Ombudsman slams lax review of federal prison deaths from natural causes

The national prison ombudsman says he has serious concerns about the quality of care provided to ailing prisoners in federal custody.

A report released Monday by correctional investigator Howard Sapers also found it often takes more than two years for Correctional Service Canada to complete a mandatory review when someone behind bars dies of natural causes.

Sapers says he uncovered questionable diagnostic practices, incomplete records, lax information-sharing and delays or lack of follow-up on treatment recommendations.

In addition, prison staff did not investigate the circumstances of natural deaths beyond recording the cause as either unexpected or sudden.

Correctional Service’s process for reviewing such in-custody deaths failed to generate significant findings or recommendations, Sapers says. There is no way of determining whether a death was preventable or premature.

On average, about 35 federal prisoners die each year for natural reasons — by far the most common cause, the report says.

“More offenders are growing old in custody and succumbing to chronic disease in prison.”

It calls on the prison service to do a comprehensive “lessons-learned exercise” to identify measures to reduce or prevent natural-cause deaths.

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.

The process for reviewing deaths in prison should also be subject to a “quality control audit” by an outside medical examiner, Sapers says.

Correctional Service spokeswoman Sara Parkes said Monday the agency has “already begun work in many of the areas” identified by Sapers.

However, Parkes could not say which recommendations the prison service might adopt.

In preparing the report, Sapers’ office hired an independent doctor to study the medical care provided to a sample of 15 offenders before they died. All of the deaths involved men and all but one was anticipated by the prison service.

In each case, the doctor looked at the same medical charts, files and records that were part of Correctional Service’s case review.

In one case of an inmate who died of a cancerous tumour, a review of his medical chart showed lack of continuity of care, incomplete and poor documentation, lack of progress notes and an absence of follow-up on treatment recommendations.

In five of 15 cases, recommendations for further testing or referrals to specialists were not followed and unexplained delays in treatment occurred, the report adds.

It says the original prison service death reviews “do not indicate the rationale upon which the treating physicians relied or why recommended tests or referrals were not followed.”