In August 2018, the Independent Review of Ontario Corrections (IROC) submitted its Institutional Violence in Ontario: Interim Report to the Minister of Community Safety and Correctional Services. The Interim Report presented a number of findings following a 90-day investigation of reported incidents of inmate-on-staff violence in Ontario’s provincial correctional facilities. The current report builds upon many of those findings and presents the Case Study: Toronto South Detention Centre (TSDC), an in-depth analysis of the institution that reported the highest number and greatest rate of increase in reported incidents of inmate-on-staff violence in 2017. The Independent Review Team undertook further engagement with correctional employees, via the IROC Institutional Violence Survey, to directly inform the Institutional Violence in Ontario: Final Report. While some of the findings and recommendations are specific to TSDC, others apply more broadly across Ontario’s provincial institutions. The Final Report presents key findings and offers 42 recommendations under the following themes:

  • data collection and information sharing
  • institutional culture and staffing
  • operational practices

Data collection and information sharing

There is a clear need to improve the Ministry of Community Safety and Correctional Services’ (MCSCS) data collection and sharing practices. The Independent Review Team found that the ministry’s current province-wide tally of reported incidents of inmate-on-staff violence is ineffective at identifying the unique issue(s) experienced by each correctional institution. To gain a thorough understanding of institutional violence and, subsequently, develop an individualized operational response, local analyses at each of Ontario’s provincial facilities must be conducted to account for variation in, for instance, staff complement, inmate demographics, and institutional culture.

Correctional employees report incidents of violence (i.e., threats, attempted assaults, assaults) using an MCSCS-specific process. The TSDC Case Study revealed that there was inconsistency with respect to when incidents were reported, beyond the local level, to the MCSCS Information Management Unit (IMU), and how much detail was reported on Inmate Incident Reports (IIRs). While the incident reporting process is inevitably subjective, the ministry could modify policies to limit the amount of discretion applied by reporting sergeants, for example, clearly outline when to report incidents on IIRs, or establish mandatory elements for reporting, such as which employees are involved in incidents. This would assist in the identification of trends, increase transparency and accountability, and inform the development of an appropriate operational response. Further, data relevant to institutional violence ought to be monitored at the corporate, regional, and institutional levels within the ministry and communicated expediently among these levels to allow for appropriate policy and operational responses.

To ensure compliance with law and ministry policy and to avoid unnecessary staff misconduct reviews, it would be advisable to conduct routine audits of reported incidents and corresponding paperwork. More broadly, institutional violence should be monitored in regular time intervals and as close to real-time as possible on a number of variables including time, location, staff, and inmate(s) involved in an incident. The ministry may wish to consider how these responsibilities could be allocated to the office of the Inspector General of Correctional Services, an oversight body created in the Correctional Services and Reintegration Act, 2018.

Institutional culture and staffing

The Independent Review Team relied upon correctional employees’ experience to gain a greater understanding of the work culture within Ontario’s provincial facilities. Several themes emerged from this engagement including employee concerns with the safety of the work environment, strained staff-management relationships, and attitudes regarding correctional work, training, mentorship, and job shadowing opportunities.

Just over half of correctional officers who responded to the IROC Institutional Violence Survey reported that they did not feel safe working at their institution while two-thirds of respondents in all other positions (i.e., excluding those who identified as correctional officers) reported that they did feel safe at their facility. Furthermore, 66% of frontline officers indicated that they worried about being assaulted by an inmate at least once a week compared to only 27% of respondents in all other employment positions, and nearly half (44%) of this latter group advised that they never worried about being assaulted. This variation in responses among those working inside Ontario’s provincial facilities is of particular interest considering that many of the employees who are not correctional officers (e.g., sergeants, programs and health care staff) also have frequent direct contact with inmates.

The IROC Institutional Violence Survey also revealed a strained relationship between frontline officers and various levels of management. For example, 38% of correctional officer respondents did not feel supported by sergeants at their institution, and over two-thirds did not feel supported by senior administrators. In their written feedback, many correctional officers referred to a disconnection between management and those working on the frontlines. While most officers (58%) felt that communication was good among colleagues, only 13% believed that there was good communication between staff and management at their institution. Any ministry efforts to mitigate institutional violence must consider how the frontline staff-management relationship functions and the channels of communication must be strengthened in order to establish clear directives, expectations, opportunities for feedback, and accountability.

A general punitive and discipline-oriented philosophy, particularly among correctional officers, emerged from responses to the IROC Institutional Violence Survey. While over half of respondents who identified as correctional officers and sergeants (including staff sergeants) reported that they had a good relationship with inmates, and 40% felt that friendly relationships with inmates at their institution did not undermine staff authority, the large majority (74%) of respondents supported the notion that inmates should be under strict discipline. Punitive views were further apparent in the written feedback of many survey respondents as well as from the measures – e.g., mandatory minimum sentences, more restrictive confinement – they believed would increase staff safety.

Over one-quarter (26%) of survey respondents advised that staff use of force was a key mechanism that contributed to safety at their institution. Despite claims that correctional officers were reluctant to use force, ministry data revealed that reported use of force incidents have actually increased from 1,249 incidents in 2013 to 2,490 in 2017. The TSDC Case Study supported this finding, as reported use of force incidents increased at that institution between 2014 and 2017. Interestingly, the Case Study further revealed that staff use of force preceded the reported inmate-on-staff violence in approximately 11% of all incidents. Given the ministry’s emphasis on using force as a last resort, this finding highlights the need for greater emphasis on verbal de-escalation and defusion skills in staff training.

After a four-year moratorium on all correctional officer recruitment, in 2016 the ministry committed to hiring 2,000 officers over the following three years. The sudden commitment to hire so many new correctional officers resulted in efforts being focused on hiring instead of a much needed redevelopment of the Correctional Officer Training and Assessment (COTA) curriculum. Although the ministry has acknowledged that the COTA program is outdated and in need of revision, no changes have been implemented. At present, de-escalation and communication skills are sorely lacking in the COTA curriculum. In reforming the course curriculum, the ministry must ensure that COTA graduates receive sufficient training in human rights, correctional law, and self-care and resiliency for dealing with workplace stress. Training must be applicable to the day-to-day situations that correctional officers face in their work environments when dealing with inmates.

The importance of experienced staff and training was reflected in the responses to the IROC Institutional Violence Survey, yet, over half (52%) of correctional officer respondents reported that they did not feel prepared to start working immediately after being hired, and just under half (48%) indicated that they did not feel prepared to start working after graduating from the Ontario Correctional Services College. Moreover, most correctional officer respondents (55%) were not satisfied with the local training provided at their institution and 58% advised that they were unsatisfied with the localized mentorship or job shadowing opportunities.

The TSDC Case Study offered further insight into correctional employees’ concerns regarding the lack of localized training, mentorship, and job shadowing opportunities. Although some local initiatives existed, they were largely volunteer-based and dependent on the availability and willingness of experienced staff to mentor incoming recruits. The introduction of a correctional officer position to provide a senior or supervisory role could offer skilled and motivated staff with developmental incentives and meet the need for peer mentorship. In addition, this would have the added benefit of enhancing Ontario Corrections’ response to meeting the rehabilitative and specialized care needs of inmates requiring the most support. It would be important, however, that progression between correctional officer classifications be based on demonstrated skill, merit, and training certification rather than seniority alone.

Operational practices

Operating policies, practices, and procedures must consider the factors that are unique to an institution, such as its size and purpose (e.g., remand, sentenced, treatment), inmate population, and workplace culture. More importantly, however, correctional operations must be firmly grounded in evidence-based practices to maximize institutional security and the safety of employees, inmates, and, ultimately, the public. The Independent Review Team received a number of suggestions from correctional staff regarding operational practices that might help curb institutional violence. Issues raised included disciplinary segregation policy, the use of conducted energy weapons (CEWs), proper inmate classification, and correctional programming. With respect to segregation, ministry data have demonstrated that, although frontline correctional employees claim that it has been “taken away”, segregation continues to be routinely used as a disciplinary tool. The TSDC Case Study confirmed that segregation is used and, in fact, was the sanction imposed in most formal misconducts stemming from reported inmate-on-staff incidents.

In Canadian jurisdictions where CEWs were piloted or implemented, they are rarely used or have been discontinued due to a lack of evidence suggesting that they lessened the risk of institutional violence. Moreover, the existing research has demonstrated that importing these weapons into the correctional setting carries a number of risks and has been associated with several negative consequences, including serious injury, death, and costly civil lawsuits. In spiWe of this, some correctional employees have continued to request that the ministry add CEWs as a use of force option, and remain convinced that Ontario’s experience will be different than that of other jurisdictions.

Some correctional employees have identified incidents of violence that occur through cell door meal hatches as a pressing safety concern. At TSDC, 43% of reported inmate-on-staff assault and attempted assault incidents in 2017 occurred through the cell door meal hatch. Most occurred on segregation units and large proportions of the remaining incidents took place on the Special Handling Unit and the Mental Health Assessment Unit, suggesting that hatch-related incidents may be restricted to a subgroup of the inmate population. There is scant research examining the use of cell door meal hatches with a ‘sally port’ function and their utility in reducing institutional violence has not been established. Therefore, widespread implementation of modified meal hatches would be ill-advised, although the ministry may wish to consider, on a trial basis, retrofitting a very limited number of cell door meal hatches in some institutions. The institutions selected for the pilot should be those with the highest number, or overrepresentation, of reported inmate-on-staff incidents that occurred through the cell door meal hatch. It would be important to implement these modified hatches only for appropriately classified inmates housed on specific units, in conjunction with other measures (e.g., inmate programming, additional staff training), and after the ministry established policies governing the proper use of these hatches. Furthermore, rigorous data collection – on the use of specialty hatches, additional simultaneous interventions, reported hatch-related incidents, and inmate outcomes – is essential to conduct an evaluation of the trial.

The importance of appropriately assessing and classifying inmates has been established in the empirical literature and was echoed by correctional employees in their responses to the IROC Institutional Violence Survey. Unfortunately, the ministry does not conduct regular security risk or classification assessments, but relies on alerts in the Offender Tracking Information System (OTIS) that are subject to correctional employee discretion and are not verified by clinicians. While the ministry has acknowledged the need to implement an evidence-based security screening tool and has created an Advisory Group to aid in its development, to date, no ministry-wide tool has been created, which has led to localized solutions at some of Ontario’s institutions. For instance, TSDC developed and currently uses the Internal Placement Report (IPR) to classify inmates based on housing needs.

Once classified, it is imperative that inmates can be appropriately housed based on their identified security risk and programming needs. The IROC Institutional Violence Survey found that some correctional employees recognized the importance of the availability and proper use of alternative housing. In the TSDC Case Study, though it was not possible to obtain an average inmate count at TSDC by unit type, based on a one day snapshot, approximately 43% of the TSDC inmate population was found to be housed on a general population direct supervision unit while only about 10% of all reported inmate-on-staff incidents (26 of 252) in 2017 occurred on these units. This suggests that, although the IPR is not evidence-based and has not been evaluated, appropriate classification and housing can directly impact staff safety. In contrast, while roughly 3% of the inmate population was housed on a segregation unit, they accounted for 28% of all reported inmate-on-staff incidents at TSDC in 2017. Similarly, about 11% of the inmate population was housed in a Special Handling Unit or Behavioural Management Unit, however, around 18% of all reported inmate-on-staff incidents occurred on these units at TSDC in that same year. This highlights the importance of proper classification and housing of inmates, and the need for an evidence-based ministry-wide security risk assessment tool to be implemented expeditiously.

The empirical literature has recognized providing and ensuring access to appropriate inmate programming as a crucial component of evidence-based correctional practice and has noted its potential benefits with respect to rehabilitation and reintegration and mitigating institutional violence. Feedback from correctional employees revealed that many recognized the importance and potential benefits of inmate programming, although a number expressed concerns regarding the availability of such programming at their institution.

The TSDC Case Study offered considerable insight into many issues related to programming that may apply to other institutions. For instance, the Independent Review Team discovered that most of the programs offered at TSDC are not focused on rehabilitation or treatment and that their delivery is dependent on non-contracted community organizations or volunteers which, consequently, makes them vulnerable to cancelations due to staff shortages, lockdowns, and competing operational demands. At present, only two ministry-developed and facilitated programs are offered at TSDC; both use a motivational approach and are informational sessions that were not created with the intention of rehabilitating or providing treatment to inmates. The TSDC Case Study also revealed that inmates being housed on more restrictive units are less likely to be able to access institutional programming. Lack of access to programming at TSDC can be the result of a host of operational factors. It is imperative that the ministry allocate appropriate resources and supports to ensure that evidence-based rehabilitative programs are routinely scheduled and consistently available in each institution based on individualized risk/needs assessments.

Successful correctional systems depend on staff and inmates feeling safe. Diligent data collection and monitoring are crucial to ensure that incidents of violence are adequately analyzed and understood. Many factors that compromise staff and inmate safety are not unique to Ontario; evidence-based practices and lessons from other jurisdictions provide valuable insight to transformation efforts underway within MCSCS. The evidence and experience of other jurisdictions has continued to show that, contrary to the expressed beliefs of some correctional employees, increasing security-driven measures alone will not address underlying issues of institutional violence. Staff-management relationships, recruitment and training, proper assessment and housing, and delivery of inmate programming are some areas that need to be prioritized to address institutional violence and increase safety across Ontario’s correctional facilities. Moreover, efforts to modernize corrections in Ontario need to include a focus on a strong care-based, ethical, and empathetic decision-making framework.

Evidence-based practices must be at the core of correctional operations. Notwithstanding, the voices of those working and living inside provincial facilities must not be dismissed – their experience is an invaluable source of evidence and their concerns are valid and deserve the ministry’s attention. Corporate personnel must meaningfully engage frontline correctional employees in the development of ministry reform initiatives. Frontline staff require ongoing support to implement corporate policy at the local level, providing important feedback along the way.

It is important for the ministry to make a concerted effort to assist and support institutional employees as they cope with occupational stress and injuries. Frontline staff have expressed that the current supports available to them to manage occupational stress post-incident (e.g., Critical Incident Stress Management program; Employee and Family Assistance Program) are insufficient. Given the impact that working in a correctional facility can have on an individual’s mental health, developing a comprehensive strategy that provides self-assessment, self-care, and external supports must be a ministry priority.

Implementing the recommendations in the present report could dramatically improve the safety for staff and inmates. The ministry and the Government of Ontario must seek to maintain the momentum of recent modernization efforts to protect the safety, dignity, and human rights of those who live and work in the province’s correctional institutions.