Review of all inmate deaths within all facilities during 2021
The ministry is committed to providing greater transparency regarding any custodial-related deaths. The ministry is releasing data on all custodial-related deaths that occurred between January 1, 2021 and December 31, 2021.
The data is disaggregated based on:
- individuals with mental health disabilities (including risk of suicide or self-harm) whether identified through mental health alerts, mental health screening and reassessment, or by being reported and confirmed
- demographics including age, gender and race
- location of death
- 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 the ministry’s 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. Death inquest reports and schedule of inquests are publicly available.
Demographics
Between January 1, 2021 and December 31, 2021, 49 (0.16%) inmates died out of a total population of 30,244 unique individuals in custody. These deaths include custodial deaths where an individual was under the ministry’s supervision, as well as non-custodial deaths where an individual may have been on an unescorted temporary absence pass, on parole, in police custody, in custody of the Canada Border Security Agency, or had their charges stayed.
Of the inmates who died in 2021, six inmates (12%) self-identified as female, while 43 (88%) self-identified as male. There were 16 inmates (33%) who had self-identified as white, two (4%) self-identified as Indigenous, five (10%) self-identified as black, two (4%) identified as middle eastern, and three (6%) identified as another race category. The race of the remaining twenty-one individuals (43%) was unknown or not reported.
Four (8%) inmates were under the age of 25 at the time of death, 27 (55%) inmates were between the ages of 25 and 49, and 18 (37%) were 50 or older. Further breakdown of this information by cause of death is available in the addendum.
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 highly restricted in movement and association with others for 22 hours or more per day
- 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 gender, race and 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 45 inmates covered in this report. For the four occurrences where the means of death was officially declared, they were determined to be the result of natural causes.
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 cause of death for the 49 inmates include:
- 33 unknown to the ministry at the time of this release
- five resulting from drug toxicity
- four as a result of natural causes
- seven as a result of a medical cause other than the above categories
In 2021, 27 (55%) deaths occurred within general population units, 11 (23%) in specialized care units, five (10%) in segregation conditions, and 6 (12%) deaths occurred outside of a correctional facility. Further analysis of this information is available in the addendum.
| Medical cause of death | General population or protective custody unit | Specialized care unit | Segregation conditions | Outside of a facility | Grand total |
|---|---|---|---|---|---|
| Drug toxicity | 4 | 1 | 0 | 0 | 5 |
| Natural causes | 1 | 3 | 0 | 0 | 4 |
| Other | 3 | 2 | 1 | 1 | 7 |
| Unknown | 19 | 5 | 4 | 5 | 33 |
| Grand total | 27 | 11 | 5 | 6 | 49 |
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.
All mental health alerts are required to be verified by mental health professionals. Health care staff are required to assess individuals and verify mental health alerts in the ministry’s Offender Tracking Information System (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.
| Housing unit type | Mental health alert | Suicide risk alert | Suicide watch alert |
|---|---|---|---|
| General population or protective custody unit | 13 | 9 | 1 |
| Specialized care unit | 4 | 4 | 0 |
| Segregation conditions | 5 | 0 | 0 |
| Outside of a facility | 1 | 1 | 1 |
| Grand Total | 23 | 14 | 2 |
Of the 49 individual deaths examined in this report, 23 individuals (47%) had a mental health alert on their file and 14 (29%) had a suicide risk alert. Two inmates (4%) had a suicide watch alert on file. Further analysis of this information by cause of death is available in the addendum.