Prison health-care woes go undiagnosed, says watchdog
OTTAWA — The review process for deaths in Canadian prisons is failing to address systemic misdiagnoses, poor continuity of care and lack of followup for sick inmates, Canada’s prison watchdog has found.
In a report released Monday, correctional investigator Howard Sapers said his office decided to investigate the mortality review process — which looks into natural deaths of those in custody — after looking at more than 100 reviews and finding virtually no recommendations for improvement and no mention of compliance issues.
A medical expert contracted by Sapers’s office looked into 15 of those cases and found myriad instances in which major health indicators appa r - ently were m issed or not followed up on, with no explanation.
“We weren’t really looking for quality-of-care issues,” Sapers said in an interview. “We were really investigating the review process, but it became clear there were some serious quality-compliance issues around things like diagnostic services, followup, treatment and prescription medication administration.”
Sapers called the review process “flawed and inadequate,” but said the findings don’t come as a surprise, since the No. 1 complaint his office receives is about access to health care in prisons.
Regarding the two-thirds of prison deaths attributed to natural causes, Sapers’s report said a streamlined review process adopted in 2006 does not “meet minimum standards for an investigative process or satisfy (Correctional Service of Canada’s) statutory duty to investigate fatalities regardless of cause.”
In some cases, lack of proper care appears to have contributed directly to inmate deaths. The report cited one who was treated for pneumonia three times over two years, despite multiple X-rays showing a mass in his chest and blood work suggesting a more serious condition. He was eventually diagnosed with lung cancer by an outside hospital, but the tumour had become inoperable.
A mortality review of the case failed to “raise any questions concerning the diagnostic process followed by health-care providers and it does not consider the possibility that the initial diagnosis of pneumonia might have been incorrect,” the report said.
In another case, an inmate diagnosed with a dormant form of tuberculosis and hepatitis C was given tuberculosis medicine known to adversely affect patients with liver conditions. Yet his mortality review said his care “was ‘consistent with professional norms and standards.’”
Sapers also said mortality reviews are not being completed in a timely manner — they start an average of 10 months after an inmate’s death and take up to two years to complete.
The health-care concerns raised by the report also pose a threat to public health, he added. With the vast majority of prisoners destined to be released into the community, any untreated health issues — such as HIV, hepatitis and tuberculosis — can then be introduced to the general population.
Correctional Services Canada did not respond to a request for comment.