Ontario Deaths

in Custody on
the Rise
December 2022
Tracking (In)Justice: A Law Enforcement & Criminal Justice Data & Transparency Project
Scope of report
This report from the Tracking (In)Justice, a law enforcement and criminal justice
data and transparency project, focuses specifically on the deaths of individuals
incarcerated within Ontario provincial jails and prisons.

In Canada, people sentenced to less than two years of incarceration, and those
detained pre-trial, are held in the custody of the provincial and territorial
governments. The figures provided in this report refer exclusively to deaths of
individuals in the custody of Ontario provincial jails and prisons from 2010-2021.

In this report, a death in custody is defined as any death directly occurring while in
the legal custody of Ministry of the Solicitor General (SOLGEN). The death must
have resulted directly from events within an Ontario provincial jail or prison. To be
defined as a death in custody, both of these criteria would have to have been met:

The event leading to the death occurred within an provincial jail or prison;
While the actual death might have not occurred within the institution the person
was still legally in SOLGEN custody at the time of the event.

Deaths of people under community supervision or released on a temporary

absence are not included in the data in this report. As a result, the numbers in this
report may differ from figures provided in the SOLGEN open data portal, which
include deaths on temporary absence, provincial parole, police custody, and after
charges have been stayed. In contrast, data in this report focuses specifically on
deaths which both occurred in SOLGEN custody and resulted from event occurring
within a SOLGEN institution.

Data for this report were obtained through requests to the Ministry of the Solicitor
General (SOLGEN). Complementing these data are qualitative interview findings
with lawyers who have represented bereaved families following a death in custody,
and transcripts from testimony at inquests into deaths in custody in Ontario
collected by doctoral candidate Sarah Speight, University of Ottawa.

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Responding to public
concern about
deaths in custody
Deaths in custody in Ontario are on the rise. Due to a systemic lack of transparency,
information about deaths in custody is hard to come by, and inconsistently released
to the public and families of those who have died.

The Ontario Coroner’s Office is currently conducting a review of deaths that took
place at Ontario provincial institutions between 2014 and 2021. In the meantime,
however, deaths have continued to mount. Bereaved families, activists, and people
with lived experience of incarceration have worked tirelessly to focus public
attention on this issue, calling for transparency, oversight, and accountability on the
part of the provincial government.

Those impacted by deaths in custody have held protests at Ontario provincial

institutions and government buildings, organized public education events, and
supported each other through systems navigation following the loss of loved ones.

The purpose of this report is to contribute to informed public and policy

discussion on in-custody deaths in Ontario’s provincial jails and prisons by:

Releasing existing Ontario government data confirming that deaths in

Ontario provincial institutions are increasing despite a decreasing
custodial population.

Providing background on the deaths in custody reporting practices and

their impact on bereaved families.

Identifying policy issues behind access to information barriers following

a death in custody.

page 3
 280 28
28 reported
deaths in Ontario
custody in the first
10 months of 2022

41
41 reported deaths in
Ontario custody in
2021

Since 2010 there have been over 280

deaths in Ontario provincial jails & prisons

23
23 reported

Key trends
deaths in Ontario
custody in 2020

What is remand?
76% Remand is custody for people who are held
while waiting for a court appearance or who
are waiting for a bail hearing. A small portion
of people on remand have been tried, found
guilty, and are awaiting sentencing. The vast
In 2021, 76% of the majority of people held in remand are held in
Ontario provincially custody before their trial because they have
incarcerated population been denied bail.
was on remand.

page 4
 missionin custody are
Deaths
increasing despite a
declining prisoner
population
Since 2010, there have been over 280 deaths within Ontario provincial jails and
prisons.[1] In 2021, the number of people who have died in Ontario provincial
custody almost doubled, from 23 deaths reported in 2020, to 41 reported last year
(Figure 1). This far surpasses a marked increase in deaths starting in 2017, which
saw a rise from 17 deaths in 2016 to 24 deaths the following year. Compared to
2010, the rate of deaths in Ontario provincial custody in 2021 increased 173.3%.
Preliminary numbers for 2022 report 28 custodial deaths, already surpassing
numbers from 2020.

Figure 1: Deaths in Ontario Provincial Institutions 2010-2021

page 5
 mission
Most provincially-incarcerated
people are in pre-trial custody rather
than in the community on bail
The average daily counts of people in custody have decreased in Ontario, pre-trial
detention rates have risen 137% over the past 30 years. [2] In 2010, the average
daily count for the provincial population was 8,761 (62.3% on remand). In 2021, the
average daily count for the provincially incarcerated population was 7,162 (78.6%
on remand). The increase in remand rate affects deaths in custody as individuals on
remand face heightened suicide [3] and drug overdose risk [4] compared to those
serving sentences. Suicide risk for people on remand is four times that of the
sentenced population [5] due to the challenges of adjustment, uncertainty, drug or
alcohol withdrawal, disrupted personal relationships, isolation, restrictive
conditions, and first time incarceration. Drug toxicity risk in pre-trial detention is
heightened due to reduced drug tolerance and high turnover of people rotating
through facilities, which facilitates the entry of drugs into institutions. [6]

Figure 2: Average daily count and remand percentage in Ontario provincial

institutions

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Deaths in custody
trends are shifting
From 2012 to 2017, the most reported means of death in Ontario provincial
institutions was “natural.” This is a classification of death reflecting an underlying
medical cause. However, deaths classified as natural may still raise serious
concerns regarding medication dispensing, medical documentation practices, or
conditions of confinement. In an interview, a lawyer representing the family of a
young man who died unexpectedly in provincial custody described the challenge
with natural death classification:

“It was clear that the way this death occurred was anything
but natural. The severe dehydration, the video imagery of
[him] the day that he was picked up while riding his bicycle.
He was well enough to be riding his bicycle, and you can see
him joking around when he’s getting [processed] and then
you see after him five days [in custody] presenting with gross
emaciation. He looked like a character from the walking
dead. It was just horrific. So to see that and to say hmm
natural causes – it may have been a natural process that he
died from but it was a very unnatural course in prison that led
him to die from. That was our theory and I think that it was
established.” - Lawyer

This example illustrates that the proportion of deaths in provincial custody

classified as natural over the past decade should not immediately be taken at face
value as such deaths may have arisen out of questionable circumstances.

Although deaths in custody have risen across the province, means of death trends
have changed. According to a SOLGEN prisoner data release, “The increase in
deaths between 2017 and 2018 are a result of a rise in suspected overdose as the
reason for death.” [7] The ongoing drug policy crisis has resulted in a highly toxic
drug supply and a dramatic increase in drug-related death across Canada. This
already-high risk of drug toxicity prior to incarceration is amplified in custodial
settings and following release. [8]

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Due to lack of transparency, we do not yet know the reasons for the current
increase in deaths between 2020 and 2021. There is anecdotal evidence that in the
general population, the COVID-19 epidemic, has amplified risks associated with
drug toxicity and access to supports, which could increase risk of drug related
deaths. [9] Similarly, the level of isolation imposed on Ontario provincial prisoners,
and uncertainty during the COVID-19 pandemic may have contributed to a rise in
suicide deaths.

Reporting deaths in custody in Ontario

There is no publicly available information breaking down deaths by institution or
manner of death over an extended period. Ministry policies are absent of sufficient
direction regarding the notification of next of kin, the transfer of belongings, and
access to official reports. SOLGEN is not required to inform the public of the death
through news releases so there is no way for members of the public to keep track
of decedents’ names and demographic information. Ontario provincial institutions
receive little direction regarding information sharing following an individual death in
custody.[10]

Due to lack of transparency and policy, determining with certainty how many people
have died in provincial custody is a challenging process.[11] During the Independent
Review of Ontario Corrections, investigators attempted to obtain a concrete figure
on deaths within Ontario provincial institutions but were unable to do so, as the
figures provided by different branches of government did not align. The problem
was that different units tracking deaths in custody were not sharing a uniform
definition of what “in custody” meant.

Following a death, families of the deceased can request a copy of the investigation
report, however SOLGEN is not required to provide it – and they may choose to
redact the document considerably before providing it to loved ones. At a recent
inquest into a suicide death in custody, a mother described her experience with the
death in custody notification process at the provincial detention center where her
son died, where she stated:

“I am still waiting for them to call me back regarding my son being in a psychosis [before
his death]. I did call them after [he] had passed and this was about three, possibly four
days after. I asked to speak with the superintendent and I am still waiting for him to call
me back. [H]is receptionist had asked me why I wanted to speak with the superintendent,
and I said, “Well, because my son just died in your facility” and she said “oh really we
didn’t hear about this”. I thought well, this is strange because the whole [prisoner]
population knew and five or six of them called me at my home to let me know that they
knew what happened to [my son].” - Parent

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The failure of SOLGEN employees to communicate with this young man’s mother –
both before and after his suicide – is commonplace. In this case, there was a three-
year gap between the death in custody and the inquest. In that period, a mother
waited years for answers regarding the circumstances of her son’s death.

Correctional Service Canada (CSC) and reporting deaths in

custody

In contrast, federal penitentiaries operated under the authority of Correctional

Service Canada have a more systematic approach to tracking and reporting deaths
in custody. Following a death in federal custody, CSC is required to contact a
Coroner and the Office of the Correctional Investigator (OCI), and to conduct an
internal review of the death. The OCI tracks deaths in federal custody and conducts
additional investigation where they feel it is required. The number of deaths in
custody each fiscal year is included in the OCI’s annual reports.

People in the custody of CSC are required to provide a designated contact in the
event of an emergency. Some people have different designated contacts for
different situations in which case the appropriate contact for death notification will
be informed of the death. If this person is unreachable, CSC consults the
decedent’s visitors list in order to identify next of kin. Following family notification,
CSC’s institutional family liaison follows up with the appropriate person to answer
remaining questions and facilitate access to information. The family liaison provides
next of kin with information on claiming their loved one’s body and reclaiming their
belongings.

Within a few days after CSC has notified the family of a death a news release
informs the public of a death. This typically includes basic information about the
death including the name of the individual, [12] their institution, and age, where
available. News releases via the CSC website facilitate real-time tracking of deaths,
which helps to identify important trends.

All deaths in federal custody that occur within the province of Ontario are subject to
inquests held by the OCC in cases where the death is determined to have occurred
unnaturally. However, when a death appears to have occurred by natural means
CSC conducts a “Mortality Review”. This is a medical review of the decedent’s
medical and institutional files to examine medical treatment prior to death. These
reports are internal and may include recommendations to improve the delivery of
medical services within CSC institutions. Family members are required to file an
Access to Information request to obtain access to this document.

page 9
How are deaths in-custody
investigated?
In Ontario, three separate bodies conduct in-custody death investigations, 1) the
Office of the Chief Coroner (OCC), 2) SOLGEN’s Correctional Services Oversight
and Investigations (CSOI) office, and, 3) SOLGEN Corporate Healthcare.

1) The Office of the Chief Coroner

Following a death in custody, the institution is required to notify a Coroner who will
conduct their own investigation into the death. An inquest is mandatory under the
Coroners Act only if the death is determined to be unnatural. [13] Discretionary
inquests into natural deaths in custody are rare, leaving a significant gap in arms-
length oversight of custodial deaths presumed to be natural.

What is an inquest?
The purpose of an inquest is to determine the circumstances
of a death [14] and produce recommendations to prevent
similar deaths in the future. If the investigating Coroner
determines that a death in custody occurred by “natural”
means, an inquest is not mandatory but may go forward as a
discretionary inquest if it is determined that doing so would
serve the public interest.

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In an interview, a lawyer who has represented both families and public interest
organizations at inquests into deaths in custody described the challenges of
accessing information when a death has been classified as natural and it becomes
clear an inquest will not be held:

“If someone dies in the hospital – or someone is hit by a car, there are all
kinds of opportunities to ask questions, and to sit down. Even in a natural
death that happens at a hospital…. if you are a grieving spouse and you say
to a doctor “I just want to sit down and have you explain your notes” – they
will make that time because people recognize that someone died and this
is a serious thing. The black box of a death in custody is hard to
penetrate…. [Families] have good reason to believe that if they go knocking
on the police door or the prison door saying, “I’ve got some questions
about my son’s death” that they’re not going to get very good answers...
If someone dies of a heart attack in jail and their family says, “I feel like
he’s been poisoned” and you never get that result, you have a grieving
family with questions. Also, it’s no one’s job in a jail to deal with a grieving
family, to answer their questions, to get them their belongings, just
addressing that human piece is one thing.” – Lawyer

Despite a reduced number of mandatory inquests now that natural death inquests
are no longer required, the OCC continues to face significant inquest backlogs.
During an interview, one lawyer with experience in representing families at inquests
into deaths in custody described challenges of waiting five years for an inquest into
an overdose death:

“I think it is just terrible if the purpose of an inquest is to

prevent similar deaths in the future... Waiting two years while
more and more deaths are occurring is counterproductive. I
can understand it when there are criminal charges pending or
something like that but that has not been the case in most of
these [deaths]. It’s not only counterproductive to wait that
period of time, but it’s very difficult for the families because
they’re basically left in the dark about what happened to their
loved one for years. – I mean look at, [my client’s son], we are
coming up on five years without an inquest.”
– Lawyer

page 11
If and when an inquest is eventually held, there is no systemic funding routinely
available for families to obtain counsel to represent their interests at the inquest
unless it is determined that the death resulted from a crime, or the Legal Aid Test
Case Fund approves costs.

At the conclusion of an inquest, a jury of five members of the public render a

verdict, which may include risk regulatory recommendations. Parties in receipt of
recommendations must provide a response within six months indicating whether
they intend to implement inquest recommendations and providing justifications for
their decision. Responses to recommendations are not publicly available, but are
available upon request. Out of the twenty-one lawyers interviewed as part of Sarah
Speight’s doctoral work, only three reported that they had followed up to check the
responses to inquest recommendations submitted by the Ministry of the Solicitor
General. One lawyer who represented medical professionals at inquests explained
that, “my retainers are done at that point so I don’t think I reviewed them with any
kind of professional hat on.” There is a lack of systemic tracking and follow up on
responses to recommendations resulting from inquests into deaths in provincial
custody.

2) Correctional Services Oversight and Investigations Office (CSOI)

The CSOI investigation functions parallel to the initial Coroners investigation into a
death and is required to report on each death. From the outside, the purpose or role
of these investigations is not stated to the public, although based on a review of
these reports, they tend to focus on procedural issues like the performance of
security rounds, record keeping practices, and emergency response. [15] To initiate
an investigation, regional SOLGEN offices contact CSOI to request a “level 1
investigation.” [16] An inspector acting on behalf of CSOI interviews witnesses,
reviews documentary and video evidence, and examines the healthcare file of the
deceased person.

The OCC provides the CSOI investigator with the cause of death. Once the
investigation is complete, a report is forwarded to SOLGEN legal services and the
appropriate regional director. There is no requirement to share CSOI report findings
beyond this, but families of the deceased and Coroners may request copies. If
there are concerns that the file contains sensitive human resources information, the
report may be redacted.

After the report is finalized, regional directors are required to report action taken
because of the findings of the report. CSOI is required to produce annual reports
but does not release them.

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3) SOLGEN Corporate Healthcare
SOLGEN Corporate Healthcare is a small unit within SOLGEN that works on strategic
planning for medical services within Ontario provincial institutions. Following a
death, members of the team conduct a medical file review to identify any
healthcare delivery issues connected to the death. This could include medication
dispensing issues, unanswered requests for medical services, or communication
issues between healthcare and institutional staff.

Conclusion
Deaths in custody in Ontario are increasing at an alarming rate despite a declining
provincial custody population.

As bereaved families continue to call for increased transparency and accountability

in the aftermath of deaths in custody, SOLGEN poses significant barriers to
accessing consistent, reliable data. Greater transparency is required, including the
provision of real-time reporting on deaths in Ontario provincial custody through the
news release format utilized by Correctional Service Canada - excluding any
information related to sentencing. Data reported on deaths in custody need to be
made public, in consistent formats, ensuring that information reported over multiple
years is comparable.

Detailed information on deaths in custody is only available to the public after an

inquest, which often occurs years after a death. In the time that families are waiting
for an inquest, they may obtain some access to information through the review of
CSOI or coroner’s reports, but there is no guarantee that these documents will be
provided, and they may be heavily redacted. In such cases, families wait years for
answers regarding the death of their loved one. Institutions must ensure that each
institution has a staff member appointed to liaise and share information with
bereaved families in the aftermath of a death in custody.

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mission
What is the Tracking
(In)Justice project?
Tracking (In)Justice is a law enforcement and criminal justice data and
transparency project that tracks and analyzes police-involved and carceral deaths
across Canada.

We believe that accurate and verified data is one way to support communities
advocating for justice, accountability, and transparency from police and
corrections officials, and oversight bodies.

At the core of Tracking (In)Justice is a public, living database that provides

information on police-involved deaths when force is used, from the year 2000 to
the present. We are working to expand our database to include all police-involved
deaths and deaths in custody across Canada. We will be making our data publicly
accessible via an online database going live in 2023.

We are currently comprised of the Data and Justice Criminology Lab at the
Institute of Criminology and Criminal Justice at Carleton University, the Canadian
Civil Liberties Association (CCLA), Center for Research and Innovation for Black
Survivors of Homicide Victims (CRIB), the Empowerment Council, the Ethics and
Technology Lab at Queen’s University JusticeTrans, Women’s Health in Women’s
Hands Community Health Centre, and Maggie’s Toronto Sex Work Action Project.

How to cite this report:

Sarah Speight, Alexander McClelland. (November 2022). Ontario Deaths
in Custody on the Rise. Tracking (In)Justice.

Acknowledgements: Thank you to Erica Chen, Evelyn Maeder, Data &

Justice Criminology Lab, Carleton University; Abby Deshman, Canadian
Civil Liberties Association; Catherine Stinson, Ethics & Technology Lab,
Queen's University. We are funded by the Social Science and
Humanities Research Council of Canada.
References

[1] Email communication, Ministry of the Solicitor

General. October 6 2022
[10] Supra, Note 2.

[11] Note: When our team attempted to access deaths in

[2] Sapers, Howard. 2017. Ontario Corrections: custody figures through the SOLGEN open data website,
Directions for Reform, Page 5 ISBN: 978-1-4868- we found that the available data in the deaths in
0702-4 (Print) custody tables for 2019 and 2020 were categorized
differently in each year that data was provided making
[3] Zhong, Shaoling, Morwenna Senior, Rongqin Yu, data difficult to compare. The files for the past several
Amanda Perry, Keith Hawton, Jenny Shaw, and years defined custody too widely for the purposes of
Seena Fazel. “Risk Factors for Suicide in Prisons: A this report. Beyond obtaining basic figures like those
Systematic Review and Meta-Analysis.” The Lancet shared above accessing information on deaths in
Public Health 6 (February 1, 2021 p.167). custody becomes more challenging and requires the use
https://doi.org/10.1016/S2468-2667(20)30233-4. of data use agreements and Freedom of Information
Requests.
[4] Bucerius, Sandra M., and Kevin D. Haggerty.
“Fentanyl behind Bars: The Implications of [12] Unless subject to publication ban.
Synthetic Opiates for Prisoners and Correctional
Officers.” International Journal of Drug Policy 71 [13] Coroners Act, R.S.O. 1990, c. C.37 s.10(4.3)
(September 1, 2019): 133–38.
https://doi.org/10.1016/j.drugpo.2019.05.018. [14] Coroners Act, R.S.O. 1990, c. C.37 s.31

[5] Supra, Note 3 p. 168. [15] Supra, Note 6.

[6] Supra, Note 4. [16] Sapers, Howard. 2017. Ontario Corrections:

Directions for Reform, Page 64 ISBN: 978-1-4868-0702-
[7] Ministry of the Solicitor General (2019) Data on 4 (Print)
Inmates in Ontario. SOLGEN. Updated: March 28,
2022.

[8] Stöver, Heino, Anna Tarján, Gergely Horváth,

and Linda Montanari. “The State of Harm Reduction
in Prisons in 30 European Countries with a Focus on
People Who Inject Drugs and Infectious Diseases.”
Harm Reduction Journal 18, no. 1 (June 29, 2021): 67.
https://doi.org/10.1186/s12954-021-00506-3.

[9] See: Impacts of the COVID-19 Pandemic on

People Who Use Substances: What We Heard:
https://www.ccsa.ca/sites/default/files/2020-
07/CCSA-COVID-19-Impacts-on-People-Who-Use-
Substances-Report-2020-en.pdf & How the COVID-
19 pandemic is impacting people who use drugs:
https://ohrn.org/wp-
content/uploads/2021/05/Impact-of-COVID-19-on- Cover image: Rennison, John. Hamilton Wentworth Corrections
People-Who-Use-Drugs_April-2020.pdf Centre. From the Hamilton Spectator, retrieved November 15
2022: https://www.therecord.com/ths/news/hamilton-
region/2019/04/13/family-wants-answers-after-krystle-
catherwood-dies-of-suspected-overdose-at-barton-jail.html

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 Ontario Deaths in Custody on the Rise 2022

Tracking (In)Justice: A Law Enforcement & Criminal Justice Data & Transparency Project