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"We probably tracked livestock better than we do human beings," is a bureaucratic understatement for the ages.

Said by an official in the ministry overseesing Ontario's prisons, the comment only hints at the degree to which the province has failed to properly monitor inmates in solitary confinement.

This is not just a case of a farm losing a few cows. It's a farmer who can't tell a cow from a duck.

The confusion is laid bare in a new report by the Ombudsman of Ontario, Paul Dubé. The report was prompted by the news, last October, that a young indigenous man named Adam Capay had been awaiting trial in solitary confinement in a Thunder Bay prison for more than four years.

Shocked by Mr. Capay's mistreatment, a team of investigators from the Ombudsman's office visited four provincial jails and interviewed ministry and correctional staff, one of whom invoked the livestock metaphor.

Investigators found that prison staff routinely fail to keep accurate records of how long inmates have been in solitary. The system was found to be so riddled with errors that Mr. Dubé bluntly concludes in his report that "the Ministry's tracking and review of segregation placements is unreasonable, wrong [and] oppressive."

This is not news to Mr. Capay, who was in solitary for more than 1,500 days without anyone in the ministry doing anything about it. Mr. Dubé now knows why this is happening, though: The province has no codified definition of segregation.

Mr. Dubé's team found that "correctional staff and Ministry officials expressed conflicting understandings of what conditions of confinement and placements amounted to segregation." In the most absurd cases, some inmates in solitary confinement, but whose cells weren't located in a dedicated segregation unit, weren't considered to be in solitary. If a cow's in a duck pond, is it a duck?

This makes Mr. Dubé's main recommendation so important: He wants the province to define segregation, once and for all.

Everything else flows from that. Prison staff and ministry officials can't track time in segregation, and ensure no one spends more than a few consecutive days in it, until they have a clear definition of "segregation." Without this first step, all other reforms will fail.

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