The federal prison ombudsman says the practice of locking up mentally ill offenders alone for long periods must end to help cut the risk of death behind bars.
Howard Sapers, the correctional investigator, also calls for round-the-clock health care at medium- and maximum-security prisons, more rigorous patrols and head counts, and better education for front-line staff who respond to crises.
"This is challenging work. There aren't any shortcuts," Mr. Sapers told a news conference as he released an extensive report Wednesday on the correctional service's response to deaths in custody.
Mr. Sapers concludes many of the same structures and policies that failed teenager Ashley Smith three years ago remain in place.
He has harshly criticized the prison service over the 2007 death of 19-year-old Ms. Smith, who choked herself with a strip of cloth at the Grand Valley prison in Kitchener, Ont.
Since then, more than 130 offenders have died in federal custody, Mr. Sapers said Wednesday. He examined nine of these cases in detail, saying they underscore longstanding gaps and problems.
"Mistakes and recommendations should not need to be repeated," says the report released Wednesday. Mr. Sapers found:
– A lack of emergency equipment, delays in responding to crises and sometimes inadequate medical care;
– Poor information-sharing between medical and correctional workers;
– Shoddy patrols that failed to ensure prisoners were alive and well;
– Placement of offenders with mental-health concerns in segregation for lengthy periods;
– Flawed investigations that were not always chaired by independent clinical professionals.
Last December, Mr. Sapers asked the service to clearly spell out what it was doing to help the mentally ill in its care. He requested updates on initiatives including treatment plans and the hiring of mental-health professionals.
In March the Correctional Service promised to more closely monitor offenders with mental-health problems placed in segregation.
Ten to 12 per cent of offenders entering the federal prison system have a significant mental problem.