A preventable death
Report highly critical of how corrections officials handled case where Cape Breton man died
A highly critical report into the death of a Cape Breton man in a federal prison in May 2015 concludes the death was preventable and that Correctional Services Canada needs to offer “a significant response” to how it handled the situation.
Matthew Ryan Hines, 33, of Ferry Street, Sydney, died May 27, 2015, after corrections staff at Dorchester Penitentiary in New Brunswick used excessive force, according to a newly released report from the Office of the Correctional Investigator.
In his report, tabled Tuesday in the House of Commons, Ivan Zinger sharply criticizes how the correctional service handled the situation and offered 10 recommendations for improvement.
“The lessons learned from Matthew’s death should be shared broadly across the service. Nearly everything that could have gone wrong in a use of force response went wrong,” said Zinger, in his report.
“I conclude that Matthew’s
death in federal custody was preventable. It was proximate to multiple uses of inappropriate force. The implications of this case extend far beyond the immediacy of Dorchester Penitentiary or the tragic events of May 26, 2015.”
The cause of death was determined to be acute asphyxia (a severe deficient supply of oxygen to the body) due to extensive pulmonary edema (excess fluid in the lungs) after being pepper-sprayed.
Video shows corrections officers punching and kneeing Hines in the torso, jaw and upper body. The report notes that Hines was sprayed directly in the face with pepper spray multiple times despite showing no signs of aggression.
Hines was sentenced in Sydney in 2010 to serve a five-year term on charges including bank robbery. He was to be released in October 2015.
While the death continues to be investigated by RCMP, Zinger said his investigation has shown there is much room for improvement in how the service investigates custody deaths, what lessons it learns from such tragic incidents and how it publicly reports them.
“I am particularly disturbed by the lack of public transparency in this case, including misleading information/ statements that were initially provided to the media and the next of kin in the immediate aftermath of Matthew’s death,” said Zinger.
Hines family was initially told he died after a seizure while media outlets were told it was the result of a drug overdose.
“The family has until very recently been led to believe that Matthew’s death could not have been prevented. My findings in this case suggest otherwise,” said Zinger.
Zinger also offered scathing comment on the manner in which the correctional services investigates in-custody deaths.
“The manner by which CSC investigates and reports on death in custody and what it learns from these events is inherently flawed,” he said.
Zinger notes the internal investigation concluded staff did not follow policy and procedure but yet failed to address how those shortcomings contributed to the death of Hines.
“Given that CSC investigates itself largely on the basis of compliance with policy and procedure rather than accountability, most boards of investigation do not issue recommendations of national significance.”
Zinger added that the internal investigation did not produce one finding to suggest the death could have been prevented other than staff did not follow policy or procedure.
“In other words, an investigative process that does not concern itself with accountability or prevention will invariably fail to learn from repeated, and potentially, catastrophic failures in which the staff response was inadequate, flawed and inappropriate,” said Zinger.
The board investigation report offered only four recommendations and Zinger said none substantively addressed the “multiple and significant” areas of non-compliance to policy and procedure by staff.
He said there is an irreconcilable difference between the findings and recommendations in the board report and the measures taken to discipline staff involved in the fatal incident.
“In this case, given the catastrophic breakdown in the staff response it is appropriate to review and question the adequacy and appropriateness of CSC staff investigating and disciplining itself,” said Zinger.
“Staff failed to pull back or reassess the situation and their options as events unfolded. Their errors were compounding and ultimately catastrophic,” he said.
“As this is made worse by the fact that 13 correctional officers were present. Certainly, someone should have known better,” he said, adding that not a single officer responding stepped forward to assume leadership over a situation that spiralled out of control within minutes.
When it came to discipline at the jail as a result of Hines death, Zinger noted the following:
The nurse on duty at the time was on probation and was not hired by the correctional service. Her case was referred to the New Brunswick College of Nurses.
The nurse was criticized for not conducting any assessment of Hines including vital signs, neuro-signs and oxygen levels.
For correctional officers were initially identified
with respect to their level of force in dealing with Hines. Zinger again criticized the service because the disciplinary review was conducted by the prison warden, a process Zinger said “lacked functional
independence much less credibility.”
Two officers received a written reprimand while a correctional manager was docked a day’s pay. Insufficient evidence was cited as the reason why the fourth officer was not disciplined.
The report also notes that no senior manager at the institution, regional or national level has ever been disciplined in connection with the Hines case.
In issuing 10 points of findings, Zinger said the issues have repeatedly been identified by his office in other cases and offered five other recommendations to ensure the mistakes from the Hines case are never again repeated.
As the ombudsman for federally sentenced offenders, the Office of the Correctional Investigator serves as an independent overseer of the Correctional Service of Canada by providing accessible, impartial and timely investigation of individual and systemic concerns.
Shown above is Dorchester Penitentiary, a Canadian federal corrections institute in Dorchester, N.B.
Sydney native Matthew Hines died on May 27, 2015, after corrections staff at Dorchester Penitentiary in New Brunswick used excessive force, according to a newly released report from the Office of the Correctional Investigator.
Shown above is the sign that greets visitors before they enter the gates of Dorchester Penitentiary in Dorchester, N.B.