CSC’s internal review process ‘seriously compromised’ — investigator

This photo from the Correctional Investigator's report shows the aftermath of last year's deadly riot at the Saskatchewan Penitentiary.

Office of the Correctional Investigator slams internal report, which dismissed Sask. Pen riot as ‘random’ event

Correctional Service Canada’s (CSC) own process to review major events, such as 2016’s deadly riot at Saskatchewan Penitentiary, has become “seriously compromised,” the Office of the Correctional Investigator (OCI) has found.

A look into the National Board of Investigation procedures, specifically around the Sask. Pen investigation, features prominently into the OCI’s annual report, released publicly Tuesday.

The riot left one inmate dead, two seriously injured and caused damage estimated at $3.5 million. Ranges were left inhabitable, with 133 cells unserviceable. In the immediate aftermath of the riot, inmates and the union representing the facility’s guards connected the incident to concerns that had been raised about the food. Inmates had been on strike for a few days already protesting what they said were portions that were too small, along with perceived mistreatment of inmate kitchen staff by CSC employees. The correctional investigator, Ivan Zinger, came to a similar conclusion.

The National Board of Investigation (NBOI), the CSC’s internal body that looks at serious incidents, though,) determined the incident was a random event that couldn’t have been predicted or prevented.

Those findings, Zinger wrote, “raised a series of red flags.”

Among the shortcomings in the work of the NBOI, Zinger found it didn’t take into account a simmering dispute over quantity and quality of food, nor did it consider the makeup of the ranges that rioted — 85 per cent of inmates were involved, and about half were members of street gangs, he said.

The NBOI investigation was intended to promote wider learning, prevention and improvement. However, “the impulse to contain bad news runs deep,” Zinger wrote, adding that the internal review focuses almost exclusively on policy compliance.

Of even more concern, Zinger said, was that the official report released to the public by the CSC— as opposed to the internal report — did address food issues and was “more complete” than what the NBOI came up with.

“The two markedly different versions point to underlying transparency and credibility issues with respect to how the CSC investigates itself in the aftermath of a serious incident and how the agency publicly reports on these incidents.”

According to Zinger, the board only interviewed one inmate and relied primarily on management’s interpretation of events. That investigation also chose an inmate whose credibility was questionable, Zinger found, and ignored any of the other inmates who were involved.

Though the NBOI report acknowledges that some tensions were rising with regards to the food, it rejected the notion that those tensions led to the riot.

“The Board’s endorsement of random event theory and its conclusion that food quality or quantity played no role in the riot raises the possibility that its absence of “findings” in this area may have been pre-determined,” Zinger wrote.

“The Board’s interpretation of the riot … meant that the violence could not have been attributed to failure in CSC food services policy or any other CSC shortcoming. The random event interpretation seemed to give the Board license not to scrutinize Sask. Pen. authorities or call into question contested aspects of the Service’s national food services modernization initiative.”

In contrast, Zinger said, inmates interviewed by his office described the mood leading up to the riot as “volatile” and “tense.” Guards suggested the environment was “stressed” and “toxic.”

Through other inmate testimonials, Zinger’s office found that their concerns were consistent, including the frequency and nature of food shortages, perceived protein shortages, selection, replacement and substitution of food items, meal quality and portion sizes and perceived maltreatment, intimidation and disrespect of inmate kitchen workers.

Zinger said inmates told him the intention was to continue the nonviolent protest. The day prior to the riot, inmate representatives rejected concessions offered by the warden and asked for things he wasn’t able to provide, such as doubling the amount of protein.

The warden, in an attempt to get inmates back to work and the institution to return to a normal routine, had officers order inmates to return to work or be locked up. Inmates said the officers delivered a series of demands and ultimatums, including the loss of gym privileges, socials and the Christmas canteen if they refused to go back to work. Inmates also claimed the guards told them the emergency response team was preparing to deploy.

Once the staff left, inmates began destroying cameras, putting on masks, and making barricades.

“Things just got crazy … things getting smashed – the guys felt like they had enough and they just felt that their voice wasn’t being heard,” one inmate told Zinger.

“It was building up, building up, and guys were frustrated. This is the only way, they felt, that their voices would be heard.

Once things got started, there was no turning back.

Zinger said the move from peaceful protest to riot was caused, in part, by a “critical breakdown” in the ability to compromise. The usual channels of inmate representation and communication weren’t working, Meanwhile, management’s decision “to go from offering concessions to issuing ultimatums in a charged and volatile environment considerably upped the ante.”

Once the riot was over both staff and inmates spoken to by Zinger’s office confirmed a history of broken promises and commitments that had provided temporary relief to long-standing kitchen issues.

Importance of gang dynamics

Zinger also found that CSC’s internal report failed to take into consideration the makeup of the ranges that participated in the riot. The units involved were integrated ranges, where members of multiple street gangs coexist in the same unit. Of the 21 principal instigators, he found, 18 were Indigenous, and 11 gang-affiliated.

Perceived mistreatment and the use of punitive measures strengthen gang cohesion, Zinger wrote. Failing to take that into consideration means the board didn’t attempt to assess or analyze living conditions, group dynamics, gang management, circumstances, institutional behaviour or the profile of the inmates involved.

“This board is largely silent on points of learning, prevention and corrective measures, which are the aims of convening and conducting boards of Investigation in the first place,” Zinger wrote.


Zinger wrote that overall, the NBOI explanation is “highly improbable, superficial and self-serving.” He found that the public account of the riot doesn’t match the facts, findings or conclusions of the NBOI investigation, despite saying that it is based on that investigation. He also found the NBOI approach to be lacking transparency and credibility.

Zinger placed the blame for sparking the riot on a breakdown of communications and the officers’ show of presence on the ranges prior to the riot, while food issues were contributing factors, and group dynamics on integrated ranges also need to be understood.

He recommended that the Minister of Public Safety independently review the NBOI’s process, and possibly authorize independent investigations into major disturbances, and a review of internal monitoring and performance mechanisms, as well as the inmate complaint and grievance system. He also recommended that CSC conduct an external audit of its food services modernization initiative to review the cost of the implementation and the impact on inmate employment and canteen purchases.

Finally, he recommended that CSC create and appoint a deputy commissioner position for Indigenous affairs to ensure that attention and accountability focuses on Indigenous issues in federal corrections.

Timeline of events:

Thursday December 8, 2016

  • A list of numerous issues involving food services and inmate working conditions in the kitchen are delivered to Management.

Friday December 9, 2016

  • Inmate kitchen workers walk off the job in protest over scrambled egg portions served at the breakfast meal.

Monday December 12, 2016

  • A meeting is held between Management and more than 40 inmate kitchen workers to resolve the ongoing kitchen dispute.
  • General population inmates are refusing to attend school, work or programs in solidarity with the kitchen workers’ protest.
  • Later that day, the Warden has his own meeting with the same inmate representatives, who are instructed to come back with a more reasonable list of issues and demands.

Tuesday December 13, 2016

  • The Warden’s four key concessions to settle the kitchen protest and end the inmate strike are delivered to the inmate representatives.

Wednesday December 14, 2016

9:00 am – Inmate representatives turn down the Warden’s concessions and raise new demands, including doubling of the meal protein allotment.

1:00 pm – Work up is called.

1:15 pm – Inmates on E1&2, E3&4, F1&2 and F4 ranges refuse to attend work and refuse to lock up.

1:20 pm – A contingent of officers is assembled to show presence on E3&4 ranges in an attempt to enforce the Warden’s order for inmates to attend work and programs or lock up. A few minutes after Officers withdraw from E3&4 ranges, inmates are seen donning balaclavas and masks and the range camera is painted over. Visual observation is lost. Similar events take place on other implicated ranges (E1&2, and F4).

Riot begins at/around 1:30 pm.

1:55 pm – Crisis Negotiators begin making contact with implicated Ranges.

3:40 pm – The Deputy Warden reads the Riot Act Proclamation over the all-call system.

4:15 pm – F1&F2 ranges peacefully lock up.

4:35 pm – Emergency Response Team (Riot Squad) breach E3&4 range barriers and meet with serious resistance.

7:25 pm – The last of the implicated ranges is secured and the institution is deemed secure.