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."
The report says CSC often resisted or ignored coroners' recommendations, and that an average of 16 months elapsed between a death and the adoption of formal measures arising from its investigation.
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.
The report found that in some cases, mental-health professionals believed inmates expressing suicidal thoughts were faking, or trying to manipulate them. One psychologist failed to view an inmate at an elevated risk of suicide even though he was giving away his possessions and had tried to kill himself before.
"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.
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