In total, we offer 18 recommendations below, and several are related to more than one of the actionable themes (A to E) that are described above in Part two. See Reference indicators for each.

  1. The Deputy Solicitor General, Correctional Services (DSG), will establish an Intersectoral Custody Advisory Committee (ICAC) that will meet on an ongoing quarterly basis under the leadership of an Assistant Deputy Minister (ADM). (Reference Themes A, B, C, D & E)
    1. In addition to select officials from the Ministry, including a representative selection of operational leaders as determined by the ADM, the ICAC will include at least two or more members from each of the following representative groups:
      • persons with prior lived experience in Ontario custody facilities, family survivors and/or advocates;
      • experienced front-line and supervisory correctional officers (COs);
      • experienced front-line nursing staff or nursing managers;
      • an executive member of the OPSEU provincial bargaining unit;
      • senior representation from the Ministry of the Attorney General (MAG) prosecution services.
    2. Among other agenda items to be jointly determined on a continuing basis, the ICAC will include periodically:
      • a review of deaths and serious injuries in custody facilities, and the status of investigation progress and results, including postvention insights gained in the case of deaths by suicide, and contraband insights gained in the case of accidental drug toxicity deaths;
      • a review of policy compliance and non-compliance as identified in investigations and custody complaints, and responses implemented;
      • an objective review of safety improvements implemented across all facilities;
      • a review of community-based alternatives, diversion programs and harm reduction practices that have resulted from Ontario court decisions as alternatives to incarceration, their demonstrated outcomes and missed opportunities where such alternatives were not applied;
      • a review of CO competency models and recruit training practices, evaluation methods and the state of compliance with prescribed in-service training requirements;
      • a review of the efficacy of custody complaint processes and facility visitation practices;
      • a review of the frequency, duration and causes of lockdowns in all facilities.
    3. Within the first six months of operation, the ICAC will establish and publish a renewed mission, vision and guiding principles statement for the Ministry of the Solicitor General, Correctional Services, establishing a clear balance between security and care considerations in custody.
  1. Appropriately assigned staff in the Ministry of the Solicitor General (SOLGEN staff), in cooperation with the ICAC and the custody operations management team, will develop, implement and report on new resources and procedures for enhancing the informed intake of people entering custody, including: (Reference Themes A, C & E)
    • transportation and admission processes that ensure the reliable transfer of all pertinent health information;
    • methods to ensure a full orientation and understanding by new persons-in-custody of their rights and responsibilities, available spiritual and health care resources, and methods of recourse for unmet concerns about their health and wellness, with attention to literacy, language, culture and other considerations;
    • the application of evidence-based admission screening processes and practices to reflect and mitigate unique needs of people entering custody, including health intake practices to reflect important morbidity and mortality risks that could impact correctional stay, and SAFER and other methods for achieving risk-commensurate placements to the extent possible;
    • additional screening processes required to increase identification and response to traumatic brain injuries (on entry and after critical incident experiences in custody), fetal alcohol spectrum disorders and physical and developmental disabilities.
  1. In cooperation among the Family Support Liaison (FSL), Correctional Services Oversight and Investigations (CSOI), and operational management, SOLGEN staff will develop, implement and report on an expanded family-centered approach for continuous information flows and compassionate support for survivors of deaths in custody, including engagement with chaplains, NILO’s, social workers and select community-based supports. (Reference Themes A, C & E)
  2. Within one year, the DSG will assign a project team working in cooperation with family survivors, cultural advisors and operational management to examine, determine and report on appropriate and available means for memorializing deaths in custody, and to track plans for their implementation at each institution and across the custody system. (Reference Theme A)
  3. Within one year, the DSG will assign a project team to identify, implement and report on improvements and removal of barriers in all facilities for access to community supports, including in-person family visits and available hours, access to legal advice, costs of telephone and mail, and access to peer support programs and community organizations that can assist with transition planning. (Reference Theme A)
  4. Within six months, the DSG will initiate a project in collaboration with the Deputy Attorney General (DAG) to conduct research and provide an updated report to the DSG and DAG on available strategies for reducing the number of people remanded into institutions. The scope of the joint project will include: (Reference Theme A & B)
    • enhanced risk-assessment methods for informing courts of available alternatives;
    • consideration to barriers limiting community-based alternatives;
    • enhancing access to multi-agency support resources, including housing, Ontario Disability Support Program (ODSP) and substance use treatment;
    • culturally specific and gender-specific considerations for over-represented groups.
  1. Within one year, the DSG will receive an initial, comprehensive report from the Superintendents and Regional Directors Committee (SRDC; see 10 below), developed in cooperation with Ministry program design and implementation staff, which outlines strategies implemented, successes achieved and ongoing evaluation models for expanding the effective operation and more consistent availability of all forms of programming in each facility, including: (Reference Themes A, B, D & E)
    • strategies for increasing reliable cooperation with available community-based supports;
    • expanding available and suitable spaces to accommodate programming;
    • reducing barriers to accommodate internally and externally provided programs;
    • increasing program support related to employment and transferrable skills, including education, books and literacy, including for remanded persons-in-custody;
    • increasing access and uptake of meaningful activities by all persons-in-custody;
    • applying gender and cultural lenses to achieve equitable access and participation in programming and skill-building;
    • achieving consistency across institutions to ensure continuous learning and best practices in program quality and efficacy;
    • establishing ongoing reporting requirements beyond this initial report.
  1. Within six months, the DSG will initiate a project team to assess and report on the current progress and future planning with regard to achieving inclusive practices, anti-racism, culture and gender considerations, and LGBTQ+ inclusivity in all facilities, including attention to: (Reference Themes A, B, C & D)
    • zero-tolerance policies;
    • sensitivity training for correctional staff;
    • collection, reporting and use of race-based data;
    • culturally specific product availability within canteens and facilities;
    • means for safely and appropriately accommodating women and gender diverse individuals without a continuing reliance on segregation conditions.
  1. Upon receipt by the DSG, the reports generated by the project teams identified in Recommendations 2 through 8 above will be provided to ICAC for their consideration and review in the next available quarterly meeting, where the scope of each report’s distribution will be determined by consensus of ICAC, and unless otherwise restricted by Ontario Public Service policy, consideration will be given to extending distribution to persons-in-custody, families, correctional staff, OPSEU and the general public. (Reference Theme A)
  1. The Assistant Deputy Minister (ADM) of Institutional Services will establish an ongoing Superintendents and Regional Directors Committee (SRDC) that will meet quarterly to establish a robust community of practice (CoP) model for the sharing of experiences, concerns, innovations and applicable metrics for cross-institutional collaboration and learning. (Reference Themes B & C)
    1. Within the first year of operation, the SRDC will initiate and report to the ADM on a review of policy compliance and non-compliance across all 25 facilities. Included in the report will be recommendations for amending policies deemed to be inappropriate to current conditions, new policies required to better align with current and future conditions, and any measures implemented or required for achieving more reliable and consistent compliance for policies that continue to apply.
    2. Within the first six months of operation, the SRDC will initiate and report to the ADM on strategies to strengthen the quality, reliability and necessary management supports in the supervision of correctional officers and other staff in general, and in specific areas to include:
      • applications of isolation conditions, when applied explicitly in accordance with segregation policy, when applied for other reasons outside of those policy guidelines, and when inappropriate to health and wellness conditions;
      • the identification of systemic barriers to reducing the use of isolation and lockdown conditions;
      • interferences with complaints and concerns from persons-in-custody;
      • staff rotation practices that ensure variability of care is balanced with appropriate connections with persons-in-custody;
      • the reliable application of all CO competencies and best practices;
      • surveillance techniques including electronic options and the viability and potential scope of body-worn cameras to enhance safety.
  1. Within the next six months, the ADM of Institutional Services will initiate a project in cooperation with Ministry partners, including Justice Technology Services (JTS), to deliver within two years of this report a comprehensive Corrections Transparency and Data Quality (CTDQ) strategy that will improve the quality, reliability, completeness and availability of all data collected and applied within custody operations, with emphasis on the following priority areas: (Reference Themes B & C)
    • develop an inventory of the barriers to the collection of all applicable, relevant and available corrections data (e.g., non-mandatory fields, Wi-Fi capabilities);
    • capture all health information in an electronic system;
    • capture information on medications, visits with care providers (including general practitioners, mental health care and specialists) and visits to health care facilities outside of the institution;
    • ensure accessibility of relevant health information to internal staff, staff at other institutions (e.g., in the case of transfers) and by staff within SOLGEN, including a review of real and/or perceived information sharing barriers due to privacy or other considerations;
    • assess and remedy gaps in data collection, particularly where reporting to SOLGEN is optional;
    • develop and document standards for how data are collected and captured (e.g., minimum data fields and time between event and reporting to the Ministry);
    • improve accountability and general transparency in all data collection and reporting;
    • raise the numeracy and data literacy of institution and ministry staff;
    • where data are currently collected via telephone or email or are paper-based, set out a realistic timeline for transition to fully electronic data collection and transfer (e.g., prisoner transfer, program cancellations, use of force, visits and mail received);
    • share this comprehensive strategy with the SRDC and the ICAC for comment.
  1. Within one year of this report, the DSG will commission a report from the correctional services senior management team and other SOLGEN partners as required to determine the viability of seeking Cabinet approval for establishing the current CSOI unit as an Inspectorate of Corrections (IOC). (Reference Themes A, B & C)
    1. Within the next two years, CSOI (or the IOC if approved and implemented) will implement specific improvements to the transparency and accountability of custody operations, including:
      • introduce public reporting on all deaths in custody with an annual report structure, including facility and manner of death;
      • prioritize investigations into incidents and behaviours that may have improperly interrupted the flow of information, requests and complaints from persons-in-custody, and provide a timely report on each incident to the ADM, the SRDC and the ICAC on actions taken as a result;
      • increase access to rights and information pathways for persons-in-custody (e.g., CSOI contact numbers, hotline booth);
      • ensure access to CSOI investigators to conduct proactive safety audits and reviews, periodically in all correctional facilities;
      • expand analytic and reporting capacities to support more timely and wider access to the outcomes from all investigations, audits and reviews.
  1. Within one year of this report, the Director of the Human Resources Strategic Business Unit (SBU) will develop a report to the DSG outlining viable pathways to, timelines and budget requirements for aligning the compensation rate for all professional service staff and contracted providers in custody facilities, including physicians, nurses, mental health physicians, mental health nurses, social workers, chaplains and other spiritual advisors at levels commensurate with positions outside of the Ministry, to attract and retain the numbers and quality of staff required to serve the needs of persons-in-custody. (Reference Themes B & E)
  1. Within one year of this report, and in cooperation with OPSEU, the Director of the Human Resources Strategic Business Unit (SBU) will develop a report to the DSG outlining viable pathways to and realistic timelines for eliminating the widespread use of fixed-term correctional officers, including a plan, budget requirements and collective bargaining considerations for normalizing a full-time permanent staffing model to the extent achievable over the next three to five years. (Reference Themes B & D)
  1. Within 18 months of this report, the ADM of Operational Support will establish, complete and report to the DSG, the SRDC, and the ICAC a review of the core competencies and an evaluation of the effectiveness of delivery for all correctional officer training, including basic and in-service, with an emphasis on the following considerations: (Reference Themes A, D & E)
    • engagement of people with lived experiences and experienced front-line and supervisory CO perspectives in training curriculum and design;
    • engagement of people with lived experiences and experienced front-line and supervisory CO perspectives in the design and use of experiential and scenario-based learning models;
    • balanced emphasis on prevention, support and security;
    • ongoing mental health and substance use training;
    • mandatory trauma and violence-informed training;
    • compliance and completion levels in all facilities.
  1. Within six months of this report, the Chief Administrative Officer/Assistant Deputy Minister (CAO/ADM) of Corporate Services will initiate a project that within one year will develop, implement and report on new quality standards for correctional health care services, in alignment with best practices from relevant professional colleges and organizations (including the College of Nurses of Ontario, the Registered Nurses Association of Ontario and the College of Physicians and Surgeons of Ontario) and with the following additional considerations applied: (Reference Theme E)
    • ensure minimum standards are met (or exceeded) across provincial correctional facilities;
    • build a framework for ongoing monitoring and reporting on quality standards;
    • ensure equivalence for health care in custody with health care in the community, with integration of care with programs funded and delivered by other institutions with expertise, such as Ministry of Health or Ontario Health;
    • empower health care staff to function in accordance within professional standards of practice and support strategies to identify and remedy conflicts;
    • hold Superintendents accountable to ensure no operational barriers exist to the delivery of health care that meets professional standards;
    • align adequate resourcing for equitable application of public health best practices;
    • implement best practices for treatment of substance use disorders, and remove barriers to opioid agonist therapy (OAT);
    • implement best practices for harm reduction, including naloxone access, and explore opportunities for supervised consumption and safe supply.
  1. Within one year of this report, the DSG will receive from the SRDC a comprehensive report on best practices implemented, those requiring further Ministry support and ongoing evaluation methods for eliminating the trafficking of contraband in all facilities, with immediate emphasis on: (Reference Themes B, C, D & E)
    • all facility access will be dependent upon reliable forms of contraband screening, with the inclusion of corrections staff in all scanning and inspection procedures;
    • in cooperation with CSOI (or the IOC), improved intelligence and surveillance methods, including wider deployment of canine units, will be developed and applied for the recognition and interdiction of contraband;
    • in cooperation with the ICAC, the establishment and roll-out of an effective ‘never event’ strategy to eliminate toxic substance deaths across all institutions.
  1. Within six months of this report, the DSG will establish and announce an updated Capacity Threshold Policy for Ontario Custody Facilities (CTP-OCF) that will declare any facility temporarily closed for in-bound transfers of persons-in-custody either until capacity can be restored or occupancy can be reduced sufficiently to comply with the following criteria, and/or other criteria to be determined by the DSG, and will develop system wide metrics and a reporting regime to track all such determinations: (Reference Themes A, B, C, D & E)
    • staffing levels and attendance patterns are sufficient to support full and adequate operations with due safety for COs and without lockdown conditions;
    • staffing levels and attendance patterns are adequate to support optimal health care access and functioning, access for spiritual and psychological support personnel, and access for community-based program providers;
    • staffing levels and attendance patterns are adequate to ensure uninterrupted family and legal advisory visitation access within established policies;
    • staffing levels and attendance patterns are adequate to enable resources in support of approved external appointments for persons-in-custody;
    • staffing levels and attendance patterns are adequate to enable emergency response procedures, when and as required.