A pre­ventable death

Re­port highly crit­i­cal of how corrections of­fi­cials han­dled case where Cape Bre­ton man died

Cape Breton Post - - Front Page - BY CAPE BRE­TON POST STAFF

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.


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