New Brunswick·CBC Investigates

Forgotten Deaths: Secret reports raise questions about jail supervision

Documents obtained by CBC News reveal that jail staff have been cited for inadequate supervision, poor report writing and, in one case, not offering immediate help to someone who needs it.

Department of Public Safety won't talk about inmate who didn’t get immediate medical help in jail

Most of the details from this inmate death report have been redacted by the Department of Public Safety. The department says it couldn't release some details because it's considered personal health information. (CBC)

Inside an unnamed New Brunswick jail, an anonymous inmate is found in medical distress.

The reaction to the discovery is delayed because jail staff don't offer the person immediate assistance. They wait for someone else to arrive.

But it's too late. The inmate won't make it.

That's one situation detailed in copies of previously-secret inmate death reports, obtained as part of a CBC News investigation into 13 deaths in custody of New Brunswick's jails, dating back to 2004.

They reveal that jail staff have been cited for inadequate supervision, poor report writing and, in this case, not offering immediate help to someone having "medical difficulty."

The Department of Public Safety has censored most of the details inside the reports, including the name of the jail where the death happened, signatures of the people who wrote the report and even the year it was written.

It says those details could be considered third-party or personal health information and are protected under provincial privacy legislation.

Jeffrey Hood, Carolyn Warnock and Jason Hopkins are three of the 13 people who have died in New Brunswick jails in the last 12 years. (Photos submitted)

Ombudsman Charles Murray said he is "absolutely concerned" by the details found in the documents.

Murray has called for a full, public review of every inmate death in the province, and said this is more proof that "a larger look" is needed.

"Were [the jail staff] not sufficiently trained?" Murray said.

"Was the nature of the medical distress such that it wasn't easily ascertained by an observer? These are all follow-up questions which an organization needs to be vigilant to ask to ensure we're doing the best we can."

Department defends current protocols

When asked if he is concerned by the suggestion that his staff didn't immediately help an inmate in medical distress, Len Davies, the province's director of correctional services, said he has "full confidence" in his correctional officers.

In an interview, Davies said his office takes the recommendations that come out of an inmate death seriously and often makes changes as a result.

(The department requested that Davies not be interviewed on camera.)

New Brunswick isn't tracking the number of non-fatal drug overdoses that happen inside provincial jails, according to a right to information request. (CBC )

He said CBC News was "speculating" on what the heavily-redacted reports may mean.

But he declined to provide any details about what happened inside the unnamed jail on the day of the anonymous inmate's death. He said he can't talk about specific cases.

"If you look through those reports too, there's probably places in there that you're not mentioning about adhered to policy, did a good job, responded effectively," Davies said.

"Did you notice those parts of the report?"

'You either believe me ... or you don't'

Little information is available about how an inmate died if a coroner's inquest isn't held into the death. Unlike in Ontario, inquests are not automatic in New Brunswick if a person dies in jail.
A number of investigations happen after an inmate dies in jail, including probes by police, the Department of Public Safety and the coroner.

Cases in need of further review are handed over to a critical incident response team, who write the heavily-redacted death reports.

The coroner also has the power to call an inquest if he feels that questions remain unanswered.

With the exception of a coroner's inquest — which is not mandatory after an inmate death in New Brunswick — the public has little access to details on how inmates are dying and how the deaths might have been prevented.

Only four out of 13 of the deaths CBC News has investigated received an inquest.

Davies defended the system that's in place, arguing there are enough checks and balances to hold his staff accountable.

"You either believe me and trust that or you don't," he said.

Province will notify public after jail death

Public Safety Minister Denis Landry would not address the ombudsman's call for automatic, public reviews into inmate deaths. (CBC)

Public Safety Minister Denis Landry declined an interview and did not answer emailed questions about the inmate who was in medical distress.

Landry also didn't address Murray's call for automatic, public reviews to dig deeper into inmate deaths.

​But the minister said in an emailed statement that his government wants to be more transparent about inmate deaths.

The department quietly changed its policy around public notification of inmate deaths in late June, agreeing to start telling the public within 12 hours of someone dying in custody.

That public news release will include the inmate's name, age and facility where he or she was incarcerated.

It won't include the person's cause of death, a crucial detail some critics say is needed to determine whether the death could have been prevented.

Poor supervision flagged in report

Ombudsman Charles Murray flips through copies of redacted inmate death reports obtained by CBC News. (CBC)

The department only provided the recommendations section of the death reports, severing the part where the critical incident response team explains how they believe an inmate died.

In the report about the anonymous inmate in medical distress, the authors — whose names are blacked out — recommend that jail staff be given "constructive direction" on how to respond to an emergency.

It says staff should be reminded of "the importance of readiness in a correctional environment and the offering of immediate assistance of someone in medical distress."

That same report reveals that staff at the jail had a practice of supervising inmates in the medical and segregation cell area through a video monitor after 11 p.m., a violation of policy.

"Therefore supervision checks were not in accordance to standards set out within provincial policy or procedures," the report says.

Union wants internal review

Mike Davidson, the president of CUPE Local 500, said he is not aware of a correctional officer ever being disciplined in connection with an inmate's death. (CBC)

Mike Davidson, a Canadian Union of Public Employees (CUPE) national representative based in Saint John, said he can't remember any jail staff being disciplined as a result of an inmate death during the past 12 years.

"I know that one thing that we should be doing is reviewing these situations to try to see [what] we can improve on, obviously to try to prevent any kind of situation," said Davidson, who represents correctional officers.

He said jail staff are struggling to meet the needs of mentally ill inmates, who may also have addiction issues.

To add to the challenge, Davidson said as many as one-third of correctional staff are working casual hours.

The root of these problems, he said, lies in the lack of access to mental health services both behind bars and in the community.

"There's not a whole lot of available resources for somebody who doesn't have any kind of insured benefits plan to be able to get the specialized help they need through psychologists and those kind of different professions," the union leader said.

Davidson said he is in favour of a deeper look into inmate deaths in provincial jails, but doesn't believe that should be a public review.

"I'm not sure [if] the access to the public is going to improve anything, other than it maybe identifies some of the issues a little bit more," he said.

Do you have a tip about a death in custody of a jail? You can send your story tips to New Brunswick's investigative unit by clicking here.

Secret New Brunswick jail deaths prompt calls for public review


To encourage thoughtful and respectful conversations, first and last names will appear with each submission to CBC/Radio-Canada's online communities (except in children and youth-oriented communities). Pseudonyms will no longer be permitted.

By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Please note that CBC does not endorse the opinions expressed in comments. Comments on this story are moderated according to our Submission Guidelines. Comments are welcome while open. We reserve the right to close comments at any time.