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Ten recommendations from Office of the Correctional Investigator

The following are the 10 recommendations from the Office of the Correctional Investigator who examined the death of 33-year-old Matthew Ryan Hines of Sydney at Dorchester Penitentiary in May 2015.

1. Individual Correctional Services Canada managers at the institutional, regional and national levels should be held answerable and accountable for the deficiencies identified in the inappropriate, unnecessary and multiple uses of force that directly contributed to Matthew’s medical emergency and ensuing death.

2. The case of Matthew Hines should be used as a national teaching and training tool for all existing and future CSC staff and management. The case study would include analysis and understanding of the gaps in the use of force and health-care responses proximate to Matthew’s death in federal custody.

3. CSC should immediately develop a separate and distinct intervention and management model to assist front-line staff in recognizing, responding and addressing situations of medical emergency and/or acute mental health distress.

4. CSC should review and revise the channels, methods and flow of information between clinical and front-line staff to ensure first-response staff members are adequately prepared to safely manage medical and mental health needs.

5. A scope of practice review should be undertaken to ensure registered nursing staff is adequately trained, supported and prepared to work in a correctional environment and include specific instruction in use of force, inflammatory agents and provision of emergency trauma care.

6. CSC should ensure clarity in the leadership role of the officer in charge in situations where no correctional manager is present.

7. CSC should review institutional, regional and national controls on the use of inflammatory agents in federal penitentiaries. Policy direction should be issued to provide clear instruction that inflammatory agents can only be used after all other means of conflict resolution have been exhausted and only when there is a clear and present risk of imminent harm.

8. CSC front-line staff members should receive regular refresher and upgraded training in conflict de-escalation. Training should emphasize how to manage oppositional/ defiant behaviours in situations where underlying mental health issues are present or previously identified.

9. CSC should immediately develop mechanisms to reconcile Board of Investigation findings with the staff disciplinary process.

10. Boards of investigation into deaths in custody should be required to examine and clearly state whether and how the death in question could have been prevented.