Review of all inmate deaths within all facilities during 2023

The ministry is committed to providing transparency regarding any custodial-related deaths. Data on all custodial-related deaths that occurred between January 1, 2023 and December 31, 2023, is available on the Open Data Catalogue.

The data is disaggregated based on:

• individuals with mental health alerts
• demographics including age, gender and race
• housing location
• region

Depending on the circumstances surrounding a custodial-related death, several investigations may occur, including:

• a death investigation by the Office of the Chief Coroner to determine the cause and means of death
• a local police investigation to determine if the death resulted from any criminal activity
• an internal investigation to determine whether all ministry policies and procedures were followed with respect to the care and custody of the inmate

The ministry is committed to ensuring the safety and security of all inmates. It is ministry policy that all institutional staff are responsible for the care of inmates. If staff believe that an inmate may pose a danger to themselves or others, staff must alert the appropriate officials and take necessary steps to ensure the safety of all involved. Suicide awareness training is required for all corrections and healthcare staff. Protocols are in place to care for inmates who are at risk for suicide, including the initiation of suicide risk alerts and suicide watch alerts.

If a coroner’s investigation determines that a death was not a result of natural causes, a mandatory inquest is called to examine the circumstances. Examples of natural causes can include internal body or organ failure not caused by external factors, a pre-existing health condition, or illness that could lead to death. The ministry carefully reviews and considers recommendations from an inquest to help prevent similar incidents from occurring in the future.

Demographics

Between January 1, 2023 and December 31, 2023, 33 (0.09%) inmates died out of a total population of 35,593 unique individuals in custody. These deaths include custodial deaths where an individual was under the ministry’s supervision, either inside an institution or escorted in the community (for example, at a hospital). It does not include those who were in police custody, on an unescorted temporary absence pass, on parole, in the custody of the Canada Border Security Agency or had their charges stayed.

Of the inmates who died in 2023, two inmates (6%) self-identified as female, while 31 (94%) self-identified as male. There were 20 inmates (61%) who had self-identified as white, 10 (30%) self-identified as Indigenous, and three (9%) identified as another race category or reported more than one race.

Twenty-three (70%) inmates were between the ages of 25 and 49, and 10 (30%) were 50 or older.

Housing location

The ministry collects and analyzes information on all custodial-related deaths.

For the purposes of this report, the location prior to death has been organized into the following four categories:

• general population or protective custody units
• segregation conditions, where an inmate was in highly restricted conditions for 22 to 24 hours or does not receive a minimum of two hours of meaningful social interaction each day, excluding in circumstances of an unscheduled lockdown
• specialized care units, where an inmate was held in a unit that is neither segregation nor general population and may be subject to some level of restriction on movement or interactions with others. For the purposes of this review, specialized care units include medical units and infirmaries within institutions
• outside of a correctional facility, such as cases where an inmate was not within the ministry’s custody at the time of death

Where an inmate was transferred to a hospital prior to death, the last known unit type has been included in the report.

Medical cause of death by housing location

The means of death are determined by the Office of the Chief Coroner through a death investigation or an inquest. The official means of death have not been declared for all 33 inmates covered in this report.

The medical cause of death is determined by the Office of the Chief Coroner. For the purposes of this report, the specific medical causes of death from the Office of the Chief Coroner have been consolidated into categories by the ministry. The medical causes of death for the 33 inmates include:

• 11 from natural causes
• 16 resulting from drug toxicity
• six due to a medical cause other than the categories above

In 2023, 25 (76%) individuals were in general population units, four (12%) were in specialized care units, and four (12%) were in segregation conditions. 

Mental health alerts

Staff may initiate the following alerts for inmates:

• mental health alert, if the inmate discloses a history of a mental health condition, is showing signs that may indicate presence of a mental illness, or has disclosed thoughts about self-harm or suicide
• suicide risk alert, if the inmate had previous suicide attempts or is at risk of posing harm to themselves or requires enhanced supervision
• suicide watch alert, which is a type of suicide risk alert that indicates when an inmate requires increased supervision such as frequent in-person checks due to a high-risk of suicide or self-harm and requires increased supervision

An initial mental health screening is required within 48 hours of an inmate being admitted to an institution. If an inmate screens positive for a possible mental health condition, they are further assessed by health care professionals and may be referred to a psychiatrist or physician. Additionally, inmates are also reassessed for mental health care needs at least once every six months of continuous custody. Mental health professionals are required to add mental health alerts, verify new and existing mental health alerts and expire inactive alerts as appropriate throughout an individual’s stay in custody.

Serious Mental Illness alerts are also included in the list of mental health alerts in the ministry’s Offender Tracking Information System (OTIS). The identification of an inmate requiring a serious mental illness alert is made when one of the following criteria occurs:

• a regulated health professional who is qualified to make diagnoses within their clinical scope considers the inmate to be experiencing at least one disorder as identified in Ontario Regulation 778
• an institutional staff member has determined that an inmate is experiencing at least one of a list of symptoms outlined in Ontario Regulation 778.

All mental health alerts are required to be verified by mental health professionals. Healthcare staff are required to assess individuals and verify mental health alerts in OTIS within 48 hours of the alert being entered. As a result, the data for this release includes both verified and unverified mental health alerts recorded on the inmate’s file for the period of supervision prior to death.

Of the 33 individual deaths examined in this report, five individuals (15%) had a mental health alert and one individual had a suicide risk alert on file.