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Foreword: Lost lives that must matter to all of us

Any death that occurs in the custody of a provincial correctional facility is one too many. The persons who enter custody do so for a wide range of reasons, and at their point of entry they surrender almost all autonomous control over their well-being. They have every reason to expect that those who assume control over so many aspects of their lives will at minimum protect them from harm and unwellness, while also continuously respecting their dignity and their human rights.  These individuals matter to their families and friends. Moreover, their well-being and safe return is tied to our entire society’s expectations for justice and public safety. Any failure to deliver on these basic promises undermines the confidence of every citizen of Ontario.

Our review examined lives lost between 2014 and 2021 while in the custody of Ontario correctional facilities. In all, there were 186 in-scope deaths during this period, and the trend line has risen dramatically over the period, from 19 deaths in 2014, to 25 in 2019, and 46 in 2021. 

Our mandate was not to conduct in-depth inquiries into any specific death, but rather to examine evident patterns, systemic gaps and common factors that can and must be addressed toward improvements that will prevent further deaths in custody and restore healthier conditions for everyone. Nonetheless, each one of the individuals in this tragic sample remained with us throughout our studies and deliberations.  We were privileged to learn their names and to get to know some of their personal stories. We met some of their families, we felt the poignancy of their losses and we listened to their enduring shock and disbelief. With very rare exception, almost every life lost in our sample could be deemed a preventable death.

We also met many of the individuals who staff and manage the 25 correctional facilities across the province.  This included the policy makers who guide and oversee the provincial corrections mandate of the Ministry of the Solicitor General (SOLGEN), the professionals who interact with people in custody on a daily basis and the labour officials who represent staff interests and career ambitions.  We learned of the traumatic impact these lost lives have had on everyone involved. We heard how their growing inability to protect the well-being of many others is undermining their own health, morale and well-being to alarming degrees.

Ultimately, we learned much about a criminal justice system that is struggling to deliver on the basic promises above, and an in-custody reality that in its current state is increasingly both ineffective and unsafe. The picture varies from opaque to astoundingly clear. The solutions range from simple to frustratingly complex. 

The need for action is simply compelling and urgent.

Respectfully,

The Members of the Ontario Chief Coroner’s Expert Panel on Deaths in Provincial Custody

December 2022