The Province of Ontario currently operates 25 custodial facilities as part of a correctional system that also includes community parole and probation services. These facilities span the province and reflect considerable differences in size, capacity, age and design. For the most part, persons-in-custody are held in maximum security conditions. The average length of stay currently ranges from 48 days for unsentenced persons on court-ordered remand, and 60 days for sentenced individuals. Individuals on remand account for almost 70% of the people in custody on any given day.

During 2014, 19 persons died while in custody in Ontario facilities. In 2021, that number had risen to 46, and the cumulative number of deaths in that eight-year period had reached 192. In January 2022, the Chief Coroner for Ontario initiated the Correctional Services Death Review (CSDR) to examine the 186 of these tragedies where the manner of death was not deemed a homicide. With differences across age cohorts, deaths due to accidental drug toxicity and deaths by suicide featured heavily alongside accidental and natural causes.

The review process included considerable data analysis and research intended to reveal as much as possible about themes and patterns found across the system and in each facility that may have contributed to deaths, and those which may have interfered with or impeded their prevention. In turn, the results of that work were presented for interpretation by a diverse nine-member Expert Panel which convened in October and November. This report summarizes the work of the panel as the members sought to understand and identify practical and actionable improvements. The report includes 18 recommendations for action.

In Part One of the report, the panel sets a foundation for the reader by exploring several defining characteristics of correctional custody in Ontario, and by presenting a cumulative understanding of the in-scope deaths based on several dimensions revealed through the data analysis phase of the review. In Part Two, the panel has organized a wide range of factors under five distinct themes. These factors emerged from the data, from additional and important insights gained from 21 contributing delegations and from the panel’s own deliberations. Each of these action themes is examined in depth and supported by the available evidence. Informed by these actionable factors, and with a view to preventing further deaths and serious injuries in custody, Part Three sets out specific recommendations, including proposed roles, responsibilities and timelines.

Central to these recommendations is the opening-up of a system that currently operates with very little transparency and in isolation from many important perspectives. A more open approach, including greater attention to the lived experience of persons-in-custody, front-line staff, family survivors and other justice and health care partners will better inform and support overall safety and guarantee more humane conditions in all facilities. It will also open more channels for seeking and promoting alternatives to current custody arrangements, with greater reliance on community-based and health care supports that may be more suitable to the complex needs of many of today’s persons-in-custody.

Connected to this is a call for improvements in data quality and availability, as well as strengthened oversight and ongoing reviews of correctional practices. Importantly, there must be an enhanced ability to understand and respond to such practices not only as they are set out in policy, but also as they are actually occurring. There is a need to advance a learning culture at every level.

The prevention of further deaths requires the removal of barriers to health care and more reliable standards of quality care on an aggressive schedule. More insights and improvements to the training and competencies of correctional staff are also urgently needed. Taken together, and supported by other recommendations, an important goal is to balance the essential mission of all custody facilities to ensure that care becomes as dominant a priority as security and control.

The final recommendation confronts a hard reality and may call for hard decisions, in the near future. Capacity limitations sit at the core of the unsafe and unhealthy conditions that must be improved considerably if further deaths and serious harms are to be prevented. The frequency of lockdowns and general staffing deficiencies present ongoing barriers to effective care, humane conditions, meaningful programs and the connections to family that are all essential to well-being for those in custody. Security and control alone are inadequate to keeping people safe and to meeting their complex needs. Recovery, life skills and transitional supports must be equal parts in the equation if persons-in-custody are to return to healthier lives in the community.

The panel has determined that over recent years, these conditions have significantly decreased the safety for persons-in-custody. They have also led to alarming deteriorations in the safety, wellness and career satisfaction for the dedicated individuals who work within the current environment of custodial corrections.

The panel recognizes that the health, social and criminal justice evidence, as well as economic realities, may all argue against increasing capacity and infrastructure for custody in Ontario. Alternatives may exist for reducing demand on the system and for safely meeting the needs of individuals who come into conflict with the law in other ways. Within current correctional resources, adjustments to leadership practices, staffing models and new methods to promote system-wide learning might stimulate a range of operational improvements. In turn, such improvements may ultimately reveal greater capacity for supporting persons-in-custody, for operating healthier workplaces and for preventing further deaths.

Finding and mobilizing all such options is an urgent obligation.