Canada’s prison ombudsman has “significant concerns” about the quality of care provided to prisoners and the system to review deaths of natural causes that occur in penitentiaries. That process was recently streamlined and the ombudsman wanted to see how effective it now is.
When someone incarcerated in a federal prison dies, the law requires the Correctional Service of Canada to “forthwith” conduct an investigation. There are similar rules in provincial and territorial prisons which house offenders who have sentences of under two years.
Reviews “flawed and inadequate”
The process of reviewing prison deaths is “flawed and inadequate,” wrote Howard Sapers, Correctional Investigator of Canada, adding that “it is not carried out in a timely and rigorous manor as required by law. It fails to thoroughly establish, reconstruct or probe the factors that may have contributed to the fatality under review.”
Sapers hired a medical doctor to review the cases of fifteen deceased offenders. The doctor’s findings raised concern about the quality of care they received, access to care, diagnostic services, follow-up services, use of prescribed medication.
Wrong treatment found
One inmate was found to have been treated for pneumonia when in fact he was in the final stages of breast cancer. Another was given a drug for tuberculosis when it was known he had hepatitis and the drug was not safe for him. A third received the wrong dose of the wrong drug.
Reviews failed to generate lessons learned
The reviews of the deaths were found to often have taken more than two years and, once they were done, Sapers says they did not lead to change. “Even though those treatment and compliance issues were part of the record when the review was done, the conclusion was that there was nothing significant in the review that would lead to a change in policy or practice. We’re very concerned about that.”
To correct this Sapers recommends policy changes, that reviews must involve a physician, there should be a quality audit of the review process and that the information be shared with the families of the deceased. There are a total of 14 recommendations which will be sent to Parliament.
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