Skip to main content

The Globe and Mail

Lax review of prison deaths puts inmates at needless risk, ombudsman says

Correctional Investigator of Canada Howard Sapers speaks during a news conference in Ottawa on November 26, 2013. The federal prison ombudsman says it often takes more than two years for the Correctional Service to complete a mandatory review when someone behind bars dies of natural causes.


Inmates may be dying needlessly in federal prisons because authorities aren't doing enough to track and prevent deaths on their watch, the national prison watchdog says.

A report released Monday concludes that an untold number of the roughly 35 supposed "natural cause" deaths that occur each year in federal prisons could have been avoided with proper health care and improved tracking of incidents.

Correctional investigator Howard Sapers said his review of the way Correctional Service Canada tracks deaths uncovered disturbing incidents of poor medical treatment, including misdiagnoses, bad drug interactions and shoddy care in 15 sample cases.

Story continues below advertisement

"As we were investigating the process, we came across example after example of inadequate administration of care," Mr. Sapers said in an interview. "What our external medical consultant tells us is that while similar mistakes do happen in the [non-prison] community, he wouldn't expect them to happen with the same frequency."

The report, for example, cites several examples of poor care leading to death, including one inmate with lung cancer who was treated for pneumonia and another with hepatitis who was given a drug that interacted with a pre-existing liver condition.

"There is little that is natural about dying in a federal penitentiary," the report states.

More broadly, the report found incomplete records, lax information-sharing and delays or lack of followup on treatment recommendations. "Part of the puzzle here is that things aren't always well documented," Mr. Sapers said.

The result is that authorities often don't know if a death was preventable, and therefore aren't doing enough to prevent future mistakes. Prison staff often don't look at the circumstances of natural deaths beyond recording the cause as either unexpected or sudden.

Overall, the report also faults Correctional Service Canada for a "flawed and inadequate" mortality review process.

On average, about 35 federal prisoners die each year for natural reasons – by far the most common cause, the report says. More than 500 inmates died behind bars between 2003 and 2013.

Story continues below advertisement

"More offenders are growing old in custody and succumbing to chronic disease in prison," according to the report, which calls on the prison service to do a comprehensive "lessons-learned exercise" to identify measures to reduce or prevent natural-cause deaths.

Mr. Sapers recommends several other changes:

  • All sudden or unexpected fatalities should be subject to a full national board of investigation, the kind of inquiry that now happens when there’s a suicide or homicide;
  • The board should convene within 15 working days of the fatality;
  • All reviews of prison deaths – no matter the cause – should be led by a doctor;
  • Death review reports should be shared with family members in a timely way.

Correctional Service Canada officials were not immediately available for comment.

With a report from The Canadian Press

Report an error Editorial code of conduct Licensing Options
As of December 20, 2017, we have temporarily removed commenting from our articles. We hope to have this resolved by the end of January 2018. Thank you for your patience. If you are looking to give feedback on our new site, please send it along to If you want to write a letter to the editor, please forward to