2020 data on inmates in Ontario

Human rights-based data collection for inmates in segregation

The ministry is committed to publicly releasing data annually regarding the use of segregation for all individuals in Ontario’s adult correctional system, excluding those on lockdown and to also include the following in the report:

• the duration of time each inmate spent in segregation, including continuous and total days over the last year
• the reason the inmate was placed in segregation
• the number of inmates who had a suicide alert or suicide watch alert

Furthermore, the ministry has disaggregated the data 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
• gender
• facility/institution
• region

The review also covers human rights-based data and has been disaggregated by gender, race, age and religion or spiritual affiliation. This data is consistent with the Ontario Human Rights Code and follows the requirements in the Anti-Racism Data Standards under Ontario's Anti-Racism Act to monitor systemic racism.

The 2019 data release on the use of segregation covered the period of July 1, 2018 to June 30, 2019. For the 2020 data release and for future releases, the reporting period has been changed to align with the government’s fiscal year, between April 1, 2019 and March 31, 2020. As a result, the 2020 data release overlaps with the 2019 release by a three-month period.

Disclosure on data collection method

Segregation is defined by the ministry’s policy as any type of custody where an inmate is highly restricted in movement and has limited meaningful social interaction with others for 22 hours or more a day (excluding circumstances of unscheduled lockdown), which can occur anywhere in an institution. To collect the data, a report was generated through the ministry’s Offender Tracking Information System (OTIS) to identify any individuals recorded as meeting segregation conditions between April 1, 2019 and March 31, 2020.

A record is created each time an inmate meets the conditions of segregation and closed when the inmate no longer meets those conditions. As of October 29, 2019, a break in a segregation placement occurs when an individual is out of segregation conditions for 24 or more continuous hours. For the purposes of this data release, this definition has been applied retroactively to cover the entire reporting year.

OTIS is an electronic database used to track individuals under the supervision of the ministry and includes demographic, institutional housing and placement history. Individual information is entered into OTIS manually and, due to technological limitations, may be recorded through other means and entered into OTIS at a later time.

The report generated through OTIS identified all individuals with a segregation placement within the identified time period. For these inmates, the report captured:

• the number of placements
• the duration of placements
• reasons for placements
• demographic information
• alerts for mental health concerns, suicide risk and suicide watch

Demographic information entered into OTIS is mainly self-reported or is reliant upon information provided to the ministry by police agencies or the courts and therefore may change over time. OTIS displays the most recent details for an inmate and maintains a record of information previously entered into the system. The report generated for this release captured demographic information that was active at the time of an inmate’s most recent period of supervision.

The information on race and religion or spiritual affiliation extracted from OTIS is aligned with the Anti-Racism Data Standards.

OTIS records inmates’ gender as either “male” or “female”. Additional expressions of gender are recorded by a “transgender alert”. Where an inmate has a transgender alert, the gender field in OTIS will reflect the individual’s preferred gender identity and may change over time.

The identification of inmates with mental health conditions is based on the presence of a mental health alert that is recorded in OTIS. Mental health alerts do not indicate a confirmed mental health diagnosis. However, they signal the presence of potential mental health concerns and are the trigger for assessment for appropriate healthcare supports.

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 OTIS within 48 hours of the alert being entered. To capture the potential presence of a mental health concern, the data for this release includes both verified and unverified mental health alerts present on the inmate’s file at the beginning of each segregation placement.

The ministry has developed definitions of mental illness and serious mental illness to better align with parameters used by community health service providers. These definitions are currently being integrated into policy, and the mental health alert system is in the process of being updated to more appropriately and accurately reflect the presence of a mental illness.

Review of all inmates in segregation between April 1, 2019 and March 31, 2020

Inmates with an intermittent sentence have been separately reported in the data. As a result, the total population numbers and the segregation numbers below exclude cases where an individual was flagged as having an intermittent sentence.

At the time of this review, approximately 5% of the total inmate population was in segregation conditions on any given day, compared to 7% in the 2019 reporting period. There were 10,727 (29%) inmates identified as having at least one placement in segregation between April 1, 2019 and March 31, 2020, out of a total population of 36,436 inmates. Fifty-nine per cent of inmates had a single placement in segregation. In total, there were 22,665 segregation placements during this time period.

An individual’s custodial location may change across placements. As a result, the location in the following tables specific to unique individuals reflects the information on file for the most recent placement during the reporting period. The location specific to placements reflects the information on file at the time of each placement.

Population breakdown

Of the 10,727 inmates who were in segregation between April 1, 2019 and March 31, 2020, 1,569 (15%) identified as female and 9,158 (85%) identified as male. These numbers include 100 inmates who self-identified as transgender during this period. Trans inmates are captured in the dataset based on their gender identity.

Of the overall population in provincial institutions, 31% of females in custody and 29% of males in custody experienced at least one placement in segregation.

Number of placements

There were 6,288 (59%) inmates with a single segregation placement during the time period, while 4,439 (41%) had been placed in segregation two or more times. The highest number of times an inmate was placed in segregation was 49.

Duration of time spent in segregation

Across all regions, the consecutive length of segregation placements for males ranged from a minimum of one day to a maximum of 566 days. Consecutive placement lengths for females ranged from one to 96 days. The median number of days consecutively spent in segregation was four days for both females and males. The most frequent, or mode, consecutive placement length was two days. These placement lengths include time that was spent in segregation conditions prior to April 1, 2019 if the placement continued into the April 1, 2019 to March 31, 2020 reporting period.

Ministry policy requires that inmates placed in segregation be reviewed within 24 hours, and every five days thereafter. As of November 1, 2019, Ontario introduced regulatory changes that require an independent review of inmates in administrative segregation conditions at least once every five consecutive days. These reviews include considering alternative strategies to remove individuals from segregation conditions and into appropriate and less restrictive conditions as soon as possible. For inmates with mental health conditions, alternatives may only be rejected if there is a significant risk to their own health and safety or the health and safety of others if they are not held in segregation conditions. Inmates in segregation receive a baseline assessment by a nurse upon entering segregation conditions and have their physical and mental health status assessed daily by a member of the health care services team.

Following the implementation of the independent review of segregation placements in November 2019, the duration of placements has shortened considerably. All placements exceeding 365 continuous days ended in 2019 and all placements exceeding 100 continuous days ended by February 2020. By March 31, 2020, at the end of the reporting period, the longest active continuous placement was 96 days.

Across all regions, the aggregate number of days for segregation placements ranged from a minimum of one day to a maximum of 348 days for males and from a minimum of one day to a maximum of 228 days for females. The overall median aggregate number of days was seven, and the most frequent aggregate number of days spent in segregation was two.

Aggregate days are calculated based on the total number of days in segregation during the one-year reporting period. The total number of aggregate days in segregation were counted to March 31, 2020.

Reports of inmates in segregation for 30 continuous days are provided directly to the Assistant Deputy Minister of Institutional Services and the Solicitor General. These reports include additional details about the circumstances of each individual’s segregation placement and the alternatives to segregation considered to the point of undue hardship. This level of detail also applies to the 60-day aggregate reports that go to the Assistant Deputy Minister of Institutional Services.

Reasons for placement in segregation

The ministry’s policy during this time period required that segregation only be considered for an inmate if they:

• need protection such as security or medical concerns
• have requested to be segregated
• pose a security or safety risk to others
• are under medical observation or isolation
• have committed alleged misconduct
• require confinement following misconduct

*One placement in segregation may include more than one associated reason. As a result, the total number of placements in this table exceed the actual number of segregation placements.

Throughout a segregation placement, the reason for the placement may change. Of the 22,665 placements, 18,733 (83%) had one associated reason, while 3,932 (17%) had more than one reason associated with segregation placements. For example, an inmate may be placed in segregation for their own protection and subsequently request to remain in those conditions once approved for release. The most frequent reasons for segregation placement included:

• 7,159 (32%) occurrences where inmates requested to be placed in segregation
• 6,555 (29%) placements as a result of medical reasons such as observation, isolation and safety
• 4,426 (20%) placements as a result of an alleged misconduct

Mental health alerts

A mental health alert is recorded in an inmate’s file by staff including correctional, medical and clinical staff, if the inmate:

• discloses a mental illness
• is showing signs of, or has disclosed thoughts about self-harm or suicide
• is demonstrating behaviour that may suggest a mental illness

The ministry’s policy requires an initial mental health screening to be completed within 48 hours of an inmate being admitted to an institution. All active mental health alerts are required to be verified by mental health professionals within 48 hours of the alert being entered into OTIS. 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.

Of the 10,727 inmates identified as being placed in segregation over the period of April 1, 2019 to March 31, 2020, 4,533 (42%) had an active mental health alert on file for at least one of their placements in segregation. Fifty-three per cent of females in segregation and 40% of males in segregation had an active mental health alert on file for at least one of their placements. Of the overall population in provincial institutions, 43.5% of all females in custody and 27% of all males in custody had an active mental health alert on file at any point between April 1, 2019 and March 31, 2020.

Suicide risk alerts

A suicide risk alert is recorded in an inmate’s file when they require enhanced supervision or if they are at risk of posing harm to themselves. Suicide risk alerts are broken down into the following categories:

• enhanced supervision
• previous suicide attempt(s)
• suicide watch

Of the 10,727 inmates covered in the review, 3,471 (32%) had a suicide risk alert on file for at least one of their placements in segregation. There were 34% of females and 32% of males in segregation who had a suicide risk alert on file for at least one of their placements. In comparison, 24% of females in the overall custodial population and 18% of males had a suicide risk alert on file at any point between April 1, 2019 and March 31, 2020.

A suicide watch is a type of a suicide risk alert that indicates when an inmate requires increased supervision due to a high risk of suicide or self-harm. Of the 10,727 inmates included in the review, 1,462 (14%) were on suicide watch. Thirteen per cent of females in segregation and 14% of males in segregation had a suicide watch alert on file for at least one of their placements. Overall, 6% of females and 5% of males in custody had suicide watch alerts on file at any point between April 1, 2019 and March 31, 2020.

Ministry policy requires that an assessment, monitoring and documenting process including frequent in-person checks occur at least once every 10 minutes. Between 7 a.m. and 11 p.m., correctional staff are required to interact verbally with the inmate on an hourly basis.

Demographics

Demographic factors were extracted as they were recorded in OTIS at the time of the most recent supervision period and therefore does not reflect where the information may have changed over time.

Age

The average age amongst all inmates at the start of their placement in segregation was 33 years old.

Race

Of the 10,727 inmates covered in the review, 6,111 (57%) self-identified as white, 1,534 (14%) self-identified as black, and 1,210 (11%) self-identified as Indigenous. There were 204 inmates (1.9%) who identified as another racial origin, 187 (1.7%) as Middle Eastern, 176 (1.6%) as east or Southeast Asian, 146 (1.4%) identified as South Asian and 126 (1.2%) as Latino. There were 1,033 inmates (10%) who did not report this information or it was unknown.

Religion or spiritual affiliation

There were 3,732 inmates (35%) covered in the review who did not report a religious or spiritual affiliation or it was unknown, while 2,842 (26%) self-identified as being Christian, and 2,195 (20%) stated they had no religious or spiritual affiliation. There were 788 (7%) who self-identified as Muslim and 626 (6%) self-identified as having Indigenous spirituality. Of the remaining inmates, self-identified religions included: 106 (0.9%) Jewish, 50 (0.5%) Sikh, 45 (0.4%) Hindu and 40 Buddhist (0.4%). There were 303 inmates (2.8%) who reported “another religious or spiritual affiliation”.

Intermittent sentences

When the court imposes a sentence of imprisonment of 90 days or less on a convicted offender, the court may order that the sentence be served intermittently, based on the age and character of the offender, the nature of the offence and/or the motive. An intermittent sentence is a custodial sentence that is served during specific recurring days and times, rather than all at once (for example: every Friday at 6 p.m. to Monday at 7 a.m. for five weeks).

Inmates who were serving an intermittent sentence any time during the reporting period have been removed from the above data but are included below for separate review. Additionally, inmates may have had multiple incarceration types or status during the reporting period. Segregation lengths may exceed the general length of an intermittent sentence, as some inmates may have been serving an intermittent sentence which was later changed to a non-intermittent sentence.

In total, there were 3,520 individuals who served an intermittent sentence between April 1, 2019 and March 31, 2020. Of these 3,520 individuals, there were 651(19%) who had a mental health alert on file, 416 (12%) with a suicide risk alert and 64 (2%) who had a suicide watch alert.

Of the 3,520 individuals serving an intermittent sentence, 722 (21%) had at least one placement in segregation. Of these 722 inmates, there were 179 (25%) who had a mental health alert on file for at least one placement, 120 (17%) who had a suicide alert, and 24 (3%) who had a suicide watch alert.

Human rights-based data collection for inmates in restrictive confinement

The ministry is committed to publicly releasing data annually regarding its use of restrictive confinement for all individuals in Ontario’s adult correctional system, excluding those on lockdown, and to include the following in the report:

• the duration of time each inmate spent in restrictive confinement, including continuous and total days over the last year
• the reason the inmate was placed in restrictive confinement
• the number of inmates who had a suicide alert or suicide watch alert

Furthermore, the ministry has disaggregated the data 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
• gender
• facility/institution
• region

The data has also been disaggregated on additional data related to race, age and religion or spiritual affiliation. This data is consistent with the Ontario Human Rights Code and follows the requirements in the Anti-Racism Data Standards under Ontario's Anti-Racism Act to monitor systemic racism.

The ministry defines restrictive confinement as any type of confinement that is more restrictive than the general population but less restrictive than segregation. As a result, the ministry is reporting any case where an individual was held in a unit regularly scheduled to be locked down for 17 hours or more per day. This timeframe is considered more restrictive than that of the general population based on an assessment of provincewide lockdown times. Regularly scheduled lockdowns are daily routine times where movement out of a cell is restricted, such as during meal times and overnight.

The ministry is reporting on a one-year period between April 1, 2019 and March 31, 2020. This time period aligns with the government’s fiscal year.

Disclosure on data collection method

To collect the information required, a report was generated through the ministry’s Offender Tracking Information System (OTIS) to identify any individuals who were held in a unit that was regularly locked down for 17 hours or more per day. OTIS is an electronic database used to track individuals under the supervision of the ministry and includes demographic, institutional housing and placement history. Information is entered into OTIS manually and, due to technological limitations, may be recorded through other means and transferred into OTIS later.

As an individual’s housing location may change daily, data on restrictive confinement was extracted for each day within the reporting period, rather than one single extraction, to provide more accurate data. Currently, the reason and number of placements or continuous days in restrictive confinement by individual cannot be tracked due to the data collection method. The ministry recognizes the challenges in accurately tracking inmates within restrictive confinement and is currently developing a new tool to track inmate movement in and out of cell.

The data captured in this report excludes any cases where an inmate was held in a unit that was regularly locked down for 17 hours or more but was considered to meet segregation conditions based on the information recorded in the inmate’s file.

Demographic information entered in OTIS is largely self-reported or reliant upon information provided to the ministry by police agencies or the courts and therefore is subject to change over time. OTIS displays the most recent details for an inmate and maintains a record of information previously entered into the system. The report generated for this release captured demographic information that was on file for each day that an individual was held in a unit that was locked down for 17 hours or more.

OTIS records inmates’ gender as either “male” or “female”. Additional expressions of gender are recorded in a “transgender alert”. Where an inmate has a transgender alert, the gender field in OTIS will reflect the individual’s preferred gender identity and may change over time.

The information on race and religion or spiritual affiliation extracted from OTIS is aligned with the Anti-Racism Data Standards.

The identification of inmates with mental health conditions is based on the presence of a mental health alert that is recorded in OTIS. Mental health alerts do not indicate a confirmed mental health diagnosis. However, they signal the presence of potential mental health concerns so assessments for appropriate health care supports can be provided.

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 OTIS within 48 hours of the alert being entered. To capture the potential presence of a mental health concern, the data for this release includes both verified and unverified mental health alerts present on the inmate’s file for each day where they were held in a unit that was locked down for 17 hours or more.

The ministry has developed definitions of mental illness and serious mental illness to better align with parameters used by community health service providers. These definitions are currently being integrated into policy, and the mental health alert system is in the process of being updated to more appropriately and accurately reflect the presence of a mental illness.

Review of all inmates in restrictive confinement between April 1, 2019 and March 31, 2020

Inmates with an intermittent sentence have been included in the data. As a result, the total population numbers and the numbers of individuals who were housed in a unit that was locked down for 17 hours or more per day include cases where an individual was flagged as having an intermittent sentence. An intermittent sentence is a custodial sentence that is served during specific recurring days and times, rather than all at once.

There were 11,318 (28%) unique individuals who spent at least one day in a unit that was regularly locked down for 17 hours or more per day between April 1, 2019 and March 31, 2020, out of a total of 39,956 inmates.

An individual’s custodial location information may change over time. As the data on restrictive confinement was generated for each day within the reporting period, the location reflects information on file for the most recent day where an individual was held in a unit that was locked down for 17 hours or more per day.

Population breakdown in restrictive confinement

Duration of time spent in restrictive confinement

Across all regions, the aggregate length of time for restrictive confinement placements for all inmates ranged from a minimum of one day to a maximum of 366 days. The median, or mid-point, number of days aggregately spent in restrictive confinement was seven days. The most frequent, or mode, aggregate placement length was one day for all inmates.

Mental health alerts

A mental health alert is recorded in an inmate’s file by facility staff including correctional, medical and clinical staff, if the inmate:

• discloses a history of mental illness
• is showing signs of, or has disclosed thoughts about self-harm or suicide
• is demonstrating behaviour that may suggest a mental illness

The ministry’s policy requires an initial mental health screening to be completed within 48 hours of an inmate being admitted to an institution. All active mental health alerts are required to be verified by mental health professionals within 48 hours of the alert being entered into OTIS. 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.

Of the 11,318 inmates included in the review, 3,516 (31%) had a mental health alert on file for at least one placement. Forty-six per cent of females and 30% of males in restrictive confinement had a mental health alert. The data includes all inmates who had a mental health alert present at any point between April 1, 2019 and March 31, 2020.

Suicide risk alerts

A suicide risk alert is recorded in an inmate’s file when they require enhanced supervision or if they are at risk of posing harm to themselves. Suicide risk alerts are broken down into the following categories:

• enhanced supervision
• previous suicide attempt(s)
• suicide watch

Of the 11,318 inmates covered in the review, 1,835 (16%) had a suicide risk alert recorded in their file. Twenty-nine per cent of females in restrictive confinement and 16% of males in restrictive confinement had suicide risk alerts. The data includes all inmates who had a suicide risk alert present at any point between April 1, 2019 and March 31, 2020.

A suicide watch is a type of suicide risk alert and indicates when an inmate requires increased supervision due to a high risk of suicide or self-harm. Of the inmates included in the review, 606 (5%) were on suicide watch while in restrictive confinement. Eight per cent of females in restrictive confinement and 5% of males in restrictive confinement had suicide watch alerts. The data includes all inmates who had a suicide watch alert present at any point between April 1, 2019 and March 31, 2020.

Ministry policy requires that an assessment, monitoring and documenting process including frequent in-person checks occur at least once every 10 minutes. Between 7 a.m. and 11 p.m., correctional staff are required to interact verbally with the inmate on an hourly basis.

Demographics

Demographic factors were extracted as they were recorded in OTIS for each day that an individual was held in a unit that was scheduled to be locked down for 17 hours or more. An individual’s demographic information may change over time because this information is self-reported. As a result, demographic information in the following tables specific to unique individuals reflects the information on file for the most recent day during the reporting period where an individual was held in a unit that was regularly scheduled to be locked down for 17 hours or more.

Age

Of the 11,318 inmates included in the review, 463 self-identified as female and 10,855 self-identified as male. These numbers include 48 inmates who self-identified as transgender during this period. Trans inmates are captured in the dataset based on their gender identity. The average age amongst all inmates at the start of the reporting period was 34 years old.

Race

Of the 11,318 inmates covered in the review, 6,124 (54%) self-identified as white, 1,942 (17%) self-identified as Black, and 713 (6%) self-identified as Indigenous. There were 304 (2.7%) inmates who self-identified as Middle Eastern, 287 (2.5%) as East or Southeast Asian, 254 (2.2%) as another racial origin, 224 (2%) identified as South Asian and 203 (1.8%) as Latino. There were 1,267 (11%) inmates who did not report this information or it was unknown.

Religion or spiritual affiliation

There were 3,694 inmates (33%) covered in the review who did not report a religion/spirituality, or it was unknown, while 3,242 (29%) self-identified as being Christian, and 2,311 (20%) stated they had no religious or spiritual affiliation. There were 1,003 (8.9%) inmates who self-identified as Muslim and 518 (4.6%) self-identified as having Indigenous spirituality. Of the remaining inmates, self-identified religions included 87 (0.8%) Jewish, 77 (0.7%) Hindu and 66 (0.6%) Sikh. There were 210 inmates (1.9%) who reported “another religious or spiritual affiliation”.

Review of all inmate deaths within all facilities during 2019

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, 2019 and December 31, 2019.

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, 2019 and December 31, 2019, 25 (0.06%) inmates died out of a total population of 40,058 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 2019, three inmates (12%) self-identified as female, while 22 (88%) self-identified as male. There were 16 inmates (64%) who had self-identified as white, one (4%) self-identified as Indigenous, and three (12%) self-identified as black at the time of their admission to the facility. The race of the remaining five individuals (20%) was unknown or not reported.

Twenty (80%) inmates were between the ages of 25 and 49 at the time of their deaths, while five (20%) were 50 or older. 

Housing location at time of death

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

For the purposes of this report, the location at the time of death has been organized into the following four categories:

• general population or protective custody units
• segregation where an inmate was held in a unit that was formerly designated as a segregation unit, or where an inmate is 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 a hospital

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 23 inmates covered in this report. For the two occurrences where the means of death was officially declared, they were determined to be the result of natural causes. Means of death for the 23 inmates covered in this review will not be determined or available until after an inquest occurs.

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 25 inmates include:

• 10 resulting from drug toxicity
• seven unknown to the ministry at the time of this release
• one unable to be determined
• two confirmed to be the result of natural causes
• five as a result of a medical cause other than the above categories

In 2019, 17 (68%) deaths occurred within general population units, four (16%) in specialized care units, three (12%) in segregation conditions, and one (4%) death occurred outside of a correctional facility. 

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.

The ministry has developed definitions of mental illness and serious mental illness to better align with parameters used by community health service providers. These definitions are currently being integrated into policy, and the mental health alert system is in the process of being updated to more appropriately and accurately reflect the presence of a mental illness.

Of the 25 individual deaths examined in this report, five individuals (20%) had a mental health alert on their file, four (16%) had a suicide risk alert and four (16%) had a suicide watch alert on file.