Quicker response by guards at Ont. prison could have saved life of inmate: report

Didn’t give first aid, slow to call ambulance for aboriginal man who bled to death

CBC News

Staff at an Ontario prison "failed to respond adequately" to serious self-inflicted injuries that caused the death of a First Nations inmate in October 2006, according to a report released Wednesday from Canada’s prisons watchdog.

"It’s a concern of mine that there seems to be a pattern of delayed and inadequate response,” said investigator Howard Sapers. (CBC)

The damning report, by federal correctional investigator Howard Sapers, examines the case of an inmate who pressed an emergency call button and was subsequently found bleeding in his cell at Pathway Aboriginal Program Unit at Warkworth Institution in Campbellford, Ont.

The prisoner, whom the report doesn’t name because of privacy concerns, was eventually taken to hospital where he was pronounced dead from loss of blood.

“Given the fact that this was self-harm, that a call for help was sent out immediately and [that] it takes some time for somebody to bleed to death, it seems to me fair to conclude that had there been a more complete response, including the administration of first aid as soon as possible, that the life could have been saved," Sapers told CBC News.

The report says that allegations of racial discrimination against the inmate were not taken seriously by Corrections Services investigators, who also looked into the incident. It found evidence of "excessive delays" in an internal inquiry into the death.

Sapers said the death comes a year after his office conducted a general review of 82 deaths in custody at various institutions over five years that seemed to have occurred under similar circumstances, based on investigations by correctional services, provincial coroners and medical examiners.

"It’s a concern of mine that there seems to be a pattern of delayed and inadequate response,” he said.

The report says the inmate, a 52-year-old man with a history of violent crime, alcohol addiction and mental illness, was in his cell when he apparently slashed his left arm, then summoned prison staff via an emergency button.

According to the report, when paramedics arrived at the scene 30 minutes later, they found the inmate "alone, unconscious on the floor of his cell, with evidence of blood soaked into the mattress, and not breathing."

No first aid by staff

Prison staff performed no first aid, investigators found.

Four staff on duty at the prison that night were disciplined by Correctional Services, but the report said persistent allegations by other staff and inmates that the victim’s race played a role in the inadequate response to his injuries were not taken seriously enough.

An internal inquiry into the incident had mentioned the allegations and recommended that prison staff be given access to "diversity awareness/sensitivity" training, but no action was taken.

Sapers said investigators believe the outcomes for individual staff were "disproportionate to the fact that there was a loss of life.”

The report recommends that the federal prisons agency immediately develop new response policies for medical emergencies, implement the diversity training recommendation and start videotaping life-threatening situations in cells and jail premises. It also says police need to be involved in investigating deaths and injuries in prisons.

There has been no reaction yet from Correctional Services Canada, but the office of the correctional investigator says the agency has received Wednesday’s report and promised to respond to all allegations and recommendations.

More transparency, accountability needed: group

Kim Pate, executive director of Canadian Association of Elizabeth Fry Societies, said the report raises issues that she and other organizations that work with people in custody have been raising for some time.

The prison system The prison system "is not a system that invites transparency, accountability” said Kim Pate, executive director of Canadian Association of Elizabeth Fry Societies. (CBC)

It highlights the need for greater accountability and transparency, she said.

"If you don’t have people monitoring, if you don’t have people working there who see the individuals there as worthy of intervention, you tend to more likely have these kinds of tragedies," she said. "The reality is I think most people don’t know what happens behind prison walls.”

That’s not unique to Canada, which she said has one of the best prison systems in the world. However, she said the corrections system has tried to restrict her organization’s access to information in some cases.

"So, the reality is it’s not a system that invites transparency, accountability.”

She said she supports the idea of videotaping emergencies, which may encourage staff to behave appropriately.

Talking about this case and what needs to change will lead to "fewer and hopefully no more deaths in custody,” Pate said.


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