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Printed and bound in Canada

Catalogue No. JS42-73/1996E

ISBN 0-662-24355-2

Ottawa, Canada, K1A 0S9

Commission of Inquiry into Certain Events at the

Prison for Women in Kingston (Canada)

Commission of Inquiry into certain events at the

Prison for Women in Kingston

femmes de Kingston.

Commissioner: The Honourable Louise Arbour.

ISBN 0-662-24355-2

Cat. no. JS42-73/1996E

I. Arbour, Louise, 1947- .

II. Title.

III. Title: The Prison for Women in Kingston.

HV9025.C65 1996365.9713'72C96-980136-X

Care has been taken to trace the ownership of copyright material in the text including tables and figures.

The Honourable Herb Gray, P.C., M.P.

Solicitor General of Canada

Sir Wilfrid Laurier Building

340 Laurier Avenue West

Ottawa, Ontario

K1A 0P8

Dear Minister:

By Order in Council PC 1995-608 dated April 10, 1995, I was appointed Commissioner to investigate and report on the state and management of that part of the business of the Correctional Service of Canada that pertains to the incidents that occurred at the Prison for Women in Kingston, Ontario, beginning on April 22, 1994. I have the honour to submit the attached report in both official languages.

Respectfully submitted,

The Honourable Louise Arbour

Commissioner

Commissioner

The Honourable Louise Arbour

Commission Counsel

Patricia D. S. Jackson

Sheila-Marie Cook

Associate Commission Counsel Chief Investigator

Guy Gournoyer Dennis Olinyk

(Ontario Provincial Police)

Assistant to the Commissioner Research & Policy Advisors

Karen McFarlane Kelly Hannah-Moffat

Legal Services Criminology Research

Jana Mills Anne-Marie Singh

Cheryl Waldrum Marnie Crouch

Sandra Hargreaves

Investigators Evidentiary Document Control Unit

(Ontario Provincial Police) Deborah Anne Whittames

Julie Cyr Barb Fiorentino

Jenny Zapotoczny Sean Lytle

Valerie Baun Leslie Wake

Administrative Services Registrar

Fern Anes Joyce Ihamaki

Melissa Jarrett

Angie McWaters

Kingston Hearings Site

Elizabeth Rolland

Annette Snowdon

Gillian Sadinsky

Editor - English

David Redgrave

Editor - French

Nicolas Joly

Figures

Figure 3 2nd Floor Layout Prison Cells 12

Figure 4 Mezzanine Layout Prison Cells 13

Plates

Plate 1 Segregation Unit upper and lower tier of Dissociation side 14

Plate 2 Upper tier Dissociation side 15

Plate 3 Interior view of a cell 16

Plate 4 Exterior view of a cell 17

Plate 5 Cell with heavy metal treadplate 18

Plate 6 Cell with heavy metal treadplate 19

Tables

Table 1 Persons Charged by Gender Selected Incidents, 1994 205

Table 2 Sentence Length of Incarcerated Federally Sentenced Women 206

Table 3 Current Region & Institution of Incarcerated Federally

Sentenced Women 207

Table 4 Offences of Federally Sentenced Women in Custody 208

HIS EXCELLENCY THE GOVERNOR GENERAL IN COUNCIL, on the recommendation of the Solicitor General of Canada, is pleased hereby.

1. pursuant to Part II of the Inquiries Act, to authorize the Solicitor General of Canada

2. pursuant to section 56 of the Judges Act, to authorize the Honourable Louise Arbour of Toronto, Ontario, a judge of the Court of Appeal for Ontario, to act as Commissioner.

Preface

The incidents that gave rise to this inquiry could have gone largely unnoticed. Until the public viewing of a videotape which shed light on part of these events, and the release of a special report by the Correctional Investigator in the winter of 1995, the Correctional Service of Canada had essentially closed the book on these events.

This was perceived as, by far, not the most serious series of events to have taken place in a Canadian penitentiary. Sadly, that is probably true. At the Prison for Women, loss of life and self-mutilation are among the many tragedies that occur, and that are largely unknown to the Canadian public.

However, this inquiry was concerned not only with what happened at the Prison for Women in 1994, but with the response of the Correctional Service of Canada to these events. The shortcomings that have been revealed in the course of this inquiry are, in my opinion, of the most serious nature. Corrections is the least visible branch of the criminal justice system. Occasions such as this, where its functioning is brought under intense public scrutiny, are few and far between. This may explain the discomfort of Corrections officials in handling this level of public attention. The lack of public scrutiny is in stark contrast to accountability processes in the law enforcement and judicial branches of the criminal justice system. Through hundreds of criminal trials and appeals, systemic shortcomings and individual performances of police officers, prosecutors and judges are examined publicly in a robust adversarial fashion.

Anyone familiar with criminal law enforcement, and with the prosecutorial and trial processes, would identify the presumption of innocence as the principle that animates the many rights granted by law to a person charged with a criminal offence. The risk of convicting an innocent person is not one which we would assume lightly.

A fair criminal process produces reliable convictions and, as a result, the management of a custodial sentence does not have to be plagued with uncertainties about the legitimacy of the enterprise. However, even though the presumption of innocence is displaced by the conviction, in the imposition of punishment, all authority must still come from the law. Parliament authorizes the imposition of certain sentences; the courts impose them and corrections officials implement the court orders. A guilty verdict followed by a custodial sentence is not a grant of authority for the State to disregard the very values that the law, particularly criminal law, seeks to uphold and to vindicate, such as honesty, respect for the physical safety of others, respect for privacy and for human dignity. The administration of criminal justice does not end with the verdict and the imposition of a sentence. Corrections officials are held to the same standards of integrity and decency as their partners in the administration of criminal law.

My objective in bringing forward recommendations on various aspects of corrections that have been touched upon by this inquiry is to assist the correctional system in coming into the fold of two basic Canadian constitutional ideals, towards which the rest of the administration of criminal justice strives: the protection of individual rights and the entitlement to equality.

Through its recent initiatives, the Correctional Service has recognized that decades of neglect and ill-adapted correctional policies borrowed from models designed for men, have failed to produce the substantive equality to which women offenders are entitled. Women's corrections should be the flagship of the Correctional Service for many reasons. For one thing, the momentum for reform is already in place and it merely needs to be sustained and expanded. The chances of success for a progressive correctional experiment are highest in women's corrections. Very few women commit crimes. This should be a badge of honour and an entitlement to reward, rather than a recipe for neglect and deprivation.

There are presently in Canada approximately 320 women in custody serving a sentence of imprisonment of over two years. As of April of 1994, there was only one federal penitentiary to detain them: the Prison for Women in Kingston, Ontario. The Prison for Women houses some 142 prisoners. The others are kept in provincial prisons. There are some 14,500 men serving a sentence of over two years. They are housed in any one of 44 institutions of all security levels (two high-maximum, 12 maximum, 18 medium and 12 minimum), as well as thirteen community correctional centres.

I am also grateful to counsel for the parties, without whose cooperation this report could not have been produced on time. They served their clients well.

I want to acknowledge as well the dedication of all Commission staff. I believe that their reward will be, in large part, the friendships that have been formed or solidified during the intense months of our work together. In particular, I am very grateful to Sheila-Marie Cook whose experience and support were invaluable to me.

Finally, I wish to thank my counsel, Trisha Jackson and Guy Cournoyer, who led the fact finding portion of this inquiry in a firm but fair fashion, with remarkable efficiency and professionalism. I admire their dedication and I valued their advice.

This report is divided into four parts. The first part is a detailed recounting of the facts examined during the course of the first phase of the public hearings of the Commission, in which evidence was gathered, in the form of documents and sworn testimony, in a trial-like fashion. This part contains my conclusions as to the facts, my comments about the appropriateness of certain actions, and my assessment of the performance of the Correctional Service in relation to these events.

The second part of the report stands back from these immediate events and examines some broad policy questions that arise from these events, and that are also informed by a public consultation process in which I embarked on roundtable discussions with the parties and others, without the intermediary of legal counsel. In that part of the report, I have deliberately not addressed certain of the specific questions discussed in the course of these roundtables. I do not wish to pre-empt in any way the work of the Federally Sentenced Women's program which is about to be implemented in the new regional facilities, except to the extent that is necessary to give effect to the broad proposals for reform that I have put forward.

The third part of the report is a brief historical overview which traces these contemporary issues through the various studies and reports that have touched upon women's corrections.

The last part lists and consolidates without further comment the specific recommendations that appear throughout the earlier parts of the report.

During the entire process of this inquiry, and in particular in the writing of this report, I have concluded that it would not be fair for me to embark upon a personal attribution of responsibility, for many reasons. Many persons were not called to testify and had therefore no opportunity to address allegations that might have been made against them. The witnesses who were called were not meant to be singled out as blameworthy, but were called for the sake of expediency, as the ones who had the most to contribute to the unfolding of the narrative. Many individuals who, by their own account, made errors, or whose actions I found did not meet a legal or policy standard or expectation, are otherwise persons greatly committed to correctional ideals for women prisoners. They were part of a prison culture which did not value individual rights. Attribution of personal blame would suggest personal, rather than systemic shortcomings and justifiably demoralize the staff, while offering neither redress nor hope for a better system in the future.

Many of the women and men whom I have encountered through this inquiry and who work in, or with, the correctional system in the area of women's corrections, have much to contribute to the rehabilitative enterprise. Many of the women incarcerated in the federal system have much to benefit from it.

The Inquiry Process

The Commission was established by the Governor General in Council on the recommendation of the Solicitor General of Canada, pursuant to Part II of the Inquiries Act, by Privy Council Order 1995-608 on April 10, 1995. Commencing in mid-April, the Commission began its process of organization which required the selection of Commission Counsel, investigators, researchers and support staff necessary to complete its mandate. The terms of reference of the Commission required me first, to make independent findings of fact regarding incidents that occurred at the Prison for Women in Kingston beginning on April 22, 1994; and second, to recommend improvements to the policies and practices of the Correctional Service of Canada. In approaching the first of these two tasks, the Commission followed conventional practice and conducted formal public hearings at which witnesses were examined under oath by Commission Counsel and by legal counsel for parties of standing. This constituted Phase I of the inquiry, entitled Findings of Fact. During the early stages of the Commission's activities, it became apparent that a highly structured form of inquiry would be inappropriate and costly in helping the Commission with its second major task of making policy recommendations. I therefore decided to undertake a separate Phase II process to focus on policy consultations. It had a less structured format: it relied on the free exchange of views by invited experts and interested parties, but it did not rely upon formal submissions and the services of legal counsel.

In late April and early May, along with Commission Counsel, I visited the Prison for Women in Kingston, and the Regional Treatment Centre where some of the women were transferred in May of 1994. Commission Counsel began discussions and consultations with prospective parties to the inquiry in order to assess the issues that would be confronting the Commission. Commission Counsel met as well with the staff and inmates at the Prison for Women in order to provide them with information on the process of a Commission of Inquiry.

On May 9, 1995, I wrote to Mr. John Edwards, Commissioner of the Correctional Service of Canada outlining the task at hand and soliciting his help in circulating the information concerning the Commission. On May 11, 1995, I made the first of a number of requests to him for the production of documents pursuant to s.7 of the Inquiries Act.

On June 8, 1995, a notice of public hearing was published in most major Canadian newspapers announcing that the first session of the Commission would be convened on June 28, 1995 in Kingston, and that the purpose of this hearing was for the Commission to entertain applications for standing. Copies of the notice were also sent to all federal correctional facilities and all institutions where federally-sentenced women were incarcerated. The public was also put on notice that the hearing of the evidence would commence on August 9, 1995. The public notice invited people who had information that they believed to be of interest to the Commission, or who wished to make written submissions, to contact Commission Counsel.

On June 28, 1995, a procedural hearing on standing was held. The purpose of the proceeding was to determine which parties should be granted standing before the Commission. The criterion for determining standing was stated in Rule 15 of the Rules of Practice (Appendix F) of the Commission which provided that persons or groups could apply to the Commission for standing if they considered that their interests were put directly at issue by the Commission's terms of reference, or that they had special experience or expertise with respect to the Commission's mandate. The proposed Rules of Practice of the Commission had been circulated among the parties seeking standing, and comments on them were sought from the parties who were granted standing.

The Parties Granted Standing

In a ruling made on July 10, 1995, included in its entirety in Appendix E, I granted standing to eight parties:

I also granted standing to parties for Phase II of the Commission's inquiries concerning policy issues. The eight parties to whom standing was granted for those sessions were:

In my ruling, I recommended that funding be extended to certain persons or groups with standing who had requested financial assistance from the Commission on June 28, 1995. They were: the individual inmates; the Inmate Committee; the Canadian Association of Elizabeth Fry Societies; and the Citizens' Advisory Committee. On July 31, 1995, the Governor General in Council, on the recommendation of the Solicitor General, authorized the Solicitor General of Canada to make ex gratia payments in accordance with criteria that were set out in Schedule ``A'' of the Order-in-Council, reproduced in Appendix G, to assist with costs incurred by intervenors to the inquiry. Those payments were to be made upon consideration of the advice and recommendations for such payment by the Commissioner.

Relevant documents obtained by the Commission were circulated to all parties with standing, subject to an undertaking by all parties and their counsel not to disclose the documents or information contained therein, unless and until they became part of the public proceedings of the Commission.

Investigations and Interviews

The Hearings

On November 2, 1995, the Commission was forced to postpone the completion of its hearing because of the late production of certain documents by the Correctional Service of Canada. The Phase I portion of the hearings was completed during the week of December 11, 1995, with the testimony of the Senior Deputy Commissioner, Andrew Graham, and the Commissioner of the Correctional Service, John Edwards. This completed the evidence called by Commission Counsel. Submissions were made as to whether further evidence should be heard, based on the witnesses' statements which had been circulated to all counsel. I ruled that no further evidence be called.

In early January, notices were sent to several persons pursuant to s.13 of the Inquiries Act. The Commission sent two types of notices, samples of which are included in Appendix I. If the person notified had given evidence at the Commission's proceedings, the notice stated that an unfavourable report or a finding of misconduct might be made with respect to certain enumerated issues. Some notices were also sent to persons who had not been called as witnesses informing them that although they would not be named in the report, adverse findings might be made about matters in which they were involved, and these findings might reflect on them. As well, Commission Counsel advised the parties that any submissions made by other parties with standing should be treated as if they were made or given in a notice under s.13 of the Inquiries Act.

The Commission received written submissions on or about January 10, 1996, and final submissions were made orally before me in Toronto, on January 15 and 16, 1996.

The Commission also embarked on a modest research program which entailed, for the most part, the identification of the findings of existing scholarly work through the services of the Centre of Criminology Library at the University of Toronto. The Commission's Senior Research Advisor, Dr. Tammy Landau, conducted additional consultations with senior officials and researchers at the Secretariat of the Solicitor General of Canada, Correctional Service of Canada and the Department of Justice. The research program facilitated the organization of Phase II of the Commission's work. For that second phase, I decided to depart completely from the courtroom model in which Phase I was conducted and to hold a series of Roundtable Discussions on selected topics, such as:

Each party granted standing in Phase II was invited to send one or two representatives to each roundtable. I also invited them to recommend additional guest participants and experts who could attend the sessions unaffiliated. and bring their particular knowledge or skills to the discussions. Experienced moderators were selected for each session. Commission researchers arranged for background materials specific to each roundtable session to be distributed to all participants. The list of participants for each session is attached as Appendix C.

In addition to the Roundtable Discussions, I received many unsolicited submissions from members of the public wishing to express their views, concerns and recommendations with respect to the conditions of imprisonment for women in Canada. The issues they raised included, among others, the physical health and well-being of women in prison, the role of men in women's institutions, and the use of mediation and restorative justice to decrease the reliance on imprisonment.

Glossary

Many different expressions are used to refer to people who work in corrections and to people who serve a sentence after having been convicted of an offence. Some expressions have both a legal meaning and a popular acceptance which may be slightly different from the legal definition.

Many of these expressions also have a political connotation, and are either used, perceived or felt as derogatory or demeaning.

I have attempted to recognise these concerns in this glossary, and to give a context for the language used in the report.

(a) a person who is in a penitentiary pursuant to

(i) a sentence, committal or transfer to penitentiary, or

(ii) a condition imposed by the National Parole Board in connection with day parole or statutory release, or

(b) a person who, having been sentenced, committed or transferred to penitentiary,

(i) is temporarily outside penitentiary by reason of a temporary absence or work release authorized under this Act, or

(ii) is temporarily outside penitentiary for reasons other than a temporary absence, work release, parole or statutory release, but is under the direction or supervision of a staff member or of a person authorized by the Service.

This definition is much broader than that which is commonly used to refer to individuals who are currently in custody. It has its roots in the medico-psychiatric community and was historically linked to the rehabilitative ideology in corrections. The term has, for some inmates and inmate advocates, connotations which mask the involuntariness of imprisonment and suggest benevolent therapy. It is a term which was the most frequently used during both Phase I and Phase II of the Commission's work. It is used interchangeably with ``prisoner'' in this report .

(a) an inmate, or

(b) a person who, having been sentenced, committed or transferred to penitentiary, is outside penitentiary

(i) by reason of parole or statutory release,

(ii) pursuant to an agreement referred to in subsection 81(1), or

(iii) pursuant to a court order.

In common vernacular, the term often refers to individuals who have been convicted of criminal offences, but are not necessarily presently incarcerated or otherwise serving a sentence. The term is quite commonly used by correctional authorities to refer to individuals who fall under their mandate and jurisdiction. Some participants in Phase II of the Commission's work expressed the concern that the term suggests a repeat or continued pattern of criminality, when many federally sentenced women have only committed one offence. It is the only term commonly used to refer to all persons under sentence, whether in prison or not.

In more general terms, prison is the commonly used term to refer to all institutions where persons are detained under the authority of the criminal law, or of provincial penal law. It is often used in that broad generic sense in this report.

Abbreviations

CAEFS

Canadian Association of Elizabeth Fry Societies

The Corrections and Conditional Release Act, 1992.

CD

Commissioner's Directive

CO/CX (1,2,3)

Correctional Officer

CS

Correctional Supervisor

CSC

The Correctional Service of Canada

IERT/ERT

Institutional Emergency Response Team

IPSO

Institutional Preventative Security Officer

LEAF

Women's Legal Education and Action Fund

P4W

Prison for Women

RTC

Regional Treatment Centre at Kingston Penitentiary

SHU

Special Handling Unit

PART I
THE EVENTS AT THE PRISON FOR WOMEN

        1. INTRODUCTION

1.1 The Structure and Organization of the Correctional Service of Canada

1.1.1 The legal and policy framework

In 1992, Parliament passed the Corrections and Conditional Release Act, S.C. 1992, c.20 (CCRA) which replaced the Penitentiary Act, R.S.C. 1985, c.P-5 and the Parole Act, R.S.C. 1985, c.P-2. The CCRA and associated Regulations are the principal legislation governing the operations of the Correctional Service of Canada.

In addition to the law, the Correctional Service has established a detailed and complex set of policies. Pursuant to the CCRA, the Commissioner of the Correctional Service is authorized to designate as Commissioner's Directives (CD's) rules for the management of the Service and the carrying out of the Act. Commissioner's Directives must be accessible to correctional staff, inmates and the public. Judicial decisions have indicated that Commissioner's Directives have at least a higher status than policy and other rules, and that they constitute, as a minimum, a set of standards of fairness to which the Service must adhere. In some cases, the Commissioner's Directives restate the law and provide specific guidance as to how the law is to be implemented within the Correctional Service, and in other areas, they set policy and practice with respect to matters not specifically dealt with in the CCRA and Regulations. In addition to Commissioner's Directives, each region may issue Regional Instructions, which either repeat or elaborate on matters dealt with in Commissioner's Directives, or address regionally specific issues.

Each individual institution also issues a separate set of Standing Orders which often repeat or further elaborate on matters dealt with in the CCRA, the Regulations, the Commissioner's Directives, and the Regional Instructions. Standing Orders provide a specific set of rules applicable to the institution. Standing Orders are further elaborated in Post Orders which provide specific instructions for those staff members who occupy particular posts within the institution and outline the responsibilities assigned to that post. To varying degrees, Post Orders, like Standing Orders, either repeat or elaborate on already existing law and policy.

Notwithstanding their enormous volume, Commissioner's Directives, Regional Instructions, Standing Orders, and Post Orders do not exhaust the written policy documents used by the Correctional Service. In addition, there are memoranda and other more specific policy manuals which further elaborate on CSC's written policy. For example, manuals on Security, Contingency Planning, Case Management, Policies and Procedures, and the Conduct of Investigations are among innumerable written policies referred to during the course of this inquiry. The CSC also sets policy by virtue of the usual practice and procedure which it employs in a given situation.

In this report, references to the law include the CCRA, the Regulations, and any applicable judicial decisions. CSC policy means both explicit written policy (Commissioner's Directives, Regional Instructions, Standing Orders, Post Orders, Manuals and other written policies) and operational policy, which is the usual practices and procedures of the CSC.

The events examined by this Commission indicate some significant discrepancies between CSC's operational policy, its written policy, and the law. Indeed, it is evident that some very important, yet essentially simple, legal principles which govern crucial aspects of the operation of the Correctional Service have become lost in a myriad of elaborate policy and regulatory provisions. It is apparent that it is not well understood within the Correctional Service that the decision to follow the law (as opposed to policy) is not a matter of discretion.

When confronted with an apparent departure from law or policy, I have found it helpful to analyze the problem by addressing the following questions:

1. What is the law and/or policy applicable to the event?

2. Is the applicable law or policy appropriate?

3. Is the applicable law or policy known within the Correctional Service?

4. Is the applicable law or policy perceived within the Correctional Service to be appropriate?

5. If the applicable law or policy is not known, why is that so? Is it due to questions of complexity, issues of communication, understanding, acceptance or otherwise?

6. Was the law or policy complied with in this case?

7. If the law or policy was not complied with, was there an appropriate response on behalf of the Correctional Service?

8. If the law or policy was not complied with in this case, what should be done about it?

Throughout this report, my findings and conclusions reflect this framework of analysis.

1.1.2 The organization

An organizational chart of the positions within the Correctional Service which are relevant to the issues examined is found at Figures 1 and 2.

Pursuant to the CCRA, the Commissioner of the Correctional Service is responsible for the regulation and management of the CSC. Throughout the period material to the events examined by this Commission, the Commissioner was John Edwards. The Commissioner reports to the Solicitor General.

The Commissioner is assisted in the discharge of his responsibilities by a Senior Deputy Commissioner who reports to and works directly with him at National Headquarters in Ottawa. In April of 1994, the Senior Deputy Commissioner was Willie Gibbs, and in September of 1994, Andrew Graham assumed this position.

The Correctional Service is subdivided into five regions (Atlantic, Quebec, Ontario, Prairies and Pacific). A Deputy Commissioner is assigned to each region and is responsible for administration and institutions within that region. In April of 1994, Andrew Graham was the Deputy Commissioner of the Ontario Region. In September of 1994, that position was assumed by Irving Kulik. The Warden of the Prison for Women reports directly to the Deputy Commissioner for the Ontario Region.

1.2  The Organization of the Prison for Women

The organizational chart at Figure 2 outlines the staff positions within the Prison for Women. A brief description of the positions which are relevant for the purposes of the matters examined by this Commission is provided below.

The next most senior position is that of Deputy Warden (Figure 2), to whom those with most of the significant inmate responsibilities (including health,

1

2

security and case management, which involves the management of prisoners' personal, institutional, correctional and program needs) report. In April, 1994, the Deputy Warden at the Prison for Women was Donna Morrin. In August of 1994, that position was assumed by Barrie Friel.

The Prison for Women's administration is organized along a model now prevalent in the Correctional Service known as unit management (set forth in CD 005). Unit management contemplates that a group of inmates will live together in a living unit, and that all aspects of management associated with that group of inmates will be centred on that living unit. The physical structure of the Prison for Women, unlike comparable male institutions, precludes the existence of separate living units. Nonetheless, the management model attempts to approximate unit management. In the result, two Unit Managers report to the Deputy Warden. One is in charge of the Segregation Unit and the Wing living area, and the other is in charge of the A and B Ranges. For the periods material to the events examined by this Commission, Barbara Hilder was the Unit Manager in charge of the Segregation Unit and Wing living area (except for some periods of authorized absence in the summer), and Cathy Beres was in charge of the Ranges. Each Unit Manager has a roster of correctional supervisors, case management officers and correctional officers reporting to her. However, due to the lack of truly separate living units within the Prison for Women, correctional staff do not report exclusively to the Unit Manager directly supervising the living area in which they are working. The primary responsibilities of a Unit Manager include the management of a diversity of supervisory and line staff roles in the planing, evaluation and control of human, financial and physical resources for each unit and the responsibility for achieving correctional objectives in each unit.

The positions which report to the Unit Manager include Correctional Officers (CX1, CX2), Correctional Supervisors (CX3), and the Institutional Preventative Security Officer (IPSO). The Correctional Officer 1 (CX1) position is the usual entry level position in the Prison for Women. CX1's are the front line staff who supervise and control inmate movement and activities throughout the prison from a security perspective. CX2's perform a similar role with added case management and supervisory responsibilities. Both groups report to the Correctional Supervisor or CX3 who supervises the operations of the correctional officers and, in the absence of members of senior management (typically in the evening and midnight shifts and on weekends), is in charge of the prison.

The prison's Institutional Preventative Security Officer is in charge of such things as the gathering of information and intelligence affecting the security of the institution, maintaining contact with police departments and criminal court officials, conducting investigations and the preparation of reports on security incidents. In April 1994, Rick Waller was the Acting Institutional Preventative Security Officer. The position was filled on a full-time basis in September of 1994 by Carmine Tedesco.

In addition to the positions described above, the prison has a large complement of health staff and psychologists, as well as individuals with principal responsibility for case management, social development, program delivery, and matters relating to the administration of inmate sentences, all as set out in the organizational chart at Figures 1 and 2. Some of these are full or part-time contractual workers.

1.3 The Physical Layout of the Prison for Women

The prison is an old fashioned, dysfunctional labyrinth of claustrophobic and inadequate spaces holding 142 prisoners of all security levels, minimum through maximum. It has been described as ``unfit for bears''. It is inadequate for living, working, eating, programming, recreation, and administration. Spaces are insufficient, poorly ventilated and noisy. They are not well connected, and frequently can only be reached through narrow corridors, steep stairwells (there are no elevators), and innumerable locked barriers. Some efforts have been made to allow lower security women greater privileges and more freedom of movement. However, the prison grounds are surrounded by an enormous wall, which in the male system, is used by maximum security institutions only, and in many other aspects the building has the characteristics of a maximum security institution.

The only true minimum security unit is actually outside the walls of the prison, although it operates under the authority of the Warden. It was opened in 1990 and is called the Isabel McNeill House. It provides a residence for 11 women who are within two years of their day-parole eligibility and who have a minimum security classification.

All other minimum security women have to serve their sentence inside the multi-level Prison for Women. There are essentially four living units inside the prison which do not strictly correspond to the formal security classification of their occupants.

The most freedom is available in a section known as the ``Wing'', which is entirely separate from the area where the incidents of April 22, 1994 occurred. It contains approximately 50 unbarred small rooms occupied by one, and in some cases, two inmates.

The living accommodation for the remainder of the inmates is contained in a series of barred cells known as A Range, B Range, and the Segregation Unit. A floor plan showing the size and configuration of these cells is found at Figures 3 and 4. A Range is a long two-tier bank of over 50 cells, each 9 feet 2 inches by 6 feet 2 inches in size. B Range is a similar two-tier bank of cells, half as long as A Range, and running parallel to it. The other half is occupied by the area which in 1994 was designated as the Segregation Unit (and which is so described for the balance of this report). It also consists of two-tiered cells, but it is separated into a protective custody area, and a dissociation side (Plate 1). Women housed in A and B Ranges for long periods of time, in some cases years, use personal effects to make their cells more home-like.

The cells in A and B Ranges and the Segregation Unit are thinly divided from each other and connected by a series of ducts. Sound travels easily, and the entire cell area is usually very noisy, made as it is of bare cement and metal.

The Segregation Unit houses inmates who are either in disciplinary or in administrative segregation. (The differences will be described below.) Women who are on suicide watches or in a state of personal crisis are also housed in the Segregation Unit, as are women who request some ``time out'' from the general prison population. These inmates are placed either in the larger dissociation side of segregation, or in the protective custody side, which is occupied by the very small number of inmates whose safety would be at risk in the general population. The two sides of segregation are connected by a door which is often left open.

The Segregation Unit consists exclusively of cells (approximately 20), a small shower area, a small office and a storage space. There is no place in which an inmate can have a private interview with a lawyer. This also precludes private interviews with a psychologist, school teacher, or anyone else. Nor is there any space for programming or recreational activities. Until late 1994, primitive wiring in the area precluded the use of televisions, radios or any other electrical appliances in any of the cells. This made it particularly unsuitable for long-term placement of inmates who were essentially confined to their cells with nothing to do. This was notwithstanding recommendations dating from 1993 that compliance with the CCRA required the installation of the necessary electrical capability, estimated to cost $2,000.00. The plumbing is also old and unreliable, and the difficult events in the Segregation Unit in April of 1994 were compounded by plumbing breakdowns, which at times prevented the toilets from being flushed.

The second tier of the dissociation side of the Segregation Unit can only be reached by a staircase at one end of the unit, which leads to a narrow corridor running just outside the cells in a balcony-like fashion (Plate 2).

In the dissociation side, a cell contains a metal bed which is attached to the wall, a sink, a toilet and in some cases, a pull down writing surface (Plate 3). The view from the cell is through the bars into the corridor beyond (Plate 4). From July, 1994 onwards, this view was obstructed by the addition of a heavy metal treadplate (Plates 5 and 6). At the same time, two cameras were installed in each cell in order to provide constant monitoring of the actions of the cell occupant.

The Segregation Unit of 1994 was perceived as so inappropriate that, following the incidents examined by this Commission, and despite the planned closure of the Prison for Women, half a million dollars were spent building a seven-cell new Segregation Unit in the basement of the prison.

It is generally accepted in the international community that a set of minimum standards should apply to imprisonment. These standards are designed to ensure that the inmates are humanely treated, that their responsibility and dignity is maintained, and that they are prepared as much as reasonably possible for reintegration in their community at the end of their term of imprisonment. The standards which the international community has generally accepted are contained in the United Nations Standard Minimum Rules for the Treatment of Prisoners, which were first adopted in 1955. While Canada, and the Correctional Service in particular, are not obliged to conform to the specific terms of the UN Rules in the management of prisons, those rules are accepted as international norms and minimum standards, and departures from them generally only occur where there is a reasoned justification.

The UN Rules indicate a broad acceptance within the international community of many aspects of Canadian law and stated CSC policy: living accommodation which is appropriately lit, ventilated and cleaned; nutritional food well prepared and served; appropriate bedding and clothing regularly laundered; regular exercise and sports; regular access to medical services; educational, vocational training, and work opportunities as part of daily life; access to religious representatives; access to books and other educational and recreational opportunities (in Canada radio and television); social case work and other counselling to assist the inmate towards a law abiding and self supporting life after release; and an ongoing opportunity to remain in contact with friends and family.

In practice, these principles are reflected in the general organization of daily life at the Prison for Women which may be summarized as follows.

Daily life at the Prison for Women is organized around three shifts, the morning or dayshift from 7:00 a.m. to 3:00 p.m., the evening shift from 3:00 p.m. to 11 p.m., and the night shift from 11:00 p.m. to 7:00 a.m. At regular intervals throughout the day, formal inmate counts are taken by the correctional staff. On those occasions, inmates are locked in their cells and remain there until the formal count is complete and all inmates are accounted for.

Following the 7:00 a.m. count, those inmates not in segregation eat breakfast in a small, centrally located eating area, in three shifts, between 7:30 and 8:30.

From 8:30 until 11:00, they leave their cell units to engage in work programs, educational or related programs, or remain in their cells, or in a small associated activity area. There are limited work programs: they consist mostly of the performance of tasks associated with the running of the institution (kitchen work, laundry, cleaning, clerical, beauty parlour, etc.). Other programs consist of a limited number of educational and vocational programs, and therapeutic services.

3

Figure 4

4

Segregation Unit upper and lower tier of Dissociation side

(From the files of the Ontario Provincial Police)

Upper tier Dissociation side

(From the files of the Ontario Provincial Police)

Plate 3

Interior view of a cell

(From the files of the Ontario Provincial Police)

Plate 4

Exterior view of a cell

Plate 5

Cell with heavy metal treadplate

(From the files of the Ontario Provincial Police)

Plate 6

Cell with heavy metal treadplate

(From the files of the Ontario Provincial Police)

Inmates are expected to work, or to participate in a program, and a small pay is allocated for both activities. The pay is used for the purchase of canteen items such as cigarettes, pop, hair care products, etc. Those who remain in their living units have the option of staying in their cells, which are unlocked, or going to a small activity area associated with their living unit which contains laundry facilities, a television set, and a seating area. B Range inmates who are not at work or in programs, remain locked in their cells, but are given the opportunity, once an hour, either to go to the B Range activity room or to remain in their cells. At 11:00 a.m., there is another count, followed by lunch. From 1:00 p.m. until 4:00 p.m. there is a further period for work, programming, or cell activities. At 4:00 p.m. there is another formal count, followed by the evening meal between 4:15 and 6:00 p.m. At 6:00 p.m., the yard opens and weather permitting, inmates rotate through the yard. They may also engage in other small group activities. There is a further count at 9:00 p.m., followed by a final count and lockup at 11:00 p.m.

Those inmates who are in segregation remain locked in their cells throughout the day, except for the one hour in which they are supposed to be provided with daily exercise.

This schedule varies slightly on weekends: there is little, if any, time allocated to work assignments or other programming, and breakfast and lunch are collapsed into one meal.

1.5 The Correctional Investigator

The CCRA establishes the office of the Correctional Investigator as an ombudsperson, independent of the Correctional Service of Canada, who reports directly to the Solicitor General. The relevant provisions of the CCRA governing the activities of the Correctional Investigator are found at section 2.10 below.

The Correctional Investigator and those he hires to assist him, conduct investigations into problems of offenders relating to acts or omissions by the Commissioner of the Correctional Service or anyone under his control and management (unless the action concerns matters relating to the National Parole Board, the Provincial Parole Board, a provincial correctional facility or provincial officer). Such investigations may be initiated by an inmate complaint, a ministerial request, or by the Correctional Investigator on his own initiative. The Correctional Investigator is given broad powers to compel the production of documents and information, including but not limited to any in the possession or control of the Correctional Service, to enter and inspect premises under the control and management of the Commissioner, and to require the giving of evidence under oath. Where the investigation indicates a problem, the Correctional Investigator is required to inform the Commissioner and may make any recommendations, which are not binding, that he considers appropriate. If the problem is not adequately responded to within a reasonable time, the Correctional Investigator is required to inform the Solicitor General. The CCRA broadly protects the Correctional Investigator, and those acting under his authority, from criminal or civil proceedings or review, and creates offences for failing to comply with lawful requirements of the Correctional Investigator.

The Correctional Investigator reports annually to the Solicitor General and between annual reports, may make special reports to the Solicitor General on matters which are of sufficient urgency or importance that they should not be deferred until the annual report. Where an annual or special report will or might reflect adversely on anyone, the person or organization must be given a reasonable opportunity to make representations with respect to the matter and a summary of those representations are to be included in the report.

There are also strict confidentiality and non-disclosure provisions imposed upon the Correctional Investigator which were of significance to his participation in this inquiry. The Act requires that neither the Correctional Investigator nor anyone acting on his behalf may disclose any information gained in the exercise of their duties. Notwithstanding this obligation of confidentiality, s.183 of the Act authorizes the Correctional Investigator to disclose information on certain limited bases. These include circumstances where he considers it necessary in connection with an investigation, or where he wishes to establish the grounds for findings or recommendations made in a report by him. However, s.189 provides that neither the Correctional Investigator nor anyone working under his direction is a competent or compellable witness with respect to any information gained in connection with the discharge of the duties of the office of the Correctional Investigator.

As described more fully below, one of the precipitating events in the appointment of this Commission of Inquiry was a special report of the Correctional Investigator dealing with the incidents which are the subject of this inquiry. At an early stage of the Commission's proceedings, the Correctional Investigator indicated his intention to cooperate fully with the Commission, and to provide as much assistance and information as he could, consistent with the statutory requirements under which he operated.

In the result, the Correctional Investigator determined that extensive documentation compiled by his office should be produced to the Commission because this release was necessary either to carry out an investigation or to establish the grounds for findings and recommendations made by him pursuant to the provisions of s.183 of the CCRA. The documentation received from the Correctional Investigator was disclosed to the parties with standing. However, the Correctional Investigator expressed the view that neither he nor his employees could testify in the inquiry's proceedings by virtue of s.189. The Correctional Investigator and the Commission agreed on a procedure in which questions from any parties with standing were directed to the Correctional Investigator through the office of Commission Counsel, and written answers were provided.

In the result, notwithstanding the statutory constraints, the Commission had substantial access to the records and information compiled by the Correctional Investigator in the course of his investigation of these events.

1.6 Other Organizations

1.6.1 The Canadian Association of Elizabeth Fry Societies

The Canadian Association of Elizabeth Fry Societies (``CAEFS'') is a federation of autonomous societies which works with, and on behalf of, women in conflict with the law. CAEFS was originally conceived in 1969 and was incorporated as a voluntary non-profit organization in 1978. There are 21 member societies across Canada, including one in Kingston, Ontario where the Prison for Women is located.

Elizabeth Fry societies are community-based agencies dedicated to offering services and programs to women who are, or have been in conflict with the law, advocating legislative and administrative reform, and offering a forum to educate the public on aspects of the justice system which affect women.

1.6.2 The Citizens' Advisory Committee

The Regulations authorize the Warden to set up a Citizens' Advisory Committee (``CAC'') consisting of members of the community to promote and facilitate the involvement of members of the community in the operation of the Service. The CAC may advise the Warden on matters within her jurisdiction, and is expected to make itself available for discussion and consultation with the public, inmates, correctional staff and management. The Regulations require the Warden to ensure that members of the CAC have access to every part of the prison, every staff member, and every inmate for the purpose of carrying out the Committee's functions.

While the Regulations give the Warden the discretion to establish a CAC, the relevant Commissioner's Directive (CD 23) requires that each prison establish one. The Directive also specifies that a member of the Citizens' Advisory Committee may only be replaced prior to the expiry of the membership term if he or she does not want to continue, or acts contrary to the Committee's mandate.

The Prison for Women had a four member Citizens' Advisory Committee, chaired by Dr. Robert Bater. Dr. Bater is a doctor of theology and former principal of Queen's Theological College and head of the Department of Religion at Queen's University. The evidence indicated that the Committee regularly visited the prison and was usually notified of exceptional events at the prison and invited for immediate visits in connection with those events.

1.6.3 Other organizations

There are other organizations who may be referred to in this report, whose functions are evident from their titles: the Union of Solicitor General Employees, the Inmate Committee, and the Native Sisterhood.

1.7  The Correctional Context: Creating Choices

The report concluded that the Prison for Women should be closed, and in its place, five smaller, regional prisons, including a Healing Lodge, should be built across the country. It also urged that a new, women-centred correctional philosophy should govern the operation of these prisons. The reforms recommended in Creating Choices were accepted by the federal government and so were the principles upon which the proposals for reform rested. These principles called for empowerment, meaningful and responsible choices, respect and dignity, a supportive environment, and shared responsibilities.

At the federal level, a National Implementation Committee was struck, whose primary role was the development of plans for the construction of the new prisons, their staffing and operations. The implementation process did not include all the Task Force partners, and generated some criticism. By the summer of 1993, the Wardens for the new prisons had been hired. The Federally Sentenced Women Program Committee, the new internal government implementation process, was put in place, and through it, the spirit of the five main principles of Creating Choices appears to have been retained. By the spring of 1994, the development of the five new regional prisons was at various stages of progress in: Edmonton, Alberta; Kitchener, Ontario; Joliette, Quebec; Truro, Nova Scotia; and Maple Creek, Saskatchewan, which was the site for the Healing Lodge.

As of the writing of this report in February of 1996, Edmonton had already received 17 women, Truro had 7 women, and the Healing Lodge had 10 women in residence. Kitchener and Joliette are still under construction, but their staffing is nearly completed. The closing of the Prison for Women is contingent on the completion of these two facilities, which are scheduled to open in the summer of 1996.

To ensure that its new prisons are appropriate to women's experience, the Correctional Service of Canada has made a financial and philosophical commitment to a program design and a delivery strategy which focuses on the particular needs of women. It has revised its selection and training programs for correctional officers, now called Primary Workers, and developed a new security management system, as well as a new model of classification.

As exhilarating as this initiative which originated with the Task Force has been for women prisoners and prisoners' advocates, the inevitably slow pace of the closure of the Prison for Women and the transition to the new facilities has created considerable tensions within the prison. In anticipation of the closure, many experienced staff members at the Prison for Women sought and obtained transfers to other federal institutions in and around Kingston, when the opportunity presented itself. By the spring of 1994, the prison had an unusually high number of inexperienced staff members.

The uncertainties of change also created anxiety and tension among the inmates, many of whom faced the possibility of a placement that would separate them from their friends. For all manner of reasons, some which are not easily explicable, the prospect of change, even of a change that could be seen objectively as positive, was not welcome by everyone at the prison.

In broader terms, the response of the Correctional Service to the incidents which took place at the Prison for Women on April 22, 1994, and the many months that followed, is difficult to reconcile with the spirit of Creating Choices which was concurrently animating its entire strategy for dealing with women offenders. Nearly every step that was taken in response to this incident was at odds with the intent of the new initiatives.

This will become more apparent in my detailed description and analysis of these events.

        2 . FACTUAL FINDINGS AND CONCLUSIONS WITH RESPECT TO THE INCIDENTS UNDER INVESTIGATION

2.1 Overview Chronology

On the evening of Friday, April 22, 1994, a brief but violent physical confrontation took place between six inmates at the Prison for Women and a number of the correctional staff. The six inmates were immediately placed in the Segregation Unit at the Prison for Women. Criminal charges were laid against them; and five of the six inmates ultimately pleaded guilty to offences connected to the incident.

On Tuesday, April 26, 1994, correctional staff demonstrated outside the Prison for Women demanding the transfer of the inmates that had been involved in the April 22nd incident.

On the evening of April 26, 1994, the Warden of the Prison for Women called in a male Institutional Emergency Response Team (``IERT'') from Kingston Penitentiary to conduct a cell extraction and strip search of eight women in segregation: the six who had been involved in the April 22nd incident, and two others. As is customary when the IERT is deployed, the cell extractions and strip searches were videotaped. At the end of the lengthy procedure, which finished early in the morning of April 27th, the eight inmates were left in empty cells in the Segregation Unit wearing paper gowns, and in restraints and leg irons.

On the evening of Wednesday, April 27th, seven of the eight inmates were subjected to body cavity searches.

On Friday, May 6, 1994, five inmates, four of whom had been involved in the April 22nd incident, were transferred to a wing of the Regional Treatment Centre, a male psychiatric treatment facility within Kingston Penitentiary. Two of these women subsequently launched habeas corpus applications, and on July 12, 1994, they were ordered returned to the Prison for Women. Four inmates were returned to the Prison for Women between July 14th and 18th, 1994, while another was transferred to the Regional Prairies Centre.

The six women who had been involved in the April 22nd incident remained in segregation for many months. On December 1, 1994, the women's agreement to plead guilty to related criminal charges was publicly announced. They appeared in court and pleaded guilty to the agreed charges on December 22, 1994.

The women were released from segregation between December 7, 1994 and January 19, 1995. (One inmate was released from the prison during the period of her segregation. She was subsequently returned to the prison and was admitted directly to the Segregation Unit.)

On January 20, 1995, the Correctional Service released the report of a Board of Investigation which had been appointed by the Commissioner of the Correctional Service to look into the incident of April 22nd, subsequent events in the Segregation Unit and certain associated matters. The report was critical of certain aspects of the management of the Prison for Women generally. It gave little attention to the IERT attendance, and in fact mis-described the nature of the IERT's procedure. It did not deal extensively, and sometimes not at all, with many aspects of the response of the Correctional Service to the April 22nd incident and its aftermath.

On February 14, 1995, the Correctional Investigator made a special report to the Solicitor General which was severely critical of the Board of Investigation Report, the IERT attendance, and the conditions and duration of the segregation of the inmates involved.

On February 21, 1995, the Solicitor General tabled the Correctional Investigator's Special Report in the House of Commons and announced his intention to call for an independent inquiry into the matters described above. The same day, substantial extracts of the video of the IERT attendance were shown on the CBC program, Fifth Estate.

On April 10, 1995, the Governor General in Council appointed this Commission of Inquiry pursuant to Part II of the Inquiries Act.

2.2 April 22, 1994

2.2.1 General findings

I indicated to all parties at the outset that a precise and definitive determination of what happened on the evening of April 22nd was not essential to the discharge of my mandate, and would be a futile, time-consuming and expensive exercise. Dozens of witnesses would have to be called to recount their recollection of an incident that lasted a few minutes and about which sufficient reliable information already exists. For the purpose of determining the adequacy of the response taken by the Correctional Service in the days, weeks and months that followed the incident, it is only important to appreciate its significant elements.

Criminal charges were laid against the inmates involved on April 22nd, and in December of 1994, guilty pleas were entered in open court, in a proceeding in which the inmates were represented by counsel who agreed, on their behalf, to a recital of significant facts presented by the prosecution.

On all the evidence before me, I am satisfied that the guilty pleas, and the facts tendered in support of these pleas, present a reliable summary of the significant elements of the events on April 22nd. These facts are as follows.

The incident took place shortly before 6:00 p.m. on April 22nd. The B range inmates were attending the hospital area, as is routine, to receive prescribed medication. Inmates Young and Shea approached the hospital barrier and inmate Young began to demand her medication in a loud and aggressive voice. The two inmates were quickly joined by inmates Twins, Morrison, Emsley and Bettencourt. Most of the inmates wore street clothes.

Inmate Young turned to inmate Twins and said: ``Where is the scissors? Give me the scissors so I can stick her.'' Inmate Twins reached for a pair of hobbycraft-sized scissors and tried to pass them to inmate Young, but they were knocked clear and taken by Officer Boston.

Officer Metivier attempted to telephone for help and the phone was disconnected by Ms. Twins who told Officer Metivier ``stay back, this doesn't concern you''.

Officer Boston pulled Ms. Morrison from Officer Vance and Ms. Morrison turned on Officer Boston delivering a number of kicks to her upper body area. At some point Ms. Morrison grabbed a telephone and attempted to use it to strike Officer Boston, but no blows were received.

Ms. Twins grabbed Officer Fabio, who had gone to assist Officer Vance, around the neck and said to her: ``You're my fucking hostage. We're going out through the front door.'' Officer Fabio was able to break free and was attacked by Ms. Young, Ms. Bettencourt and Ms. Morrison, who grabbed her and struck her. Inmate Young said: ``Grab the telephone cord. We'll string the bitch up, right here.'' Inmates Young and Bettencourt tried to pull Officer Fabio onto B range and were heard yelling: ``We've got her. She's coming with us. Let's get her.'' Inmate Young pulled Officer Fabio by the hair and clumps of hair similar in colour to that of Officer Fabio were later found on the floor.

Correctional Supervisor Gillis arrived, armed with mace, and ordered the inmates to release Officer Fabio. They wouldn't, and Correctional Supervisor Gillis maced both inmates, thereby freeing Officer Fabio who remembers thinking that she was going to be killed.

Officer Boston had attempted to go to Officer Fabio's aid and was grabbed around the throat by Ms. Twins who said: ``Give me your keys. We're going out the front door. Don't push me, Boston. I've got a shiv, and I'll stick you.'' Ms. Twins then attempted to get Officer Boston's key from her pocket. Correctional Supervisor Gillis attempted to control the situation and Ms. Twins kicked him in the groin area, whereupon he maced her.

After the immediate situation was controlled, the inmates were removed from the area to the Segregation Unit. Three of the inmates initially escaped to the range area, but were located and returned. During the course of the removal to the segregation area, Ms. Bettencourt became violent, biting, kicking and spitting at the escort officers. She kicked Officer Smith in the left knee. Officer Smith had previously had medical problems with the knee. The doctor later diagnosed a torn cartilage, and placed Officer Smith in a hip to ankle cast. She was subsequently rushed to hospital as a result of blood clotting.

The incident was very brief, lasting a minute and a half to two or three minutes at most.

The following guilty pleas were entered to the charges laid as a result of the incident:

There are only two significant factual questions that are left unanswered by the facts offered in support of the guilty pleas. The first one is whether or not the event was part of a planned escape attempt, and if so, how extensive and sophisticated the plan was. The second issue of significance is whether or not the weapon used in the assault to which Brenda Morrison pleaded guilty was in fact a syringe, indeed, whether it was possibly an HIV-infected syringe.

2.2.2 Whether there was a planned escape attempt

Although the evidence suggests that the events of April 22nd were not entirely spontaneous, it does not support the conclusion that there was much planning, except possibly for a short caucusing between inmates a few minutes before they came to blows with the Correctional Officers. The facts tendered at the hearing in support of a contention that the attempted escape was planned do not, in my opinion, support that conclusion. These facts include the alleged unusual behaviour of some of the inmates on the evening of April 21st in not attending dinner. I cannot conclude that any such unusual occurrences are sufficiently probative of a plan to escape or otherwise, for me to draw any such inference. The most probative evidence of planning is said to be that inmates involved were wearing outdoor clothing such as short bomber jackets, and that there would have been no reason for them to be dressed in that fashion on the evening of April 22nd. No efforts were made at the time to seize and preserve the clothing as evidence to support a plan to escape. In the absence of such evidence, and in light of the somewhat vague and in some cases contradictory descriptions given on that point by the witnesses, I am unable to conclude that the inmates were in fact clothed in such a way as to indicate their intention to escape. I do not think that the other evidence offered to support a conclusion of long-term planning leads to that inference and I think that some of the evidence given, for example, that one inmate the night before had requested that hot dogs be individual wrapped, is entirely incapable of supporting that conclusion.

However, I accept the evidence which suggests that the assaults were not entirely spontaneous, but rather the result of some collaboration on the part of at least some of the inmates shortly before the incident began.

2.2.3 The existence of a syringe

I believe that Officer Vance is firmly convinced that she was stabbed with a syringe. I believe her evidence that she formed that opinion at the time of the event, and to this day, she is still persuaded that this was the case. I believe that she gave her evidence honestly, and I do not find it far-fetched or unreasonable for her to be of that opinion. However, on the evidence before me, and again largely because of the insufficiency of the search that was conducted at the time, and possibly also as a result of the insufficiency of the observation reports that were recorded by the correctional officers who had been involved in the incident or its aftermath, it is impossible to conclude with a sufficient level of confidence that a syringe was in fact the weapon with which Officer Vance was stabbed.

In light of these conclusions, I cannot give effect to the submissions by the Union that in all the circumstances, a finding could be made that any of the assaults perpetrated by the inmates on the staff revealed an intentional attempt to kill. I add that no one was ever charged with attempted murder.

2.2.4 The significance of the incident

It is apparent from all the evidence that the single most important feature of what took place on April 22nd, which explains in part the behaviour of many of the parties involved in the immediate aftermath of these events, was the profound breach of trust that this unpredictable violent group attack on staff would create. Fear and distrust were two dominant emotions that were introduced in an environment in which fatigue, exasperation, even resentment and anger are not unknown.

The incident had profound and long-term effects on the correctional staff who were most directly involved. Officer Metivier was off work for a year and no longer works at the Prison for Women. Officer Boston took three months leave and no longer works at the Prison for Women. Officer Fabio immediately returned to work at the Prison for Women, but had difficulty putting the events behind her. She ultimately transferred to another institution. Officer Vance remained off work for seven months. She attempted to return to work, but was unable to do so. She no longer works at the Prison for Women, and indeed, has left the Correctional Service of Canada. Officer Vance had come to the Correctional Service with a B.A. in Women's Studies and Criminology, a background in correctional work, and had joined the Correctional Service of Canada for the specific purpose of working at the Prison for Women.

When examined from this distance, and without by any means trivializing it, the brief incident of April 22nd looks objectively less serious than it was perceived to be by the correctional authorities at the Prison for Women, and by the staff members who were assaulted and their colleagues. On the other hand, the sentiments and the emotions that it triggered were equally real and the challenge that it posed to the prison management was to deal with these two levels of reality.

2.2.5 Departures from Correctional Service policy

Mace was used to subdue three of the inmates involved in the April 22nd incident. Although Correctional Service policy contains elaborate provisions with respect to decontamination following the use of mace, in this case, decontamination was limited to pouring some glasses of water over the inmates' eyes. The inmates were taken to the Segregation Unit where they were locked in individual cells. The Post Orders at the Prison for Women and the usual practice, dictate that upon admission to segregation, an inmate is strip searched in order that any weapons, drugs, or incriminating evidence may be seized. Such strip searches were not done on the inmates admitted to segregation on the evening of April 22nd. Nor were they searched during the following four days.

Consistent with Correctional Service policy, the correctional staff involved in the April 22nd incident all completed written observation reports. In a number of cases, the reports were not completed, as is the usual practice, prior to the departure of the Correctional Officers from the prison. A number of reports were prepared over the period April 23rd to 25th, and in almost every case they were prepared after consultations, formal and informal, among the Correctional Officers involved.

Following the incident, the IPSO contacted the Kingston Police to report on the event, but advised that they not attend to conduct an investigation that night on the basis that the correctional officers were preparing statements, that they did not wish to be interviewed that night, and that there was no crime scene requiring preservation. The police accepted that advice and did not attend at the institution until Monday. No systematic search of the area was conducted by prison authorities, nor was there a concerted effort to identify, seize and retain evidence.

The detailed Use of Force Report, which Correctional Service policy requires be completed after an incident such as this, was completed in part over the following days. Contrary to Correctional Service policy, it did not describe the complete range of the use of force employed in connection with the incident, nor did it contain any mention of a second macing of one of the inmates. There was no report from a health care officer, no proper reporting with respect to the use of mace, and no record of the inmates being advised that they could provide their version of the extent of the use of force to the Warden.

I will comment on these several departures from policy in turn.

2.2.5.1 Failure to follow decontamination procedures

28. Staff members who may be required to use firearms, CN or CS gas or authorized spray irritants in the course of their duties, shall qualify with requalification to follow:

(a) every three years in the use of CN and CS gas and authorized spray irritants

29. Following incidents where force has been used, or restraint equipment applied to control an unruly inmate, all affected persons shall be examined as soon as possible by health care personnel and provided with treatment as required. Any follow-up medical attendance shall be provided as deemed appropriate by health care staff. The results of the examination and any follow-up shall be recorded and a report forwarded to the institutional head.

21. As soon as possible, persons exposed to gas or spray irritants shall be:

(a) moved from the immediate area;

(b) allowed to shower, wash and bathe their eyes;

(c) provided with a change of clothing; and

(d) examined by a health care officer and, if required, by the institutional physician.

The inmates who had been maced were not decontaminated in accordance with policy. This raises a preliminary question of the use of mace. Although there have been suggestions that it is over-used, or was over-used at the Prison for Women, there was no serious contention before me that alternatives were preferable and that therefore the use of mace should be banned. Throughout the timeframe in which these events unfolded, mace was used on several occasions. On balance, on the basis of these occurrences, I think it has been, in some instances, a preferable alternative to other methods of intervention.

However, the decontamination procedures contained in CD 605, and in the Security Manual, are important for two reasons, and should be very strictly enforced. I do not accept the position of the Correctional Service that the decontamination in this case was adequate because it was supervised by a qualified medical practitioner. This, in my view, addresses only one of the reasons for extensive decontamination procedures. I accept the evidence of Dr. Pearson that the inmates that she did decontaminate by pouring water into their eyes were sufficiently decontaminated to alleviate any medical concern. Some form of decontamination is essential to protect the wellbeing of persons subjected to mace, and failure to provide any decontamination, as was the case when Ms. Paquachon was maced on April 24, 1994, is a very serious deficiency.

However, the comprehensive use of spray irritant and decontamination procedures contained in CSC policy serve also another important purpose. Only staff members specifically authorized to do so may use mace in the course of their duties. These staff must receive periodic training. Further, the Security Manual provides that as soon as possible, persons exposed to gas or a spray irritant shall be (a) moved from the immediate area; (b) allowed to shower, wash and bathe their eyes; (c) provided with a change of clothing; and (d) examined by health care officers, and, if required, by the institutional physician. Finally, the Use of Force Reports require that the mace can be weighed after each use, and that the weight be recorded, so that the amount of mace used can be properly ascertained. These records were inadequately kept in this case.

The purpose of these procedures is not solely to ensure the physical wellbeing of people exposed to mace. It brings home to those authorized to apply it that it is not a routine procedure, and that every usage entails a set of operational and reporting consequences. The existence of elaborate procedural requirements often operates to discourage potential abuse. I believe that this should be the case when spray irritants are used, and for further control, I would recommend that additional supplies of spray irritants to an institution should only be issued upon a review of the Use of Force Reports in which the use of the spray is accounted for. In short, the policy with respect to the use of mace was appropriate, and if anything, should be reinforced. It was not complied with in part because it was not known, or, in any event, only the general medical concern for decontamination appears to have been known. It is apparent that the undesirabilitty of using more force than is necessary has to be brought home to those authorized to use force; and these events demonstrate that the constraints attached to the use of mace by the elaborate decontamination procedures were totally ineffective in achieving the dissuasive effect they should have had.

2.2.5.2 Compliance with policy concerning Use of Force Reports

This represents the beginning of a long series of deficiencies in reporting at the Prison for Women. This deficiency appears to have been tolerated by the Correctional Service, both at the Regional and the National level, and is not inconsistent with some of its practices with respect to the adequate completion of required documents.

With respect to the April 22nd incident, the serious deficiencies in the only Use of Force Report prepared constituted a violation of what had to be a known policy, since the key policy requirements are apparent from the form used. Once again, this is part of a general and obviously accepted pattern of incomplete reporting.

The failure to account adequately for incidents where force was used is a significant departure from policy which, as illustrated by this case, does not serve CSC well. Apart from communicating internally the nature of the incidents in which force was used, the completion of the report brings home to the person involved the seriousness of any interference with the physical integrity of another person. The leadership for adequate compliance with this policy requirement should come strongly at the institutional level. In its final submissions, CSC suggested that inadequate reporting on use of force should be remedied by the adoption of an elaborate system of public annual reporting on Use of Force Reports at the National level. This submission would require the setting up of a bureaucratic effort that would not need to be undertaken if the requirement were properly understood at the institutional level. In any event, I see no reason why the addition of this elaborate bureaucratic system of reporting would improve compliance at the institutional level.

Particularly in the case of a serious and unusual incident such as this one, the proper and thorough completion of the required report is essential for the safeguarding of all parties' interests in subsequent proceedings, including CSC investigations, as well as internal and external charges.

2.2.5.3 Compliance with policy regarding searches upon admission to segregation

Although the Correctional Service in its written submissions argues that the strip searching of inmates upon admission into segregation is merel