and community settings;
  • delivering more programs in the community to assist offenders to maintain crime prevention skills that they have learned while incarcerated;
  • providing electronic monitoring of higher-needs offenders released under supervision;
  • expanding the number of Aboriginal specific treatment programs to meet the needs of the larger number of incarcerated Aboriginal offenders (violence prevention, substance abuse, family violence prevention); and
  • Expanding Pathways Units to support more effective delivery of the Continuum of Care for First nations, Métis, and Inuit offenders.

Renewal Of The CSC Mission

On May 27th, 2009, the Minister of Public Safety, the Honourable Peter van Loan, officially signed the CSC Mission Statement: The Correctional Service of Canada, as part of the criminal justice system and respecting the rule of law, contributes to public safety by actively encouraging and assisting offenders to become law-abiding citizens, while exercising reasonable, safe, secure and humane control.

The Mission remains the focal point for CSC and continues to reflect a commitment that is essential as CSC moves forward with its Transformation Agenda.

Legislative Initiatives

On June 16, 2009, legislation was introduced to reform the Corrections and Conditional Release Act (CCRA) — reforms that further support the strengthening of the federal correctional system. The proposed legislation includes key amendments in four (4) main areas: enhancing the sharing of information with victims; enhancing offender responsibility and accountability; strengthening the management of offenders and their reintegration; and, modernizing disciplinary actions in response to negative offender behaviour.

Relationship Building

A thread that weaves through all of our efforts is the need to build effective relationships internally, with partners, and with communities. Greater horizontal collaboration and coordination is also essential for CSC to address coherence of correctional programs and services with the design and delivery of others across federal departments.

CSC is engaged in all major government-wide initiatives, such as Public Service Renewal. It is also involved in horizontal initiatives such as Canada's contribution in Afghanistan. CSC also continues to work with other government departments to address the challenges that contribute to the disproportionate representation of Aboriginal peoples in the criminal justice system.

CSC is working to expand or develop partnerships with other jurisdictions, non-governmental organizations and community partners in order to identify and share best practices, provide improved services to victims of crime, support mental health services and community reintegration. CSC is also working to improve the success of releasing offenders to Aboriginal communities as per section 84 of the CCRA.

Enhancing education about corrections will help citizens interact and influence CSC's management decisions. Improved public consultations with communities will benefit Canadians by assuring them of meaningful opportunities to influence policy and management decisions. In corrections, this process of informing, involving and collaborating with individuals, communities and both governmental and non-governmental partners is essential to our ability to make communities safer.

Human Resource Renewal

CSC is undergoing an exciting period of human resource renewal to ensure that CSC has the workforce and workplace required to meet its future business needs. CSC has renewed its recruitment activities and products and is anticipating hiring some 800 new employees through external processes in 2009/10. CSC is taking measures to ensure that human resource planning is fully integrated with business and financial planning in order to maximize effectiveness. In addition CSC is renewing its Human Resource (HR) processes to better support the business through improved client service, introduction of service standards in key HR disciplines and finding opportunities to leverage technology. A review of the Learning and Development function and governance will enable CSC to invest in its employees through increased opportunities for learning and development, mentoring, and talent management. Also, CSC is looking for increased partnership opportunities with other Public Safety Agencies, bargaining agents, colleges and universities.

Conclusion

The Correctional Investigator's Annual Report is an opportunity for CSC to reflect on the results of the past year. CSC will continue to strengthen its approaches as part of the Transformation Agenda in order to meet the challenges of an increasingly complex correctional environment and to further deliver on its public safety mandate.

 

Review Of Areas Of Key Concern

Mental Health

Recommendation #1

The Service should bolster its recruitment and hiring of clinical mental health professionals, giving priority to existing vacancies in underserviced institutions, and should establish permanent recruiting and training budgets for these professionals.

CSC has developed and is implementing its comprehensive Recruitment and Retention Strategy. The Strategy lays the groundwork in order for the CSC to strengthen its capacity to recruit and retain health service professionals including nurses and social workers who may work in mental health, as well as psychologists. vacancy rates for these professionals are being tracked on a regular basis to assist the CSC in addressing vacancies in under-serviced institutions (for example, vacancy rates for psychologists and nurses are highest in the Pacific and Prairies regions). CSC has a dedicated recruiting budget and resources in National Headquarters and regions, with health professionals as a priority group. There are also dedicated resources for the training of health services professionals, e.g. a national nurse training initiative and five (5) days of training annually for psychologists.

Specific initiatives planned for 2009-2010 include targeted recruitment and partnerships with universities and colleges, and marketing CSC employment opportunities through advertising, participation in job fairs and practicum placements. Analysis of the results of the Public Service Employment Survey as well as an internal survey on values and ethics will be used to inform ongoing efforts to improve employee retention.

As a result of the Strategic Review, CSC will be working collaboratively with key stakeholders on focusing psychological assessment resources on the highest-needs offenders. It is anticipated that a re-focus of psychological risk assessments in an enhanced case management process will enable CSC to redirect psychological resources towards providing mental health interventions.

Recommendation #2

Consistent with CSC's approved mental health strategy, the Service should immediately implement intermediate mental health care units in each region.

Intermediate Mental Health Care Units (IMHCU) are a key component of CSC's integrated Mental Health Strategy approved in 2004. These units were not part of the funding CSC received for the strategy. CSC is now working to better define the size and makeup of the population whose needs could not be met through other elements of the strategy such as primary care and treatment centres. Work is currently underway, to define the proposed location, number, staff requirements and infrastructure needs of such units should funding become available. The target population has now been defined to include offenders with chronic psychiatric problems, personality disorders, high risk of self-injury or low cognitive functioning. Acute psychiatric offenders awaiting transfer to a treatment centre could also be housed in such a facility. However, the Services offered by individual IMHC Units may vary depending on regional population needs. Proposals for funding consideration will be finalized for consideration by April 2010. While this long-range planning is underway, the feasibility of pilot proposals are also being developed for consideration in fall 2009.

Recommendation #3

Clinical management plans to treat offenders with mental disorders should be developed and implemented on a priority basis and should be managed by interdisciplinary teams of mental health, security and case management personnel working together.

The Interdisciplinary Team (IDT) approach has been long mandated in CSC policy to closely manage those cases where risk for self-injury or suicide is deemed high. A process for the clinical management of offenders who self-injure will be issued for immediate implementation in August 2009, to build on the existing operational management process. This integrated process, including guidelines for the development of Clinical Management Plans (CMP), will be incorporated into Commissioner's Directive 843, Prevention, Management and Response to Incidents of Self-Injury and Suicide. The IDT approach will be enhanced through this process which will provide more clarity, more rigour and better communication around how best to manage these difficult cases.

Recommendation #4

The Service should conduct an independent review of long-term segregation cases on an expeditious basis, and submit the review process to an external validation and evaluation exercise.

CSC agrees that administrative segregation is a concern in correctional settings and, as a result, will undertake an examination of long-term segregation using a representative sampling methodology and an external review process, by April 2010.

 

Addressing Incidents Of Self-harm

Recommendation #5

A national strategy for managing chronic self-harming behaviours and incidents should be developed and shared with my office. The protocol should include clear national, regional, and institutional authorities and accountabilities to ensure ongoing management and monitoring of these cases occurs, as well as staff training requirements regarding the early recognition of self-harming behaviour.

CSC has recently undertaken a review of incidents of self-injury. Results confirm that incidents of selfinjury have grown by 73% over a period of 30 months, April 2006 through September 2008. Nevertheless, although only a relatively small percentage of inmates can be categorized as chronic self-harmers, CSC takes this issue very seriously and has a number of initiatives underway to address this. Nine (9) women and 27 men over this time period engaged in 6 or more acts of self-injury.

A national working group has drafted a process for the management of inmates who self-injure. As well a review of best practices in the management of selfinjury has been completed and research into common characteristics of self-injurers is well underway. These elements will be included in a comprehensive strategy that will address areas such as policy, improved processes for managing and monitoring of incidents involving self-injury, staff training, and roles and responsibility of staff and managers. The strategy will be issued in October 2009.

Recommendation #6

Clinical management plans—which would include prevention, intervention and treatment measures—should be put in place to manage offenders who chronically self-harm.

As indicated in the response to Recommendation 3, a process for the clinical management of offenders who self-injure will be issued for immediate implementation in August 2009 to build on the existing operational management process. It will be formalized in policy following consultation on Commissioner's Directive 843. This will define the criteria which would necessitate a formal, structured and documented review by an Interdisciplinary team led by a clinician. The determination of the need for a Clinical Management Plan (CMP) will be made during this review. It is anticipated that a CMP will be recommended for any inmate who chronically self-injures.

Recommendation #7

As a matter of priority, an inventory of "best practices" in the treatment and prevention of self-harm should be developed and distributed widely throughout the Service.

A document highlighting good practices to take into consideration when managing an offender who self-injures is currently in the final consultation stage. It will be widely distributed to frontline staff and shared with the Federal Provincial Territorial Working Group on Mental Health (Heads of Corrections subcommittee) in August 2009.

Recommendation #8

Specialized and dedicated units should be immediately created in each region, as required, to manage chronically self-harming offenders.

As referenced in Recommendation 2, work is currently underway, in conjunction with each region, to define the proposed location, number, staff requirements and infrastructure needs of Intermediate Mental Health Care Units (IMHCU). The target population includes offenders with high risk of selfinjury. The requirement for specialized IMHC Units focussing solely on this population is currently under consideration. The number and location of this type of specialized unit must still be determined. Proposals for funding consideration will be finalized by April 2010. While this long-range planning is underway, the feasibility of pilot proposals are also being developed for consideration in fall 2009 and would include capacity to address the needs of self-harming offenders.

 

Health Services Review

Recommendation #9

The national essential health services framework should be submitted to a peer review process conducted by an external, independent and expert panel that is empowered to report annually and publicly over the next three years on the Service's implementation of the framework.

Defining accessibility to medical services is a common practice within many Health Services jurisdictions, in order to ensure consistency of access, better understanding of care and patient safety.

The current CSC Essential Services Framework was developed with extensive consultation including international, federal, provincial and territorial organizations.

CSC will seek advice from its external Health Care Advisory Committee on the Framework. This Committee is mandated to contribute to the effective and efficient functioning of CSC health services by reviewing and recommending changes to the policies, organization and administration of the health care service within CSC. The Framework will be discussed at their next meeting with CSC in September 2009.

As well, CSC is working with Accreditation Canada (AC), a not-for-profit, independent external organization that provides national and international health care organizations with a voluntary external peer review to assess the quality of their services based on standards of excellence. The AC surveyors are experienced professionals from accredited health care facilities who assess the performance of health organizations against national standards of excellence and provide recommendations. The accreditation process is one of the most effective ways for health services organizations to regularly and consistently examine and improve the quality of their services. Although AC does not accredit specific policies, surveyors are assessing if the organization's policies are fully implemented and in line with the information available on patient needs.

 

Correctional Programs and Case Preparation

Recommendation #10

With respect to correctional programming, i recommend that in the coming year, the correctional service make significant progress in addressing the following areas, consistent with the least restrictive principle and effective corrections:

a) Reduce program wait lists;

CSC is moving forward with fundamental transformations of correctional programs to ensure offenders receive the most effective programs at the appropriate time in their sentence to prepare them for reintegration into the community, as law-abiding citizens.

In the short term:

  • a new Correctional Program policy (Commissioner Directive 726) has been drafted and shared with the OCI;
  • offenders will be held more accountable for program participation as defined in their correctional plans;
  • offenders will start correctional programs earlier (at intake for offenders serving four (4) years or less), and resume program modules if transferred to other institutions thus reducing delays and drop outs;
  • new Correctional Program Referral Guidelines have been issued that will prioritize offenders serving short sentences and shorten the assessment period required for program referrals; and
  • CSC has developed a reinvestment strategy that will increase the capacity to deliver correctional programs (which will reduce priority wait listed offenders) and achieve a better balance of programs in the community.

In the longer term, as part of the Transformation Initiative:

  • CSC will be piloting a new Integrated Correctional Program Model (ICPM) in designated men's institutions and community sites in January 2010; and
  • the ICPM will be based on the most effective aspects of CSC's existing correctional programs and will maximize CSC's contributions to public safety by helping to ensure that offenders get the right programs, at the right intensity level, at the right time.

The CSC looks forward to continued collaboration with the OCI to ensure that concerns regarding correctional program access and content will be addressed in the ICPM.

b) Increase use of temporary absences and work releases as means to promote and improve an offender's likelihood of being positively prepared and recommended for parole;

CSC will be assessing this fiscal year the potential impact of proposed changes to legislation that strengthen the correctional planning process and provide opportunities for the use of electronic monitoring for temporary absences and work releases. The proposed changes may provide additional opportunities for eligible offenders to access temporary absences and work release while maintaining public safety.

c) Increase access to programs and programming opportunities in maximum security institutions;

The role of programming in maximum security is to promote institutional adjustment and to prepare the offender for transfer to lower security. CSC is moving forward with a renewed framework to the delivery of correctional programs in maximum security institutions. A major objective of this approach is the development and piloting of an Integrated Correctional Program Model (ICPM) which is designed to reduce the requirement for multiple correctional programs at maximum security sites where program delivery is restricted. The ICPM includes motivational components to encourage offenders who consistently refuse or drop-out of programs to reconsider their criminal lifestyle and also includes on-going support for the highest-risk offenders. It is believed that with the introduction of this new framework that offenders will have better opportunities to engage in their correctional plans and transfer to lower security where they can focus of furthering their progress towards their correctional plan and on reintegration efforts.

d) Increase program interventions and improved outcomes for special needs offenders, including older offenders, offenders with learning delays/disabilities and offenders with mental health problems; and

As a result of funding received, CSC has conducted extensive research and recently developed a web-based interactive training tool, called the Responsivity Portal, which will help staff identify, accommodate, and adapt to offenders of different age groups, those with learning delays/disabilities, and offenders with mental health problems. The Responsivity Portal, which is being piloted, is designed to improve our staff competencies to respond to the challenges of the changing offender profile. It allows staff to modify their approach or techniques to engage the offender in a correctional program and to improve their potential for success. In addition, CSC has received funding for mental health programs which will assist CSC in increasing interventions for a growing segment of our offender population. As well, funding was received to enhance CSC's capacity to address the literacy and learning delays/disabilities needs of offenders.

e) Improve inmate communication and understanding of the parole review process.

CSC and the National Parole Board have formed a joint working group on waivers and postponements and are collaborating on various strategies to improve inmate understanding of the parole review process (e.g. pamphlets, videos, etc.). This material is expected to be available in Fall 2009.

Recommendation #11

The Service should review the rationale, criteria and average waiting time for psychological assessments required for security reclassifications of offenders serving life and indeterminate sentences.

Psychological assessments prior to consideration of the reclassification of maximum security offenders serving life and indeterminate sentences are not required in policy. It is for the initial placement as per CD 705-7, Security Classification and Penitentiary Placement, paragraph 33, which states:

Psychological risk assessments will be completed during the intake assessment process for offenders serving a life sentence for first or second degree murder or convicted of terrorism offences punishable by life where consideration is being given to placement at a medium security facility. This assessment will focus on risk and institutional adjustment including risk to the public, staff or offender safety and address behavioural needs to facilitate stabilization and adaptation. Where placement is to a maximum security facility, the psychological risk assessment will be completed as soon as possible following placement.

In terms of the rationale, criteria and average waiting time for psychological assessments in general, as a result of the strategic review of CSC, we will be removing the requirement for supplementary psychological assessments at intake for low risk offenders thus allowing more time and resources for higher risk offenders. In addition, CSC has has begun to work collaboratively with key stakeholders towards a more cost-effective approach by focusing psychological and specialized assessment resources on the highestneeds offenders. This includes the need to such assessments for lower risk offenders, prior to conditional release decision making, as well as the shelf of those assessments.

 

Aboriginal Offenders

Recommendation #12

The minister of public safety should immediately direct that CSC appoint a deputy commissioner for aboriginal corrections.

In CSC's current governance structure, the Senior Deputy Commissioner (SDC) is the most senior advisor to the Commissioner on correctional matters. He has direct responsibility for the advancement of Aboriginal corrections within the Service and for providing leadership in integrating Aboriginal initiatives with the overall correctional agenda.

The SDC is supported in his function by the Aboriginal Initiatives Directorate (AID). Recently the AID has been enhanced with a more effective governance structure through the provision of additional resources. This has resulted in a greater capacity to serve and engage the frontline operations on strategic and Aboriginal issues. As such, the needs of First Nations, Métis and Inuit offenders maintain a prominent position in CSC's priority setting, planning, resource allocation, operations and decisionmaking process.

The Service has also established a solid framework for effective dialogue with, and support from, Aboriginal people and Aboriginal communities through the creation of a number of Aboriginal committees which meet regularly with CSC at the national and regional levels. For example, the Commissioner has established a very active National Aboriginal Advisory Committee to provide him with direct input on all aspects of Aboriginal corrections. Regional Aboriginal Advisory Committees have also been created to provide similar input and advice to CSC's five Regional Deputy Commissioners. The Commissioner and Senior Deputy Commissioner are also supported by the National Elders' Working Group. Issues and recommendations submitted by these advisory committees are brought to CSC's Executive Committee to engage Committee members in discussions on the impacts and effects of CSC policy on First Nations, Metis and Inuit offenders.

The momentum generated by this governance structure for Aboriginal corrections provided the stimulus for a rigorous priority setting and planning exercise that identified significant levels of resources within CSC for reinvestment to enhance the effectiveness of interventions and programming for Aboriginal offenders. Reinvestment will focus on increased Aboriginal correctional programs and expansion of Pathways units which provide a safe and culturally appropriate environment for Aboriginal offenders who choose to follow a traditional healing path toward safe reintegration in the community.

In addition, the Service has also strengthened accountability for Aboriginal corrections with all members of the Executive Committee. In 2009-2010, CSC implemented its Strategy for Aboriginal Corrections Accountability Framework along with a Template for Results Reporting and Monitoring that will identify concrete action to be taken and specific accountabilities within CSC for addressing key issues in Aboriginal corrections over the next five years. Progress will be incremental and tracked through quarterly reports on results achieved by the regions and sector heads. The SDC will bring these reports to the Executive Committee for discussion and remedial action, as required. Detailed attention to monitoring and reporting on results will enable CSC to sustain progress in Aboriginal corrections and reinforce the fact that progress for Aboriginal corrections is the responsibility of the Executive Committee, all regions and sectors of CSC.

While CSC respects the OCI position on this recommendation, the Service continues to believe that the creation of an additional Deputy Commissioner position would add unnecessary bureaucracy and cost to the current governance structure. CSC has decided instead to invest these resources in more direct frontline operational programs and interventions designed to maximize the capacity of the field, regions and sectors to collectively address the various challenges of Aboriginal corrections.

 

Federally Sentenced Women

Recommendation #13

The deputy commissioner for women should have full and direct line authority—and, therefore, accountability—for all matters concerning federally sentenced women.

CSC recognizes the need for a strong and effective governance structure to ensure that women offender issues receive the required corporate attention. Extensive discussion and review has occurred on this subject and it was determined that a functional authority for the Deputy Commissioner for Women (DCW) was the most effective governance structure. The Regional Deputy Commissioners (RDCs) have full and direct line authority over the women offender institutions and direct the activities of the Assistant Deputy Commissioners, Institutional Operations (ADCIOs) who are responsible for managing operational issues. The DCW works in cooperation with the RDCs and supports the wardens of the women offender institutions through collaboration with the ADCIOs.

CSC continues to believe that a robust functional role and strong leadership by the DCW, rather than a line authority model, is the most appropriate approach. The roles and responsibilities of the DCW have been clarified and communicated to NHQ, the regions and the women's institutions. Any change in the reporting relationship would result in additional administrative costs to support such a governance model. Such resources are needed to provide frontline service delivery to women offenders.

Recommendation #14

The management protocol for women offenders should be immediately rescinded pending further review by an external expert in women's corrections.

While the Management Protocol is not a Commissioner's Directive, it has been a formalized approach to manage higher risk women and is included in the Secure Unit Operational Plan. Since its implementation in 2003, a total of seven women have been placed on the Protocol. Currently five (5) women are being managed on the Protocol, which represents about 1% of the total population of federally incarcerated women offenders. The decision to place a woman on the Management Protocol is not one that is taken lightly or without just cause.

CSC is currently reviewing its strategy for managing higher risk women with a view to moving away from the Management Protocol and developing an alternative comprehensive approach that is much more consistent with an integrated correctional plan. Consultation will occur with management, stakeholders, and experts in the area of women's corrections in the fall of 2009.

Recommendation #15

Clinical management plans for high-needs and high-risk women should be immediately completed and implemented, and the necessary resources and services, both internal and external, should be made available to the institutions.

Fourteen external assessments have been completed and provided to institutional heads for their review and consideration in developing the best management strategies for the identified high-needs and high-risk women. In addition, contracts are now in place with external experts to conduct in-depth assessments of inmates when deemed necessary by the Chief Psychologist and Interdisciplinary mental health team members. The determination of the need for a Clinical Management Plan (CMP) rests with the Chief Psychologist at each institution and will be developed when deemed appropriate. A CMP may not be deemed necessary for those inmates who are progressing well and functioning in general population.

 

Gaps in Dynamic Security

Recommendation #16

I recommend that the correctional service refresh and reinforce the principles and practices of dynamic security in the following areas:

CSC continues to be committed to dynamic security as a key method of ensuring safety within our institutions and is an ongoing practice within our operations. Through dynamic security, CSC staff members maintain ongoing knowledge of offenders and their behaviours through daily interaction.

a) Strengthen its dynamic security training module for all new recruits so that the significance and benefits of this correctional approach is clearly understood;

CSC has enhanced the learning module on dynamic security as part of the Correctional Training Program (CTP) 2008 version. CTP 2008 has been implemented in the Ontario and Pacific regions. This training will be implemented in all other regions in 2009-2010 fiscal year. The policy is currently under revision to further re-enforce the need for strong dynamic security practices as being taught in the CTP.

b) Develop and implement a dynamic security refresher training module for all staff to be delivered as soon as practical;

CSC will develop a proposed training strategy as well as cost estimates related to the development and implementation of the proposed training. The training proposal will be submitted for approval and funding in March 2010.

c) Identify specific accountabilities for correctional managers to ensure every inmate is seen and engaged on a regular basis; and

In April 2009, Correctional Managers were given letters of expectations which identify the expectation that they shall ensure all line correctional staff practice dynamic security.

CD 560 - Dynamic Security will be revised by fall 2009 to include specific accountabilities for correctional managers and frontline staff members to ensure every inmate in a living unit or work location is seen and engaged every day. As well, there will be an existing post within each living unit with an assigned Officer in Charge responsible for ensuring dynamic security occurs on a regular basis. Staff members will be responsible to interact directly with offenders to enhance their knowledge-base of the offenders' activities and behaviours by increasing awareness of the factors that contribute to, or may compromise the safety and security of employees, offenders and the public. They will also need to report and record information and observations of the offenders' activities and behaviours that are critical to maintaining a safe environment as well as sharing it with security and case management staff and others, as deemed necessary in relation to the nature of the information.

d) Ensure regular rounds and counts are verified and conducted according to policy.

We strive to ensure that all of our activities are carried out as directed by law and policy. We are in the process of strengthening our national policy and training standards in relation to our inmate counts and security patrols as well as increasing our overall use of dynamic security.

In December 2008, a Security Bulletin was issued to remind all correctional officers of their responsibilities with regard to security patrols and counts and the importance of their observations of offender activities in all areas of the institution. As well, all Correctional Managers were reminded of their responsibility to provide constructive feedback to correctional officers when necessary.

In April 2009, letters of expectation were issued to all Correctional Managers to ensure that staff members are supervised consistently and that issues are brought to management's attention in a timely fashion.

An additional stand-to inmate count was introduced on July 10, 2009 at all maximum, medium, minimum and multi-level institutions between the hours of 18:00 and 24:00. As well as an increase in security patrols at all maximum, medium and multi-level institutions (excluding women's institutions). CSC has confirmed that all institutional policies (standing orders and post orders) are in compliance with Commissioner's Directive 566-4 Inmate Counts and Security Patrols. Furthermore, regions are randomly analysing their inmate counts and security patrols on a quarterly basis and reporting their results to NHQ and taking corrective action when necessary.

Recommendation #17

The Service should conduct an internal audit of maximum security institutions across the country to ensure the prison regime conforms to the "least restrictive" principle and dynamic security practices. this review should incorporate the following areas: access to yards and recreation, visits, programs, daily outdoor exercise, association and movement.

Given our transformation initiatives as well as current legislative amendments before Parliament, CSC will be examining all activities associated with the operations and routines of the maximum security institutions. Any changes will be considered after the deliberations on Bill C-43.

Recommendation #18

The display of a firearm should continue to be considered a reportable use of force.

Displaying and charging a firearm no longer meets the definition of "use" of a firearm. However, to ensure that these incidents are reported CSC is in the process of updating the affected policies. For example, a paragraph will be added to the CD 567-4 Use of Chemical Agents and Inflammatory Sprays that will require staff to fill out an Observation Report if OC Spray is displayed. Also, a paragraph will be added to CD 567-5 Use of Firearms that will require staff to fill out an Observation Report if they display or charge a firearm.

CSC does not in any way anticipate that the display or charging of weapons will increase simply because it is no longer a reportable use of force. As before, if staff respond inappropriately to a situation, this will not be tolerated and will be handled as a performance issue.

 

Segregation by Any Other Name

Recommendation #19

The Service should implement procedural safeguards and ensure legal compliance with offender rights, entitlements and access to programs for all forms of "segregation by any other name," consistent with its legal and policy requirements.

Over the past several years, population management has become crucial for maintaining the effective and efficient management of our offender population and to support our intervention efforts. This includes managing several separate institutional populations concurrently in an effort to maintaining institutional stability and ensuring that inmate safety and security is not jeopardized.

In addition enhanced and structured living units are part of a necessary continuum for many offenders who require additional structure and interventions to eventually reintegrate into general population. These units operate within our current policy and legislative framework.

When segregating an offender, the process for admitting and maintaining offenders in segregation already had procedural safeguards and does ensure legal compliance with offender rights, consistent with its legal and policy requirements.