Inmate deaths could have been prevented: ombudsman
June 27, 2007
CBC News

The deaths of some prisoners could have been prevented if not for "disturbing" trends in the Correctional Service of Canada, says a report released Wednesday by the federal prisons ombudsman.

The report said some inmate deaths could have been averted by better risk assessments and preventive measures, as well as more timely responses by the CSC.

"The findings are disturbing and indicate that the Correctional Service has not rigorously fulfilled its mandate to keep all inmates safe and act on recommendations related to inmate deaths," said ombudsman Howard Sapers, whose official title is the Correctional Investigator of Canada.

The investigation into federal inmate fatalities reviewed 82 deaths due to factors other than natural causes from 2001 to 2005. It found that the country's prison authority made errors "incident after incident" by failing to incorporate lessons learned and implement corrective actions. It said the CSC failed to act on a "large proportion" of coroners' and medical examiners' recommendations.

Institutional staff were faulted for failing to perform their duties as required, and accused of committing "gross errors" when responding to emergencies by frequently failing to administer first aid. Another major concern was the absence of automatic external defibrillators as standard equipment in prisons.

Important information about the risk of prisoner suicide and violence often went unrecorded or uncommunicated, the report said. It also raised concerns about mental health programming and control of illicit and prescribed drugs inside Canadian prisons.

"Although the Correctional Service says it takes corrective action to ensure similar situations do not occur again, the same problems are repeatedly occurring, resulting in the tragic loss of human lives," said Sapers.

The report noted that the annual number of prison fatalities is not declining.

Repeated mistakes lead to inmate deaths: study
JOANNA SMITH
June 28, 2007
Globe and Mail

Fewer inmates might have died in custody if the federal prison service had followed its own policies, acted on recommendations and, in many cases, checked to see whether prisoners were alive, a new study shows.

The report, commissioned by the federal correctional investigator and released publicly yesterday, examined 82 reported suicides, homicides and accidental deaths in federal prisons between 2001 and 2005.

Correctional investigator Howard Sapers called the findings "disturbing" and said they suggest Correctional Service Canada has failed to learn from mistakes repeated "across regions and over time."

Thirty-six of the cases raised some aspect of patrols or counts, including "making sure there is a living, breathing body in the cell," Mr. Sapers said.

He said it frequently was unclear how much time elapsed between an inmate's death and the discovery of the body because officers did not follow CSC's hourly patrol policy. In one case, 18 hours passed between counts.

Problems arose in two-thirds of the cases even after the body was found, with officers sometimes failing to perform basic life-saving skills such as CPR, and in one case being slow to call an ambulance because "none of the staff on duty knew the emergency number," the report said.

Just over 60 per cent of the deaths were suicides, and the lack of proper services for inmates with mental-health issues or a history of self-harm was an issue in nearly half those cases.

"These are clear flags and they weren't picked up by the professionals involved," said report author Thomas Gabor, a criminologist at the University of Ottawa.

Drugs played a role in just over a quarter of the deaths, either directly in cases of overdoses - accounting for 80 per cent of accidental deaths - or indirectly, such as when an inmate's death could be attributed to his role in the institutional drug trade.

Two inmates choked to death after swallowing bags of drugs sneaked in during a family visit, and one inmate was known to have consumed $1,000 worth of heroin every day. Some drug-related deaths involved methadone and other prescription medication.

Gang activity played a clear role in 11 of the deaths - including almost half of the homicides - and several files mentioned the lack of anti-gang strategies or trained security intelligence analysts.

Mr. Sapers said he is concerned the CSC appears to lack the financial and human resources to live up to its mandate of providing safe custody to federal inmates.

CSC spokeswoman Suzanne Leclerc said yesterday that the agency is taking the report very seriously and working to speed up the investigation process, as well as improve responsiveness and mental-health services.