Any death by suicide is traumatic and affects everyone who knew that individual, their family, friends, co-workers, and acquaintances. Those impacted by suicide include the bereaved and anyone exposed to knowledge of the death whether directly or indirectly. The pain and suffering that a person was enduring prior to the suicide does not end with their death, instead it is passed on to those left behind. Postvention, as an essential component when a death by suicide occurs, includes all the actions that are carried out to help those impacted recover and/or heal while preventing any further harms.

This Deputy Chief Coroner (DCC) Review is focused on the deaths by suicide in Ontario of individuals who were (or had been) working in a federal or provincial correctional services (CS) position. A guiding priority was to better understand their workplace, and the challenges and hazards inherent to their positions. This understanding was essential to inform the development of recommendations aimed at reducing risks, preventing further deaths by suicide and decreasing the subsequent harm to those who surround and support them. As a mandate of the Office of the Chief Coroner and Ontario Forensic Pathology Service (OCC/OFPS), there are no findings of fault or blame in this report.

Correctional service employees (CSE) often face the challenges inherent to their positions in the shadows; by shining a light on these challenges we can better understand, appreciate, support and inform these individuals on how to improve their health and wellbeing.

In January 2023, An Obligation to Prevent – Report from the Ontario Chief Coroner’s Expert Panel on Deaths in Custody was released indicating that any one death of those in custody was “one too many.” In September 2019, Staying Visible, Staying Connected, For Life: Report of the Expert Panel on Police Officer Deaths by Suicide, was released by the Office of the Chief Coroner. The report reviewed the deaths of nine police officers who died by suicide in the previous year (2018) and provided recommendations to prevent further deaths. A 2019 report by the Office of the Auditor General of Ontario related to adult correctional institutions highlighted many challenges that existed for CSE and other staff. CSE are a subset of public safety personnel (PSP). The OCC/OFPS, recognized the importance of a dedicated review given the risks and challenges inherent to CSE work.

Humane and appropriate provision of CS is an important requirement of any just and democratic society. Those who develop, oversee, and provide security and rehabilitative services are required to ensure effective and appropriate approaches that do not adversely impact the physical and mental health of CSEs. This is the shared responsibility of correctional service management, government policies and legislation, staff and unions, and the public. An important principle of this DCC review is that CSE deaths by suicide must not be considered a potential or expected outcome of their employment. This is representative of systemic challenges and risks that exist and impact on the individual CSE.

The health and well-being of many current and former CSE have been significantly and adversely impacted. In this report, the OCC/OFPS reviewed the deaths by suicide of 17 individuals that occurred between 2010 and 2019 that were current or former correctional services employees and 17 additional deaths that occurred in the five-year period of 2020-2024 (the same number of deaths in half the time period). While the review was focused on 34 deaths, the recommendations are anticipated to impact on the health and wellness of the majority of CSE as they continue in their occupation. (Note: there are likely additional deceased persons that were not included in our review because their occupation was not documented or there was an undetermined conclusion from their death investigation.)

The physical and mental health burden, suffering in silence, and impact on those working within the field was made clear by those who participated in the review. The report will hopefully help to ensure that those who choose to work in the CS field understand the nature of their jobs and that the risks and challenges of their jobs are mitigated. Enhancements in the well-being of CSE would, in turn, help improve the health and safety of justice-involved persons. (Note: this term will be used as a general term to refer to people who are incarcerated [in closed custody] or under community supervision [probation/parole]).

The greater than 90 participants of this review, all of whom consented to participate, included: staff in provincial and federal correctional services (adult and youth justice), union-related staff, CSEs, researchers, friends and families of CSE, health service providers, and other experts.

DCC Review objectives were outlined in the Terms of Reference (Appendix B1):

  1. Review multiple, previously investigated deaths of a correctional service worker (if occupation was documented) whose death was classified with a manner of suicide, for the purpose set out in clause 15 (1) (c) of the Coroners Act.
  2. To aid the DCC regarding the review of the circumstances of the death in the cases reviewed. The cases will be reviewed from two-time cohorts 2010—2019 and 2020—2024.
  3. To determine the relevant information and considerations for the review.
  4. To assist in the development of a comprehensive, holistic understanding of correctional service workers in Ontario, the death circumstances during suicide, their intersections with government and broader public sector service systems, and the regulation and enforcement of health and safety standards for their protection.
  5. To help identify local or systemic issues or gaps to facilitate the development of recommendations to prevent further deaths of correctional service workers in Ontario, with specific attention to any prevention-related factors.
  6. To help identify trends or risk factors from the cases reviewed to inform recommendations for intervention and prevention strategies.
  7. To employ public-health related principles, evidence-informed and targeted to ensure a population-health approach for recommendations that will impact on prevention.

Suicide, within the context of this review, was not seen as a pathological outcome, with a traditional medical model approach, but rather as system based. This concern was discussed with all those involved to generate recommendations to improve the system and prevent further deaths.

The commitment of all those who participated was significant and inspiring. It was encouraging to see the dedication, commitment and desire for there to be effective, meaningful and substantive change to ensure the health and wellbeing of all the CSE and to prevent further deaths by suicide.

Those working in a CS environment regularly experience challenging dynamics in three significant areas:

  1. Team dynamics: the specific interactions and impact of the specific group of individuals with whom a CSE works and the organization.
  2. CSE Interactions: the interaction of the CSE with those that are being supervised in an institutional or community setting.
  3. Public Impact: the impact of public opinion, awareness and the limited understanding and respect that is often provided to CSE in the provision of their occupational responsibilities.

Informed by the review process, this report discusses the complexity of CS provision in the context of services provided in Ontario. Considerations of potential interventions led to the development of the 28 recommendations.