Review of all inmate deaths within all facilities during 2024

The ministry is committed to providing transparency regarding any custodial-related deaths. A report is released annually on a reporting period that aligns with the previous calendar year. Data on all custodial-related deaths that occurred between January 1, 2024 and December 31, 2024, 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 use of suicide risk alerts and suicide watch alerts.

If a coroner’s investigation determines 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, 2024 and December 31, 2024, 46 (0.11%) inmates died out of a total population of 43,385 inmates in custody. These deaths include custodial deaths where an inmate 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 46 inmates who died in 2024, three inmates (6.5%) self-identified as female, while 43 (93.5%) self-identified as male. There were 28 inmates (60.9%) who had self-identified as white, seven (15.2%) as Indigenous, six (13.0%) as another race category or more than one reported category and five (10.9%) whose race was not known or not reported.

One (2.2%) inmate was between the age of 18 to 24, 26 (56.5%) inmates were between the ages of 25 and 49, and 19 (41.3%) were 50 or older.

Housing location

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

For the purposes of this report, the housing 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 restrictive 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, including medical units and infirmaries within institutions
• outside of a correctional facility, such as when an inmate died while in the ministry’s custody but before being admitted to an institution (for example, when an inmate is taken into the ministry’s custody at a hospital and dies prior to transfer to a correctional facility)

If an inmate was transferred from an institution to a hospital prior to death, the last known unit type is included in the report.

Medical cause of death by housing location

The means of death and medical cause 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 46 inmates covered in this report.

Information regarding the medical cause of death reflects the most current data available at the time of reporting and may be updated as additional findings are confirmed.

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 46 inmates include:

• 17 resulting from drug toxicity
• 19 from natural causes
• 10 due to a medical cause other than the categories above

In 2024, 35 (76.1%) inmates were in general population or protective custody units, seven (15.2%) were in specialized care units, three (6.5%) were in segregation conditions and one (2.2%) was outside of a facility.

Mental health alerts

Staff may use the following alerts in the Offender Tracking Information System (OTIS) 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 an inmate requires increased supervision such as frequent in-person checks due to a high-risk of suicide or self-harm

An initial mental health screening must be conducted within 48 hours of an inmate's admission to an institution. If the screening indicates a possible mental health condition, the inmate will be further assessed by health care professionals and may be referred to a psychiatrist or physician. All mental health alerts in OTIS must be verified by mental health professionals within 48 hours of being entered. The data for this report includes both verified and unverified mental health alerts recorded on the inmate’s file during their supervision period before death.

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 inmate’s stay in custody.

Serious mental illness alerts are also included in the list of mental health alerts in 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 (O. Reg.)
• an institutional staff member has determined that an inmate is experiencing at least one of a list of symptoms outlined in O. Reg. 778

Of the 46 inmate deaths examined in this report, nine inmates (19.6%) had a mental health alert, one (2.2%) had a suicide risk alert and two (4.3%) inmates had a suicide watch alert on file.