Ministry of the
Solicitor General

OCC Inquest - Hussein 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario

Surname: Hussein
Given name(s): Yousef Mohamed
Age: 27

Held at: 110 Laurier Ave West, Ottawa
From: April 9, 2018
To: April 17, 2018
By: Dr. Louise McNaughton-Filion
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Yousef Mohamed Hussein
Date and time of death: April 12, 2016 3:46 a.m.
Place of death: The Ottawa Hospital-Civic Campus 501 Smyth Road, Ottawa,ON
Cause of death: Suicide
By what means: Hanging

(Original signed by: Foreperson)

The verdict was received on the 17 of April, 2018
Coroner's name: Dr. Louise McNaughton-Filion
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of:

Yousef Mohamed Hussein

Jury Recommendations

To the Ottawa Carleton Detention Centre (OCDC):

  1. A stepwise transition from suicide watch to final housing in a jail should be considered by the health care provider at OCDC. This could take the form of a care map. The transition of care and supervision should be a clear, documented process, with assigned responsibilities. If, for operational reasons, the recommendations of a mental health professional cannot be put in place when suicide watch is cancelled, a discussion between a medical professional with mental health expertise (preferably the mental health professional who has completed the cancellation of suicide watch) and the person responsible for operational decision making should occur, and the resulting decision documented and enacted. To diminish the chance of error, all involved in an inmate’s care should be aware of the expectations and next steps. To assist with this, the documentation should be electronic and accessible to all, yet with different access levels depending on privacy considerations.
  2. OCDC daily briefings of correctional officers should be clearly documented with issues, action items with responsibilities and follow up. A communication tool should be in place, where everyone can see this information, as well as inmate status and requirements, and understand the plan for each inmate.
  3. OCDC should consider the assignment of specific correctional officers to a dedicated area such as segregation, or a mental health unit, to ensure a working knowledge and continuity with the inmates, in order to recognize and address changes in mental health status. These specific correctional officers should be chosen based on their demonstrated interest in mental health issues and persons with mental health challenges. These correctional officers, once identified, should receive regular, additional mental health care training, related to specific psychiatric diagnoses, behaviours and interventions. This training should help them care for those with specific psychiatric diagnoses and those whose psychiatric needs may yet be undefined. The Ministry of Community Safety and Correctional Services (MCSCS) should consider having correctional officers who work in a segregation/suicide watch context receive specific enhanced training regarding suicide prevention and mental health awareness. This training should be tracked, and consideration given to restricted work assignments in that area unless their training is up to date, and meets the required prerequisites.

To the Ministry of Community Safety and Correctional Services and the Ottawa Carleton Detention Centre:

  1. All MCSCS, OCDC employees should have a written performance plan that is reviewed annually with their manager. This should include a training plan and quantitative and qualitative goals.  
  2. Any inmate who has been identified by MCSCS and/or OCDC as having a significant mental health concern, including suicidality, should have a clearly written, easily accessible and individualized care path/treatment plan. This should be accessible to all those involved in their care, (such as correctional officers, social workers, nurses, physicians or psychologists) although it may have varied levels of access, for privacy considerations. An electronic plan, which clearly time stamps entries and indicates the author of any documentation would be preferable.  A requirement for a mandatory review at regular intervals should be considered. 
  3. A written request for psychiatric/psychology care, made by a psychologist, a non-medical practitioner or by an inmate at OCDC or a similar MCSCS detention center, should be directed to a designated central intake. This request should be flagged, acknowledged, addressed and documented in the inmate’s medical file by identified triage personnel. Regular rounds to discuss these requests, and other therapeutic initiatives, involving a psychiatrist, may be helpful.
  4. MCSCS and OCDC should work together to ensure there is effective recruitment and retention of mental health care professionals, such as social workers, psychologists, psychiatrists and mental health nurses at OCDC .   
  5. Unless there is a clear and obvious misconduct taking place (e.g. a fight) or an incident giving rise to a significant security concern at OCDC or a similar MCSCS detention centre the inmate should be removed to a secure location that is not entirely isolated and which would allow contact and communication with others, pending further steps on the misconduct charge.  
  6. MCSCS and OCDC should give inmates who are taken off suicide watch access to their basic belongings such as slippers, books, magazines as approved by the health care provider and an institutional manager.
  7. MCSCS and OCDC should consider, when cell checks are required that oversight by the operations manager should be mandatory and a part of the operations manager’s required tasks. This oversight role should be enforced in a transparent manner, with clear performance expectations for those conducting the cell check, documentation and follow up. To facilitate this, OCDC should study whether it is feasible to add an element to its watch tour monitoring system to determine which correctional officer is conducting a watch tour and how that watch tour is being conducted. If cell checks are a performance requirement, then it should be part of the correctional officer’s regular performance assessment. The exercise of oversight should be a part of the operations manager’s regular performance assessment, and a marker of quality at the correctional centre. 

To the Ministry of Community Safety and Correctional Services and Ottawa Carleton Detention Centre:

  1. MCSCS and OCDC should give strong consideration to transitioning all paper documentation to an electronic format that can be easily accessible to those permitted under privacy legislation to read and use it, no matter where the care provider may be in the institution, or between institutions.  All required documentation should have a clear, reproducible notation of the time and date, to allow health care/service providers or staff member and others understand and follow the inmate’s status and response to therapy. There should be a system to require a clear indication of the authors of documents. Tools should be in place to encourage documentation before the person signs off. The ministry should consider the implementation of an electronic health care record system that will be accessible to health care providers within a particular institution.  
  2. MCSCS and OCDC should develop an electronic system at the OCDC , which would ensure all mental health referrals are tracked and followed by an identified, responsible person, and are addressed in a timely manner. This tracking system could also introduce alerts at specific times, where re-triage or interim assessment could occur.  This tracking system would be able to assist in the determination of the appropriate number and type of mental health care providers, to ensure special needs and regular inmates receive the care they require.
  3. When new facilities or construction is being considered, by OCDC or MCSCS, attention should be given to better lighting, space and more numerous and accessible outdoor exercise areas.  OCDC should continue to implement its planned retrofit of 1-Wing to ensure that there are no anchor points on any bunk beds in 1-wing (or anywhere else in the institution) and that there are larger windows on cell doors, comparable to the windows on the doors in Pod Segregation area.
  4. MCSCS and OCDC should give consideration to having cardio pulmonary respiration (CPR) equipment for correctional officers, such as gloves and a resuscitation mask, as part of an obligatory toolkit which is attached to the correctional officer’s utility belt at all times, such as is supplied to graduates of the COTA program. This should be standard issue at detention centres, replaced as used and verified annually.
  5. MCSCS and OCDC should give consideration to increasing the number of radios available at OCDC such that each correctional officer can be provided with one at the start of the shift to improve communication.
  6. MCSCS and OCDC should help design and implement continuing mental health education for correctional officers and all who interact with inmates suffering from mental health or addiction challenges.
  7. MCSCS and OCDC should consider offering specific mental health care services for inmates, such as group therapy.
  8. MCSCS and OCDC should consider further expansion of wellness initiatives, critical incident supports, and mental health services available to front line staff to prevent and limit burnout and psychological injury (e.g., post-traumatic stress disorder) and promote a healthy workplace which may improve psychiatric care and suicide prevention for inmates.

To the Ottawa Carleton Detention Centre, the Royal Ottawa Mental Health Care group, the Champlain Local Health Integration Network:

  1. The OCDC , the Royal Ottawa Mental Health care group, Champlain Local Health Integration Network and others involved in mental health care provision, should forge a formal partnership, to aid in the streamlined, planned transfer of inmates on formal assessments at the Royal Ottawa Mental Health Care Group to the OCDC , to ensure an appropriate cell is open and available for returning inmates, to avoid a sudden, unexpected emergency, such as the arrival of a possibly violent inmate returning to the OCDC . It should be recognized that transfers are a dynamic process, and many factors can lead to sudden transfer or cancellation of the same.

To the Ministry of Community Safety and Correctional Services:

  1. The MCSCS should continue to develop and expand on its Mental Health Training both at Ontario Correctional Services College (OCSC) and Correctional Officer Training and Assessment program (COTA) and in the field.
  2. MCSCS should consider publicly accessible reporting of the percentage of staff up to date in their training in each institution for certain subjects, such as (CPR), mental health awareness and suicide awareness, which would reassure families, inmates and the public. This could be considered a quality indicator for the institution. Supervisors should be evaluated on the percentage of their correctional officers with up to date training.
  3. If necessary, MCSCS should consider temporary assignment of correctional officers from other institutions to ensure timely training of officers in institutions experiencing staff shortages.
  4. The MCSCS should consider telemedicine for psychologists, (virtual psychology) as well as psychiatrists, to ensure there is a full cohort of mental health professionals who can assess, diagnose and treat mental health issues.
  5. MCSCS should consider offering “virtual visiting” of inmates through telecommunication technologies such as Skype.

To the Ministry of Community Safety and Correctional Services, the Ottawa Carleton Detention Centre and the Correctional Officer Training and Assessment program:

  1. MCSCS, OCDC , and COTA should continue to implement the Regional Block Training Program in order to ensure that all mandatory training of correctional officers (including (CPR), suicide awareness, mental health training and use of force) at OCDC is delivered at the earliest opportunity in order to ensure that training of those correctional officers becomes up-to-date.
  2. The ongoing training of correctional officers by MCSCS, OCDC, COTA should be mandatory, scheduled, tracked and required for work. This training should apply to both new and experienced correctional officers. An automatic system of alerts and reminders should be in place, communicated to the correctional officer and their supervisor, or a person designated to take this specific oversight role, such that a correctional officer cannot work at a specific task where certification is required unless his or her training is up to date and documented. There should be an advanced warning system to ensure there is adequate time to obtain training before it expires.

To the Correctional Officer Training and Assessment Program and the Ministry of Community Safety and Correctional Services:

  1. When COTA and MCSCS consider new correctional officer and refresher correctional officer training, they should consider using scenarios based on real events, including coroner’s inquests and their recommendations. This should re-enforce, with real stories, the importance of the learning taking place.

To the Ministry of Advanced Education and Skills Development, the University of Ottawa, and the Ottawa Carleton Detention Centre:

  1. The Ministry of Advanced Education and Skills Development should consider requiring training programs, such as those for social work, nursing, physician and psychologist training to have exposure and teaching related to care in detention and correctional institutions, particularly the care and evaluation of those in custody, or who are incarcerated, in order to ensure professionals in training are aware and have the opportunity to develop an interest in these areas, to help resolve chronic ongoing staffing shortages in detention centres. The University of Ottawa, in particular, should consider a formal partnership in all these areas with the Ottawa Carleton Detention Centre, in order to allow exposure, and a direct pathway to professional engagement in an area very much in need.

To the Ottawa Carleton Detention Centre and to the Royal Ottawa Mental Health Group:

  1. The OCDC and the Royal Ottawa Mental Health Group should consider implementing a program similar to the Forensic Early Intervention Service that has been a joint program between the Centre for Addiction and Mental Health and Toronto South Detention Centre.