Fifth Independent Review Committee on non-natural deaths in custody: April 1st, 2017 to March 31st, 2019

There is a significant history surrounding non-natural deaths in Correctional Service Canada (CSC) institutions and CSC's responses to the recommendations of investigations into the circumstances of these deaths. The Correctional Investigator in his 2005-06 Annual Report raised concerns regarding the timely completion of meaningful investigation reports and action plans developed by CSC to address the underlying issues identified in these reports. As a first step, the Office of the Correctional Investigator (OCI) engaged an academic to undertake a study of non-natural deaths in Correctional Service Canada (CSC) institutions (Gabor, 2007). The report on this study provided some preliminary findings regarding recurring factors contributing to deaths in custody (e.g. lack of information sharing, security lapses, post-incident emergency care, mental health programming, and illicit drugs) and identified some areas for further study. Following this report, CSC has commissioned a series of Independent Review Committees (IRCs) with a mandate to review its Board of Investigation (BOI) reports; policies and procedures related to the investigative process; corrective measures and action plans in response to BOI recommendations; strategies to prevent non-natural deaths in custody; and best practices in other jurisdictions. Reviews have been completed by four IRCs and this is the report of the 5th IRC.