Correctional Services Ombudsman Report on How Inmate Deaths Are Investigated

Howard Sapers, Canada's Correctional Investigator, today released a report on how the federal correctional services conduct reviews of in-custody deaths.

The primary function of the Office of the Correctional Investigator is to investigate and bring resolution to individual complaints by offenders in federal custody.

In his report, Sapers found that the correctional services' review process is flawed because it is not carried out in a timely and rigorous manner as required by law.

Between 2003 and 2013, 536 inmates died in federal penitentiaries. Fully two-thirds of all inmate deaths were attributed to natural causes. Sapers contracted with a senior medical practitioner to conduct an independent and expert review of the quality and adequacy of medical care provided in a sample of fifteen deceased offenders.

The major findings of his report are (from the Backgrounder):

• The medical consultant’s review raises serious compliance issues concerning the quality and adequacy of health care provided: questionable diagnostic practices; incomplete medical documentation; quality and content of information sharing between health care providers and correctional staff and; delays and/or lack of appropriate follow-up on treatment recommendations.
• Despite these critical findings, all fifteen individual mortality reviews conducted by CSC assess the care provided to the deceased inmates as “congruent” with “applicable” health care standards and policy.
• With respect to process, the time between a fatality and the convening and completion of the mortality review often exceeds two years. This timeframe does not respect the legislative obligation for CSC to investigate an inmate fatality “forthwith.”
• The investigation further notes that the reviewer is not asked to establish, reconstruct, corroborate or otherwise probe the facts or circumstances that contributed to the fatality beyond recording cause of death as either “expected/anticipated” or “unexpected/sudden.” Most mortality reviews simply conclude with a Closure Memo stating “no further action required.”  
• To date, the mortality review process has failed to generate findings, recommendations, lessons learned or corrective measures of any national significance. Even when compliances issues are noted, there is no way of determining whether the death was potentially preventable or premature.
• The Office concludes that the mortality review process is an inadequate model for investigating deaths in federal penitentiaries. The exercise is not carried out in a timely or rigorous manner, and it fails to meet basic investigative standards such as independence, thoroughness and credibility.

Sapers' main recommendations to remedy the situation are:

1. “Sudden” or “unexpected” fatalities, regardless of preliminary cause(s), should be subject to a National Board of Investigation.
2. The convening of a board of investigation should normally be within 15 working days of the fatality.
3. All mortality reviews, regardless of cause of death, should be led by a physician.
4. Mortality reports in their entirety should be shared, in a timely manner, with the designated family member(s) who request it.
5. The mortality review exercise should be subject to a quality control audit chaired by an outside medical examiner.