The character of correctional service provision and its supporting systems do not live in an easy and safe place, facing many challenges, while working to strengthen itself and the society in which it exists. There were 34 correctional services (CS) individuals, whose deaths by suicide were reviewed with the purpose of strengthening the system, by informing change for CS in Ontario, Canada and internationally.

During the review, over 90 individuals were consulted, organizational data shared, research reviewed, and a variety of perspectives provided. A broad perspective is required to support CSE at the individual, organizational and societal level. The integration and requirement of understanding that CS, whether institutional or community-based, acts to restore order and dignity to societies and allow for the safe return of individuals to co-existence in society while following the principles of human rights and dignity.

The review evaluated specific findings from the 34 individual death investigations independently and collectively. The de-identified findings of these investigations served as the original foundation for this report. As occupation data was not systematically collected by the death investigation system throughout the review period, additional CSE deaths may have occurred. Comments and references to their loved ones provided by families that were contacted remain anonymous. Many of the individuals participating in the review wished to maintain anonymity while other individuals and/or organizational entities are listed at the end of this report.

The 28 recommendations represent opportunities for change to strengthen the systems and supports for CSE. While there are many similarities across provincial and federally operated institutions and youth centers in Ontario, there are unique differences. As the recommendations were intended to address common systemic challenges for correctional service provision, they were prepared in a manner that applies across jurisdictions and services, whether public or private. While the information provided in this report was more informed by the provincial systems, the goal was not to compare the provincial and federal systems.

The broader themes of the recommendations are:

  1. Continued incorporation and attention to the principles of human rights and dignity.
  2. Continued engagement of recognition of individual CSE, their strengths, capabilities and the risks experienced in their respective jobs.
  3. Ensuring the continued coordination and independence of educational and specific services that are provided individually and organizationally to support wellness and health.

Participants and contributors recognized and acknowledged the work and efforts that have been made and accomplished to address many of the challenges while recognizing there is more to be done. There is optimism of further success given the profound desire, commitment and actions to continue to improve the condition of corrections and the wellbeing of each individual CSE. The review highlights many considerations that could help inform the path forward.

Broader considerations that were incorporated during the development of the recommendations were:

  • Recognition of CSE and their roles within their teams, the organization in context with its surroundings (institutional and public).
  • Training, pre- and post-placement.
  • Support systems, individual and organizational, including service provision for health and wellness.
  • Ensuring the identification and assessment of individual and organizational risks.
  • Data generation and analysis to inform service provision for CSE as well as to inform organizational policy and procedures.
  • Communication with individuals, teams and organizationally to ensure ongoing connection, understanding and clarity.
  • Service provision to families and friends of those who work as CSE, as well as those who leave, retire or die.
  • Surrounding agencies involved with CSE providing services that are sensitive and appropriate to ensure improved health and well-being.

The recommendations were developed in consultation with all members of a core review team. While attempts were made for consensus, given the diversity of thought and experience, there was no expectation of universal agreement with some recommendations remaining controversial. There is an expectation that there will be formal responses to these recommendations.

Culture change takes time and while actions in response to some recommendations may be initiated more quickly in some circumstances, other responses may reflect potential areas for innovative change and may take longer.

Each participant, through their own personal experience and strengths, motivated the writing of this report on a daily basis. It is with great humility and gratitude that we thank those who participated and with profound sorrow that we remember the lost lives and ongoing loss felt by the many impacted by their death.

Reuven Jhirad, MD MPH CCFP FCFP

Deputy Chief Coroner, Office of the Chief Coroner