Correctional Service of Canada (CSC) Response to the Office of the Correctional Investigator's Deaths in Custody Study, the Correctional Investigator'

Correctional Service of Canada (CSC) Response to the Office of the Correctional Investigator's Deaths in Custody Study, the Correctional Investigator's Report: A Preventable Death and the CSC National Board of Investigation into the Death of an Offender at Grand Valley Institution for Women

Safeguarding the security and well-being of staff and offenders within our institutions is one of CSC 's fundamental responsibilities. CSC staff strive to provide offenders with an environment that is safe and secure where they receive appropriate treatment, programming and essential health care while they address the issues that led to the commission of their offences. This support assists offenders to become law-abiding citizens. It is through this work that CSC contributes to public safety.

CSC faces the difficult challenge of managing a significant number of high-needs offenders. The majority of offenders are admitted with drug or alcohol problems and the number of offenders convicted of violent offences has increased. Many offenders enter CSC institutions with identified mental health and behavioural problems, while others enter the system with no previous diagnosis or assessment of these needs.

Our staff work diligently to identify and address the needs of this population. They understand that addressing the needs of offenders with mental health problems in particular, not only reduces offenders' self-harming behaviours, but also reduces the risk they pose to others.

The death of any offender is a very tragic event and such events are taken very seriously by CSC. Despite best efforts to maintain offender safety and well-being, deaths in custody do occur. Any time an offender dies while in our custody, CSC conducts an investigation in an effort to prevent and reduce the occurrence of similar incidents in the future. In an effort to learn from these events, CSC develops and implements action plans, identifies significant findings and shares these with other institutions.

In 2007, the Office of the Correctional Investigator (OCI) released its Deaths in Custody Study which examined the circumstances surrounding 82 deaths that were not due to natural causes between 2001 and 2005. The Study also included a number of recommendations aimed at reducing future offender deaths.

Every day, thousands of correctional staff across the country interact with more than 13,000 incarcerated offenders in efforts to assist them with their rehabilitation and intervene when they are in distress.

We recognize the difficult reality, that despite the measures we have taken and those we plan to introduce in the future, some deaths in custody may not be preventable. However, we are committed to continuously identifying opportunities to improve our ability to anticipate and respond to these incidents, and to take all measures possible to prevent the death of offenders.

During the past five years, CSC has taken steps to reduce deaths in custody. We have improved many of our security practices and added better security equipment. Emphasis has been placed on our dynamic security practices based on the ongoing observation and interaction with offenders to prevent security incidents from happening and, if they do, to effectively address them in an expeditious manner.

We are continuously improving the range of correctional programs provided to offenders. Our programs are research-based and address a wide range of issues that may lead to criminal activity including violence, family violence, sexual offending, substance abuse and general criminality. CSC has also developed programming and interventions designed specifically for women, Aboriginal and special needs offenders. There is solid evidence that programs, based on sound research and theory, significantly contribute to the safe reintegration of offenders into the community.

The October 2007 death of offender Ashley Smith further highlighted issues of offender safety and the provision of treatment to offenders who demonstrate mental health and/or behavioural needs.

Improving CSC 's capacity to address offenders' mental health needs is one of our strategic priorities. We have developed an integrated Mental Health Strategy and implementation in many areas is under way, including enhanced mental health screening at intake and additional resources in regular institutions to provide care and support to offenders. We are also developing improved strategies for information sharing among key operational staff, intervening when offenders are in distress, and strengthening managerial accountabilities throughout the organization as they relate to preservation of life as well as deaths in custody.

CSC is working with its counterparts at the provincial and territorial levels as well as various subject matter experts and agencies to enhance our policies and practices around deaths in custody. In March 2009, we met with provincial and territorial Coroners and Chief Medical Examiners to dialogue on how to better address the issue of deaths in custody. We also convened a meeting of Federal, Provincial, and Territorial Heads of Corrections representatives to discuss and review best practices around preventing deaths in custody and to produce a summary of findings to share with all CSC staff. In addition, a forum was held in June 2009 to explore the nexus between Canada 's mental health and criminal justice systems. Participants examined the system-wide challenges to addressing mental health issues within the criminal justice system and mental health field, with the goal of formulating future steps and furthering the dialogue on how to address these challenges. The document below details the overall response CSC has developed with respect to the recommendations of the OCI Deaths in Custody Study, their investigation into the death of Ashley Smith and CSC 's own national investigation into her death. Some of the commitments outlined in the document have already been achieved. Others require ongoing work and attention over the longer term and are being addressed.

To ensure transparency and increase understanding of our efforts to effectively manage offenders with mental health and behavioural needs, CSC is making its response publicly available and will be working closely with the OCI to provide regular updates on our progress against the commitments.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 1: (Supported) The Office of the Correctional Investigator recommended that CSC implement and apply as widely as possible (including within men's facilities) all recommendations emanating from the CSC National Board of Investigation into the Death of an Offender at Grand Valley Institution and the Independent Psychological Report produced by Dr. Margo Rivera as part of that investigation. CSC has categorized the recommendations as follows: Administrative segregation Institutional transfers Security practices and Use of Force Interventions Service and support for women offenders with significant mental health and/or behavioural needs Training, staffing and resourcing The Women Offender Sector's role and mandate Values, ethics and disclosure	CSC acted immediately, following the death of Ashley Smith, to investigate and report on the circumstances surrounding her death and to take corrective action where necessary. CSC is addressing all recommendations from its National Board of Investigation and the Independent Psychological Report produced by Dr. Margo Rivera, which formed part of the CSC investigation, as they relate to women's facilities. As well, CSC will continue to assess and apply the learning from these reports to men's facilities.	ADMINISTRATIVE SEGREGATION CSC is taking steps to improve policies surrounding the incarceration of women offenders exhibiting mental health and/or behavioural needs in general, and in particular those placed in administrative segregation. As part of these improvements, CSC is undertaking the following initiatives: CSC has reviewed its capacity to address the needs of women offenders with mental health and behavioural needs. Short and long-term strategies have been developed on service, support and accommodation needs for women offenders identified in this group and will be pursued through regular Treasury Board processes. CSC has expanded its inter-disciplinary team approach to now include more precisely defined roles for Health Care and Psychology in the review process prior to, as well as during segregation placements. Secure interview rooms in the Secure Units of women's facilities are being created to allow for a separate space for staff and stakeholders to interact with offenders within a safe setting. Four out of five of these secure interview rooms are now being used. The fifth room will be ready for use in August 2009. CSC will undertake by April 2010 an operational examination of long-term segregation using a representative sampling methodology and an external review process.
Recommendation 1 - Continued		INSTITUTIONAL TRANSFERS To ensure that the offender's mental health needs are explicitly considered in all transfer decisions, the Commissioner's Directive 1 on transfers of offenders has been reviewed and is being amended. Amendments are expected to be finalized by September 2009. In the interim, a Case Management Bulletin was issued on May 9, 2008 to remind staff of paragraphs in Commissioner's Directive on prevention, management and response to suicide and self-Injuries, and to ensure that they apply the policy direction in the event of the transfer of relevant cases. The policy requires that no inmate considered imminently suicidal or self-injurious be transferred to an institution other than a treatment facility unless the Psychologist managing the case, in consultation with other health service professionals, deems that the transfer would reduce or eliminate the inmate's potential for suicide or self-injury. CSC has acted to address the increase in federally-sentenced women offenders and the resultant population pressures in its women's facilities by adding 45 beds to its women's institutions in general during fiscal year 2008-2009 (Fraser Valley Institution in British Columbia: eight beds; Grand Valley Institution for Women in Ontario: 30 beds; and Nova Institution for Women in Nova Scotia: seven beds).
Recommendation 1 - Continued		SECURITY PRACTICES AND USE OF FORCE INTERVENTIONS CSC has implemented new procedures to strengthen accountability in its security practices and use of force interventions. In addition, the issue of preservation of life has been communicated and reinforced extensively across the organization to all levels of staff. Specific discussions have taken place at the Executive Development Symposium for all senior leaders of the organization, at all regional management committee meetings and major union meetings at all sites across the country. In May 2008, CSC issued a Security Bulletin to clarify �immediate intervention� in response to suicidal and self-injurious offenders. Specifically, any item used by an offender to inflict or attempt to inflict self-harm requires an appropriate and immediate intervention by staff that is both safe and reasonable in order to seize/retrieve the item. The bulletin emphasized that preservation of life is the primary goal of the intervention. On April 1, 2009 , CSC revised its Use of Force policy to include: the ability of Correctional Managers, Crisis Managers and/or the Institutional Head to develop an �intervention plan� using line staff to manage a situation; the requirement to expedite use of force reviews of incidents that are identified by the Institutional Head as having serious violations of legislation or policy, or any other aspects which may cause serious concerns. This will ensure that serious incidents where staff have had to use force to manage offenders are reviewed quickly, issues identified, and corrective actions completed; and the reinforcement in policy of the current Guidelines for Health Services Responsibilities Related to Use of Force Incidents that allow for the use of certified first aid attendants, in the absence of a health care practitioner, to conduct post use of force first aid assessments.
Recommendation 1 - Continued		SERVICE AND SUPPORT FOR WOMEN OFFENDERS WITH SIGNIFICANT MENTAL HEALTH AND /OR BEHAVIOURAL NEEDS To enhance service and support for women offenders with mental health and/or behavioural needs, CSC has implemented a number of initiatives including: Assessing 14 women offenders, identified as having significant mental health and/or behavioural needs, using external clinical expertise to better inform their management. In addition, CSC has developed an internal Mobile Interdisciplinary Treatment Assessment and Consultation Team (MTAC) to assist with complex mental health cases. M TAC is an on-demand mobile skills-building team, comprised of CSC experts from various backgrounds. Members of the team provide consultation services to institutional staff as needed. On Aug. 1, 2009, CSC expanded the MTAC to include male offenders who exhibit significant mental health and/or behavioural needs. CSC has also expanded its inter-disciplinary team approach to now include more precisely defined roles for Health Care and Psychology in the review process prior to, as well as during, segregation placements. The Assistant Deputy Commissioners, Institutional Operations, Deputy Commissioner for Women and Wardens of women's institutions meet quarterly to discuss issues pertinent to women's facilities. Women's institutions share best practices as they relate to institutional operations. Discussions resulting from these meetings are documented for distribution to women's facilities and Regional Headquarters.
Recommendation 1 - Continued		TRAINING, STAFFING AND RESOURCING CSC has taken steps to ensure that training in mental health and dialectical behaviour therapy is provided to both managers and staff dealing with high-needs offenders. During fiscal year 2008-2009, CSC focused on the training of managers. Training of staff will continue during fiscal year 2009-2010 and beyond. CSC has also completed a pilot project on integrated mental health awareness and security training for front-line health, security and management staff, the three key groups critical to success in the effective management of the unique needs of women offenders. In 2009-2010, mental health training will be provided to Correctional Officers. CSC has developed a strategy to fill vacant positions at Grand Valley Institution to ensure that staff are in place, trained and effectively interacting with offenders. One hundred per cent of Primary Worker (correctional officer) positions are currently staffed, and a strategy is in place to ensure ongoing recruitment for future vacancies . The key management team positions have been fully staffed with the exception of two which are expected to be staffed by the end of September 2009. During fiscal year 2008-2009, CSC Psychologists received additional training in suicide risk assessment by an expert in forensic suicide assessment and prevention.
Recommendation 1 - Continued		WOMEN OFFENDER SECTOR'S ROLE AND MANDATE CSC has taken steps to communicate and reinforce to staff and stakeholders the Sector's role as the functional authority on women offenders. As such, the Sector provides guidance and advice to regional and institutional staff on corporate policy. Decisions related to the daily management of offenders remain with the Wardens of women's facilities, Regional Deputy Commissioners, and the Assistant Deputy Commissioners, Institutional Operations.
Recommendation 1 - Continued		VALUES, ETHICS AND DISCLOSURE CSC is committed to ensuring that all staff members conduct themselves within the highest ethical standard. To reinforce the importance of values and ethics, CSC is developing local ethics advisory committees and is in the process of establishing them at select operational sites. CSC is also providing a variety of workshops to staff members throughout CSC at all levels that include both operations and management. Regional Deputy Commissioners are also reinforcing to Wardens the importance of holding unit and town hall-type meetings to encourage increased staff dialogue and interaction. CSC is examining ways to increase its capacity to deliver additional Values and Ethics workshops across the Service. CSC is in the process of enhancing staff awareness of the Office of Internal Disclosure underscoring its availability to all CSC employees.

1 Commissioner's Directives are rules prescribed for the management of the Service as described in Section 97 of the Corrections and Conditional Release Act

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 2: (Supported) The Office of the Correctional Investigator recommended that the Correctional Service provide a full public accounting of its response to the OCI Deaths in Custody Study. This should include a detailed action plan with clearly identified outcomes and timeframes. Six themes have been identified that relate to the Deaths in Custody Study and CSC has categorized them as follows: Dynamic Security Ongoing Assessments Need to Enhance Provision of Intervention Services Physical Infrastructure Deficiencies Strengthening Managerial Accountabilities Additional Actions	The posting of this document is an important step in publicly sharing the initiatives that the Service is pursuing to address the issues identified in the Office of the Correctional Investigator study on deaths in custody. The corresponding actions contained in this document relate to recommendations made by the Office of the Correctional Investigator in the Deaths in Custody Study and his investigation into the death of Ashley Smith as well as CSC 's own Board of Investigation into her death.	DYNAMIC SECURITY Dynamic security is a key method of ensuring safety within our institutions. It requires that CSC staff members engage and interact directly with offenders to develop and maintain a knowledge of behaviours or factors that may compromise the safety of staff, offenders or the institution at large. As part of this process, staff members observe, speak with and interact with offenders in a meaningful way on a daily basis. CSC is taking the following steps to enhance dynamic security: Revising the Commissioner's Directive on Dynamic Security by fall 2009 to provide more direction with regard to responsibilities of both management and staff; Placing additional emphasis on dynamic security within the Correctional Training Program for Correctional Officers. The new Correctional Officer Training Program was piloted and is currently being delivered in the Pacific and Ontario regions. It is expected to be available in all other regions by March 31, 2010; Developing a Dynamic Security refresher course by 2010; In April 2009, letters of expectation were distributed 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; 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; 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 6:00 p.m. and 12:00 a.m. As well, as an increase in security patrols at all maximum, medium and multi-level institutions (excluding women's institutions) was introduced at the same time. CSC has confirmed that all institutional policies (standing orders and post orders) are in compliance with the Commissioner's Directive on 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 National Headquarters and taking corrective action when necessary; CSC has initiated a project to install high-resolution digital cameras in the cell range areas of all women's institutions. The project is scheduled to be completed in June 2011; and CSC is examining the use of alternate systems, including proximity card technology that identifies, tracks, and records the presence of Correctional Officers conducting security patrols and inmate counts, and is exploring the use of new technologies to enhance security and increase staff ability to verify offender well-being, especially during the night shift.
Recommendation 2 - Continued		ONGOING ASSESSMENTS Effective screening for mental health issues is key to ensuring the safety and security of offenders and staff within our institutions. CSC has taken the following steps to improve screening. An enhanced mental health screening tool was implemented at 13 intake assessment sites in fiscal year 2008-2009. Using empirically validated tools, offenders are being screened for depression, suicide risk and feelings of hopelessness. The tool will be in use at all 16 intake assessment sites by the end of fiscal year 2009-2010. During fiscal year 2008-2009, CSC Psychologists were provided training in suicide risk assessment by an expert in forensic suicide assessment and prevention. Guidelines on sharing mental health-related information will be developed by CSC and shared with staff to provide important reference points to follow when staff are considering what can be shared and under what circumstances. These guidelines will be in place by December 2009.
Recommendation 2 - Continued		NEED TO ENHANCE PROVISION OF INTERVENTION SERVICES CSC is taking steps to ensure adequate staff and resources are available to provide intervention services to offenders. As part of our efforts, CSC is proceeding with a review of the resources available and allocated to the care of women offenders to ensure their efficient use and capacity to achieve correctional results. The completion of the review is planned for summer 2009. Other steps taken include: New deployment standards for correctional staff implemented in April 2009. Developing a more effective approach to offender case management by focusing psychological and specialized assessment resources on the highest risk/needs offenders. It will be in place by the end of fiscal year 2009-2010. As part of amendments to the Commissioner's Directive on Prevention, Management and Response to Suicide and Self-Injuries, CSC will gather information about the use of psychological and psychiatric services in the assessment and intervention of offenders at risk for suicide or self-injury. Consultation on this phase of amendments will begin in March 2010. An expert consultant is advising CSC on best practices in the assessment of risk of suicide and self-injury and in intervention techniques for offenders at risk. The advice will assist CSC 's efforts to make improvements to the existing Commissioner's Directive on Prevention, Management and Response to Suicide and Self-Injuries. The consultant is expected to provide advice on processes to allow for the sharing of information between staff when an inmate is exhibiting suicidal or self-harming ideations. CSC has adapted the Women's Violence Prevention Program to allow for delivery to women offenders in the Secure Units or Segregation Units. This will be piloted by fall 2009.
Recommendation 2 - Continued		PHYSICAL INFRASTRUCTURE DEFICIENCIES CSC 's physical infrastructure does not necessarily allow for the continuous surveillance of offenders and intervention efforts when needed. As a result, CSC is compiling a review of construction-related deficiencies identified in reports, reviews and investigations to develop appropriate criteria for future construction projects. Mitigating strategies for identified deficiencies will be developed during 2009-2010.
Recommendation 2 - Continued		STRENGTHENING MANAGERIAL ACCOUNTABILITIES Strong managerial accountabilities are key to assisting CSC in effectively responding to and preventing deaths in custody. CSC has made considerable progress over the past year in improving the quality of its investigations and ensuring that they are completed within newly-established timeframes. The policy provides for normal investigations to be completed and prepared for Senior Management review for closure within six months from the date of the incident. In certain circumstances the investigative process may take longer because of different complexities. If necessary, CSC implements corrective measures immediately following incidents at the local level while the investigative process gets underway. Quarterly summaries highlighting all pertinent issues and statistical information around deaths in custody (excluding deaths by natural causes) will be shared with the Office of the Correctional Investigator commencing in September 2009. In addition, these summaries will be provided to all regional and institutional management committees to share all findings and management actions as part of their meeting agendas on a quarterly basis commencing in October 2009. An independent review group will be formed to assess CSC 's actions and responses to deaths in custody on an annual basis. A proposed membership and terms of reference for this group will be developed by the end of September 2009. All deaths in custody are investigated by the Service under Section 19 of the Corrections and Conditional Release Act . The findings and recommendations resulting from these investigations lead to the development of corrective measures/action plans at the operational, regional and/or national levels as appropriate, and are monitored for verification purposes. Findings and issues raised in reports are used to develop and implement action plans and significant findings. CSC shares these with the applicable operational unit so that staff can learn from the incident. These are also shared with other institutions so that CSC can reduce the chances of similar future incidents. Regular meetings of the Executive Committee include review of the investigation reports and corrective measures for each death in custody. The results of these reviews are then shared at the regional and operational levels.
Recommendation 2 - Continued		ADDITIONAL ACTIONS CSC 's commitment to enhancing our capacity to assess and respond to issues related to preventable deaths in custody has been included in the Report on Plans and Priorities to Parliament for 2009-2010.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 3: (Not Supported) The Office of the Correctional Investigator recommended that CSC group its women facilities under a reporting structure independent of the regions, with the Wardens reporting directly to the Deputy Commissioner for 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 was the most effective governance structure. The CSC Review Panel also supported the functional authority model. The Regional Deputy Commissioners have full and direct line authority over the women offender institutions and direct the activities of the Assistant Deputy Commissioners, Institutional Operations who are responsible for managing operational issues. The Deputy Commissioner for Women works in co-operation with the Regional Deputy Commissioners and supports the Wardens of the women offender institutions through collaboration with the Assistant Deputy Commissioners, Institutional Operations. CSC continues to believe that a robust functional role and strong leadership by the Deputy Commissioner for Women, rather than a line authority model, is the most appropriate approach. The roles and responsibilities of the Deputy Commissioner for Women have been clarified and communicated to National Headquarters, the regions and the women's institutions.	The role and responsibilities of the Deputy Commissioner for Women and the Women Offender Sector have been clarified and communicated to National Headquarters, the regions and women's institutions. Ongoing discussions will take place to clarify for the Office of the Correctional Investigator how issues of concern in women's facilities can be brought to the national level when some urgency or serious difference of opinion exists relating to the care provided to women offenders.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 4: (Supported)The Office of the Correctional Investigator recommended that CSC issue immediate direction to all staff regarding the legislated requirement to take into consideration each offender's state of health and health care needs (including mental health) in all decisions affecting offenders, including decisions relating to institutional placements, transfers, administrative segregation and disciplinary matters. CSC decision-related documentation must provide evidence that the decision-maker considered the offender's physical and mental health care needs.	CSC has provided direction to its operational staff to reinforce the importance of the requirement to take into consideration each offender's state of health and health care needs in all decisions, including regional administrative segregation reviews.	The Commissioner's Directive on Administrative Segregation was amended in November 2007 to make the following changes: New annexes were created to provide guidelines for: Segregation Placement/Admission, Segregation Review Board Report Content, and Mental Health Assessment for Administrative Segregation. Each of these guidelines requires that an offender's state of health and health care needs be explicitly considered and documented when making an administrative segregation decision. In 2010-2011, CSC will conduct a management review to assess the level of compliance with this direction. Changes in policy objectives, expanded definitions and the formalization of a number of principles; Clearer identification of roles and responsibilities in administrative segregation at the national, regional, and institutional levels; Clearer direction on responsibilities related to administrative segregation; Provision of psychological opinions for administrative segregation cases; and Establishing a role for Health Care and Psychology to supplement the existing review mechanisms for long-term segregation placements. As well, a segregation handbook for staff has been produced and distributed to clarify the policy expectation for the timely review of these cases.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 5: (Supported) The Office of the Correctional Investigator recommended that CSC immediately review all cases of long-term segregation where mental health issues were a contributing factor to the segregation placement. Particular attention should be paid to inmates with histories of suicide attempts or self-injurious behaviours. Results of this review should be provided to the institutional heads and Regional Deputy Commissioners and, in the case of women offenders, to the Deputy Commissioner for Women.	In each CSC region, the Assistant Deputy Commissioner, Institutional Operations, is responsible for reviewing each long-term segregation case at 60 and 120 days. In addition, they must conduct verifications and site audits to ensure the regional review process has been properly implemented. CSC continues to rely on registered psychologists to conduct an assessment and evaluate each offender within 25 days of their admission to segregation and every 60 days thereafter. This is in addition to an initial assessment that is completed by a health care professional on admission to a segregation unit.	CSC conducts reviews of all cases where an offender remains on �segregation status� for a period exceeding 60 days. This includes those offenders in the transition and special units in CSC facilities where the offender is segregated from the general offender population. The addition of offenders in transition and special units increases the focus on those offenders where mental health issues were a contributing factor to the segregation placement. Particular attention is paid to offenders with histories of suicide attempts or self-injurious behaviours. CSC agrees that administrative segregation is a concern in correctional settings and, as a result, will undertake, by April 2010, an operational examination of long-term segregation using representative sampling methodology and an external review process.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 6: (Supported) The Office of the Correctional Investigator recommended that CSC seek independent expertise � with a strong women-centred component � to review its policies on managing self-injuring inmates, and inmates displaying challenging behavioural issues. This review should focus on the appropriateness of placing those inmates on administrative segregation status.	CSC has initiated a review of its policies on managing self-injuring offenders both internally and with the assistance of an expert consultant. Following this work, CSC will be initiating an external operational review of the segregation process.	CSC has reviewed its capacity to address the needs of women offenders with mental health and/or behavioural needs. Short and long-term strategies have been developed on service, support and accommodation needs for women offenders identified in this group. An expert consultant will assist CSC efforts at making improvements to its Commissioner's Directive on Prevention, Management and Response to Suicide and Self-Injuries. Enhancements to the policy will include improved communication to front-line staff of offenders' risk levels and observation status. The expert will also advise CSC on best practices in the assessment of suicide and self-injury risk. Standardized tools and guidelines for use in developing plans to address self-harming behaviours are being developed for use by operational staff and will be finalized by end of August 2009.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 7: (Not Supported) The Office of the Correctional Investigator recommended that all CSC National Boards of Investigation into incidents of suicide and self-injury be chaired by an independent mental health professional.	The Commissioner's Directive on Incident Investigations was revised in August 2007 to indicate that investigations into incidents involving health care issues will normally include a registered health care professional on the CSC Board of Investigation. The present CSC policy allows for greater flexibility in determining and ensuring that the appropriate level of health care expertise and representation is involved during the different types of investigations. National Boards of Investigation can also seek out and augment their investigative teams, where deemed appropriate, with a wide variety of external experts and specialists.	CSC will continue to use its existing process and ensure that each Board of Investigation understands that it can access a wide variety of external experts and specialists as deemed necessary.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 8: (Supported in part) The Office of the Correctional Investigator recommended that CSC review and revise its administrative segregation practices to ensure that all long-term segregation placements are reviewed by regional managers, inclusive of health care, after 60 days of segregation. They further recommended in those cases where segregation status is maintained, that the decision and supporting documentation be referred to the Senior Deputy Commissioner and, in the cases of women offenders, to the Deputy Commissioner for Women.	The Commissioner's Directive on Administrative Segregation provides guidelines for segregation/admission, Regional Segregation Review Boards, Regional Oversight Managers, how to run a Segregation Review Board, Segregation Review Board report content and providing psychological opinions for administrative segregation cases. In cases where the regions deem it appropriate, they may refer cases to the Senior Deputy Commissioner or Deputy Commissioner for Women for review and/or advice. As well, the OCI, as has been done in the past, can request the Senior Deputy Commissioner or Deputy Commissioner for Women review a particular case.	Regional Segregation Review Boards and Regional Segregation Oversight Managers are in place across CSC to perform the delegated responsibilities of the regional reviews and to ensure that the case of each inmate in segregation is reviewed regionally every 60 days. Regional Segregation Oversight Managers conduct and follow-up on action plans that result from administrative segregation audits. An inmate placed in segregation is visited by a Registered Nurse at the time of admission or without delay, and thereafter daily, to determine whether there are any health concerns resulting from the placement or any concerns for risk of suicide or self-harm. At least once within the first 25 consecutive days of an inmate's placement in segregation and once every subsequent 60 days, a Psychologist will provide a written psychological opinion on the inmate's mental health status at the time of assessment, with a special emphasis on the evaluation of the risk for self-harm. Institutional Segregation Review Boards, which may include ad hoc members such as Health Services staff, conduct hearings within five working days after the inmate's confinement in administrative segregation, and at least once every 30 calendar days following placement.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 9: (Supported in part) The Office of the Correctional Investigator recommended that CSC amend its segregation policy to require that a psychological review of the inmate's current mental health status, with a special emphasis on the evaluation of the risk for self-harm, be completed within 24 hours of the inmate's placement in segregation.	Within 24 hours of admission to segregation, an offender's mental health needs and physical health needs are assessed by a medical professional, and appropriate referrals to psychology are made as required. CSC will continue to draw on its security, intervention and physical and mental health care resources to assess and manage these cases.	Currently, the Commissioner's Directive on Administrative Segregation requires that at the time an offender is admitted to administrative segregation: Within 24 hours a Registered Nurse assess whether there are any health concerns resulting from the placement in administrative segregation, including mental health issues such as risk of suicide or self-harm. The assessment will be documented through the relevant sections of the segregation log to ensure these issues are addressed. Appropriate referrals are made to Psychology on an urgent basis. A follow-up reminder will be issued in August 2009 to reinforce the importance of performing and documenting physical and mental health assessments during these daily visits. Policy also requires that upon admission to segregation: a written psychological opinion on the offender's current mental health status with a special emphasis on the evaluation of the risk for self-harm be provided by a Psychologist at day 25 and every 60 days thereafter. Policy also requires that upon admission to segregation: Nursing staff visit the segregation areas on a daily basis to assess offenders and deal with concerns that may arise and seek out additional advice and expertise as required. Correctional officers interact with offenders in the segregation units on a regular basis every day and are able to ascertain any changes in the mood or behaviours of offenders. The Institutional Head or a delegate, not below the level of Correctional Manager, is required to visit segregation once a day to ensure conditions of confinement are in compliance with the law.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 10: (Not Supported) The Office of the Correctional Investigator recommended that CSC immediately implement independent adjudication of segregation placements of inmates with mental health concerns. This review should be completed within 30 days of the placement and the adjudicator's decision should be forwarded to the Regional Deputy Commissioner. In the case of a woman inmate, the adjudicator's decision should be forwarded to the Deputy Commissioner for Women.	CSC does not support the recommendation. However, CSC will be exploring other options that may lead to a revised review process of these segregation placements.	In the interim, CSC has introduced a National Population Management Committee to provide national monitoring of the use of administrative segregation. This committee has met and will meet on a regular basis and has established terms of reference. The Women Offender Sector will continue to provide input and support and perform a functional oversight role regarding women offenders placed in segregation. By April 2010, CSC will undertake an operational examination of segregation placements of inmates with mental health concerns using a representative sampling methodology and an external review process.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 11 : (Supported in part) The Office of the Correctional Investigator recommended that the Situation Management Model be modified to require staff give consideration to an offender's history of self-harm and his/her potential for future or cumulative self-harm when determining whether immediate intervention is required.	With respect to the CSC Situation Management Model, the existing model requires staff to consider the offender's �past behaviour� during and throughout the incident in question. This includes giving consideration to an offender's history of self-harm and the potential for future or cumulative self-harm when determining whether immediate intervention is required. However, CSC will clarify that �past behaviour� includes an offender's history of self-harm.	The issue of preservation of life as a paramount responsibility has been communicated and reinforced extensively across the organization at all levels of staff, both verbally and in writing. (Security Bulletin dated May 30, 2008) Each incident of self-harm or medical distress is assessed at the operational and regional levels for compliance with policy. Corrective action is taken if necessary. Furthermore, weekly reports containing statistics on offenders who self-harm are sent to the regions to bring their attention to these cases for further action, if required. CSC will issue a bulletin by September 2009 clarifying that �past behaviour� includes an offender's history of self-harm.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 12: (Supported) The Office of the Correctional Investigator recommended that the Senior Deputy Commissioner review all of the complaints and the Service's response to those complaints that were submitted by Ms. Smith during her period of federal incarceration, inclusive of the complaint submitted by Ms. Smith in September 2007 at Grand Valley Institution. A written response to these complaints should be issued and appropriate corrective action and policy clarification should be undertaken.	CSC has completed the review of all known complaints and grievances filed by Ms. Smith.	A written response has been completed for all complaints and grievances submitted and a summary report has been shared with the Office of the Correctional Investigator. Procedures for collecting and receiving segregation grievances at all institutions were reviewed and recommendations were made to ensure confidential, complete access to the process, as well as expeditious receipt of complaints and grievances across the Service. This was solidified with changes to the Commissioner's Directive on Offender Complaints and Grievances. A review of the access to the grievance process at Grand Valley Institution for Women occurred and changes were made to ensure timely, effective and appropriate responses. Training sessions were delivered with the institutional staff at Grand Valley Institution for Women on how to process and respond to grievances.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 13: (Supported in part) The Office of the Correctional Investigator recommended that all grievances related to the conditions of confinement or treatment in segregation be referred as a priority to the institutional head and be immediately addressed.	In response to this recommendation, the Commissioner's Directive on Offender Complaints and Grievances was amended in 2008 to ensure that complaints and grievances submitted by segregated offenders are identified daily and monitored regularly.	Grievance procedures and policies were adjusted to ensure that: On admission to segregation/placed on cell confinement status, offenders be informed they can lodge complaints and grievances about segregation, confinement conditions, and treatment. This includes their right to address sensitive or urgent requests to the Institutional Head in a sealed envelope. The Institutional Head must ensure that complaints and grievances submitted by segregated offenders are collected and reviewed daily. Should the grievance subject warrant high priority as per the criteria established in the Offender Complaint and Grievance Procedures Manual, it will be brought immediately to the attention of the Institutional Head. High priority includes matters that have a direct effect on life, liberty or security of the person or that relate to a griever's access to the complaint and grievance process.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 14: (Supported) The Office of the Correctional Investigator recommended, once again, that CSC immediately commission an external review of its operations and policies in the area of inmate grievances to ensure fair and expeditious resolution of offenders' complaints and grievances at all levels of the process.	The grievance system has been the subject of a comprehensive internal audit. CSC will undertake an external review of the offender complaints and grievance process.	The internal audit has been completed. The final audit report and initial action plans were presented to the CSC Audit Committee, which is made up of three external members, in May 2009. Actions to address findings of the internal audit, based on the recommendations and approval of the audit committee, are underway. Of the eight recommendations, five will be completed during calendar year 2009. The remaining three will be completed in 2010. This fiscal year, CSC will develop a process for an external review of the Offender Complaint and Grievance process. Development of the process will follow consultations with key stakeholders, including the Correctional Investigator.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 15: The Office of the Correctional Investigator recommended that the Minister of Public Safety, together with the Minister of Health, initiate discussions with their provincial/ territorial counterparts and non-governmental stakeholders regarding how to best engage the Mental Health Commission of Canada on the development of a national strategy for corrections that would ensure a better co-ordination among federal/ provincial/ territorial correctional and mental health systems. The development of the national strategy should focus on information sharing between jurisdictions and promote a seamless delivery of mental health services to offenders.	CSC will contribute, where appropriate, and support discussions and consultations aimed at improving models of co-ordination consistent with the direction established by the Mental Health Commission of Canada.	In support of the recommendation, CSC has taken steps to develop a cross-jurisdictional approach to mental health services that includes identifying gaps in the continuum of care, building stronger partnerships with stakeholders outside of the federal correctional system, and developing innovative solutions. In May 2008, CSC hosted a Symposium on Mental Health that brought together international and Canadian experts to examine practical solutions to improving delivery of health services. More recently, on June 2009, CSC held a forum that explored the nexus between Canada 's mental health and criminal justice systems. Participants, who included the chair of the Mental Health Commission of Canada and experts in the fields of mental health and criminal justice, examined the system-wide challenges of addressing mental health issues within the criminal justice system and the mental health field. CSC will continue work that fosters information sharing between jurisdictions and the development of a national mental health strategy for corrections.

Recommendation	CSC Response	Key Actions/Commitments
Recommendation 16: (Supported) The Office of the Correctional Investigator recommended that the CSC undertake a broad consultation with federal/ provincial/ territorial and non-governmental partners to review the provision of health care to federal offenders and to propose alternative models for the provision of these services. The development of alternative models should include public consultations.	CSC is a member of the Federal/ Provincial/ Territorial Heads of Corrections Working Group on Health. The group works collaboratively to promote policy and program development that is informed and sensitive to the complex issues surrounding health. The group also encourages and develops effective strategies to address health care issues in the correctional environment collaboratively between governments and community stakeholders and advises Heads of Corrections accordingly. CSC also chairs the Federal/ Provincial/ Territorial Heads of Corrections Working Group on Mental Health, which includes membership from the Mental Health Commission of Canada. The group, which first met in February 2009, will share best practices for assessment, treatment, training and discharge planning. The group will meet again in September 2009. CSC also works closely with other partners, including provincial coroners' offices, to discuss opportunities to prevent future deaths in custody. For example, in March 2009, CSC held a meeting with the Coroners and Medical Examiners from across Canada to discuss information sharing and to reinforce our commitment to co-operation.	In 2010, CSC will review the status of efforts with federal/ provincial/ territorial and non-governmental partners to address these complex issues and will then develop a framework to assess alternative models for the provision of health care services to federal offenders.