Independent Observer Report 2024: Death of Taran Morrison

Official title: National Joint Board of Investigation Correctional Service Canada – into the death of an inmate that occurred at Millhaven Institution (maximum) on February 4, 2024.

Executive summary

Background

The Commissioner, Correctional Service Canada (CSC), by virtue of Section 19 and 20 of the Corrections and Conditional Release Act (CCRA), convened a National Board of Investigation (BOI) on March 6, 2024.

On April 26, 2024, Michelle Duncan was appointed as the Independent Observer (IO) to oversee key points in the BOI’s activities in the matter of Taran Morrison who [redacted] on February 2, 2024, [redacted] at Millhaven Institution. Ms. Duncan was instructed to adhere to parameters set out in the Independent Observer Mandate as noted in Appendix A.

The National Board of Investigation

The BOI was comprised of three individuals that included:

• a National Investigator and Psychologist, Incident Investigations Branch (IIB), National Headquarters (NHQ) as Chairperson;
• a Correctional Manager, Port-Cartier Institution, Quebec Region and;
• a Community Board Member 

as members of the BOI.

The BOI was supported by Incident Investigations Branch, CSC National Headquarters. An IO of the BOI was appointed.

It is the IO’s opinion that the formation of the BOI was well constituted by including persons with all areas of expertise that would be required to ensure a thorough and comprehensive investigation.

Mandate timeframe

As set out in the Mandate (Appendix A), the IO would observe, make relevant suggestions, and oversee the activities of the BOI through all aspects of their work including interviews, debriefings, meetings and formation of their report. The interview stage was completed by June 2024. Preparation of the report and debriefings were to follow resulting in a draft report being submitted in July 2024 and a final report being submitted by December 18, 2024. The IO’s final report of their observations and conclusions was required by January 10, 2025.

Key findings

The IO found that the investigation was consistent with the parameters set out in the March 6, 2024, Convening Order and the Commissioner’s Directive 041 – Incident Investigations (September 8, 2020). The findings and recommendations by the BOI were supported by the evidence reviewed in the investigation. All communications both verbal and written were conducted in a professional, respectful and timely manner. There was no prejudice or bias in the findings of the investigation and that it was guided solely based on the evidence. As a result of the evidence gathered, the findings rendered and recommendations ensured that the investigation was thorough.

Recommendations

No recommendations were identified.

Introduction

On February 4, 2024, at approximately 1542 hours, a Social Programs Officer attended inmate Taran Morrison’s [redacted] cell in the [redacted] at the Millhaven Institution. Mr. Morrison did not respond to the Officer; therefore, the Correctional Manager was alerted. A radio transmission for Correctional Officer assistance and a call for Emergency Medical Services (EMS) were placed.

Once the cell door was opened, it was noted that Mr. Morrison appeared to not be breathing and [redacted] Mr. Morrison was placed onto the floor into the common area to initiate cardiopulmonary resuscitation (CPR). Paramedics arrived at approximately 1600 hours and assisted with the administration of CPR. At 1618 hours, paramedics directed life-saving measures to be stopped, and the inmate was pronounced deceased.

In response to this incident, the Commissioner, CSC, by virtue of Sections 19 and 20 of the CCRA, has convened a National BOI which terms are described under Convening Order and Convening Order amendment.

The Convening Order amendment directed CSC to appoint an IO to ensure the thoroughness, impartiality, integrity and professionalism of the investigative process.

As per the IO mandate (Appendix A), the objectives of the IO were to assess whether the work of the BOI is thorough, impartial, and professional and, where necessary and appropriate, to make observations and recommendations on any issues related to the IO mandate. Upon completion of the investigative process the IO is to provide a final report of their observations, conclusions, and recommendations by January 10, 2025. To meet this mandate, the IO was granted full access to documents, interviews, locations and information related to the National BOI. The mandate also provided the option for the IO to liaise with the Chair of the BOI to obtain access to all the information and documents they felt necessary and to liaise with the Director General, IIB, for assistance regarding any procedural or administrative matter related to the conduct of the investigation.

Methodology and approach of the Independent Observer

In adhering to the Independent Observer mandate, the IO:

• reviewed relevant legislation (Corrections Conditional Release Act, sections 19, 20, 21, 97, 98; the Inquiries Act sections 7-13; Official Languages Act; Access to Information Act and Privacy Act)
• reviewed CSC Commissioner’s Directive 041 Incident Investigations (September 8, 2020)
• reviewed evidence and incident related information online through (GCDocs), inclusive of video and audio recordings, some medical reports, staff reports, emails, checklists, and additional forms of correspondence
• received and reviewed relevant emails that the BOI had shared prior to and throughout the process
• received relevant forms of information from the BOI Chair that was not accessible online, such as the Offender Management System (OMS) and health information protected under the Personal Health Information Protection Act
• participated in BOI logistical and planning meetings throughout the investigation
• observed 12 interviews by video conference via Microsoft Teams
• participated in Microsoft Teams chats with BOI members after interviews and when clarification was required
• reviewed and/or observed debriefings at the facility/local level, Incident Investigations Branch and with the National/Regional Headquarters via email correspondence and/or video conferencing
• reviewed both drafts and the final investigation report

Throughout the investigation, the IO observed and listened to the interactions between the members of the BOI in planning, reviewing, and conducting all aspects of the investigation. The IO also observed and listened to 12 interviews conducted by the BOI, including the introductions, the questioning, and the closing remarks used by the Chair leading the interviews. The IO reviewed the outlined interview questions including the preamble and introductory remarks used by the Chair, as the primary interviewer. To assist in assessing the thoroughness of the investigation and compliance with legislation and CSC protocols, the IO drew upon their own awareness and expertise of both correctional practices and policies from a 35-year career in Provincial custody corrections and their current service with the City of Winnipeg Board of Revision.

Assessment of the Independent Observer

In this section I, Michelle Duncan as Independent Observer, will outline my findings based on the following key indicators, to assess each area as provided in the IO mandate as set out in the Terms of Reference.

Thoroughness of the Board of Investigation process

Expertise of the selected BOI members

The BOI was comprised of three individuals that included Yvan Turcotte, a National Investigator and Psychologist, IIB, NHQ as Chairperson, Michael Bond, a 25-year Correctional Manager, Port-Cartier Institution, Quebec Region and Joseph Stewart a retired police officer, as the Community Board Member.

As a result of their individual expertise and experience in their respective fields, the BOI members effectively contributed to the investigation. They were articulate and well informed on the investigative processes related to the activities and mandates of CSC. They were clear on the scope of the investigation. They were thorough, impartial, and professional in approach. Each interview was led by the BOI Chair, although all members were able to input questions or comments as they saw fit. This approach provided consistency and was an effective method of eliciting the oral evidence required for the investigation. The assessment of policies and incident specifics was jointly reviewed by the BOI, with observations and opinions presented in an open and collaborative format.

Adherence to the parameters set out in the Convening Order

On March 6, 2024, the Commissioner of the CSC issued a Convening Order that resulted in the establishment of a BOI requiring them to examine the [redacted] of Morrison as it pertained to CSC. The Convening Order set out precise yet broad authorities for the BOI to investigate administrative aspects of the CSC operations in relation to this matter. On April 26, 2024, the Convening Order was amended to include the appointment of an Independent Observer.

In order to ensure the conduct and methodologies used by the BOI maintained focus, the scope and process of this investigation, as set out in the Convening Order was reviewed and referenced, on a regular basis, throughout the investigation.

Consistent application of the established BOI process, as defined under Commissioner’s Directive 041, as well as internal guidelines, norms and standards of the IIB

As the IO, I had reviewed the Commissioner’s Directive 041 as it sets out the purpose to ensure the Correctional Service of Canada takes appropriate action following an incident and to ensure the review and the analysis of the investigation reports influence organizational policy and practices where appropriate, and significant findings and recommendations from these reports are shared in order to prevent similar incidents from occurring in the future.

The document then outlines the authorities and guidelines for investigators and CSC staff to follow during and following the investigation. These guidelines include directives as to;

• timelines
• reporting requirements
• notifications of upcoming investigations
• investigative board composition
• the staff’s duty to provide evidence
• safeguards for the persons being interviewed
• disposition of evidence
• debriefings
• consultations and reporting, and
• information sharing

The investigation, in my opinion as the IO, adhered to these guidelines throughout the investigation.

Assessment of the thoroughness of the process used by the BOI to determine findings and make any recommendation(s)

Prior to and throughout the course of the investigation, the BOI ensured through ongoing planning and regular reviews, that the process was thorough. Evidence was continually reviewed and it’s significance assessed to determine which aspects were relevant to the operations of the CSC and what could be developed into appropriate and meaningful recommendations.

Although there were some local delays in response to BOI verbal and written requests for information and limited occasions where there was no response, this did not cause a significant delay in the reporting or the thoroughness of the reporting by the BOI. Where information was not received, the BOI drew conclusions from the evidence available to them.

Impartiality of the investigative process

Absence of prejudice or bias from BOI members, the BOI support team, management and stakeholders within CSC

As the IO, I observed all components of the investigative process inclusive of all briefings and there was no identified prejudice or bias from BOI members, the BOI support team, or stakeholders within CSC detected by the IO during the investigative stages of the process.

Independence of the BOI - that no undue influence was brought to bear on BOI members or other CSC staff to amend or alter their findings or recommendation(s)

Consistent with Commissioner’s Directive 041, following the active investigation and the controlled release of the draft of the BOI report, a series of debriefings were held with key stakeholders and management. These debriefings were for the purposes of:

• being informative and for transparency
• providing clarification where required
• providing confirmation that the findings were accurate and complete, and resulted in suggestions as to how to effectively communicate the findings and recommendations

Taran Morrison [redacted] and where the incident occurred, Millhaven Institution. Separate local debriefing minutes were shared in writing, with the option of having a Teams debriefing to discuss the BOIs findings and related information. Each of the debriefings were specific to the time Taran Morrison was housed at their own facility. Each facility was provided an opportunity to respond and, where appropriate, their clarification and/or feedback was incorporated into the draft report.

The IO observed that during local debriefings, management feedback was reviewed by the BOI and questions responded to by the BOI Chair. As a result of the local debriefings, it is the IO’s opinion that there were no substantive adjustments to the draft report findings and recommendations.

In addition to the local debriefings at the individual facility levels, on November 8, 2024, IIB held a Pre-briefing to ensure from their department’s standpoint that the investigation and reporting was consistent with the Commissioner’s Convening Order and CSC established reporting protocols. There were suggestions made to better and/or further clarify issues and establish whether they are assessed as secondary issues versus primary issues consistent with the Convening Order Terms of Reference (TOR). Based on the IO’s assessment of the discussions and the review of the TOR, the IO believes all pertinent information was retained within the report and adjustments were consistent with the TOR.

On November 15, 2024, a video Joint Regional/National debriefing via Teams was conducted which included the BOI and personnel from both Regional and National levels of CSC. It was the IO’s observation that the debriefing was conducted in accordance with the Commissioner’s Directive 041.

It is the IO’s opinion that the briefings resulted in appropriate suggestions as how to revise certain components of the report for better clarity and compliance with the Convening Order TOR and from the IO’s observations, it appeared that during the investigation, the BOI was not hindered in any way from producing findings and recommendations as they deemed fit without outside influence. There was also no indication observed or vocalized that would indicate that interviewees from CSC were restrained from being open and honest during the interviews.

Findings of the investigation and/or recommendation(s) are guided solely by evidence/facts

Throughout the investigation, the BOI gathered and reported factual evidence based on documentation and recollections and perceptions of the interviewees. To ensure findings and recommendations were based on facts, the BOI Chair throughout the investigation and IIB management as part of the pre-briefing, reviewed information to ensure what was reported was based solely on facts. It is the IO’s opinion that the final report reflected only fact-based findings and recommendations that can be supported by the evidence gathered.

Integrity and professionalism of the Board of Investigation process

Assessing that interviews, verbal and written interactions/communications with involved parties and stakeholders, are carried out in a respectful and timely manner

A significant amount of evidence in the form of videos, reports and policies was reviewed in advance of the interviews and a structured plan put into place.

The bulk of the interviews were conducted in a 23-day span between May 14, 2024, and June 6, 2024. Findings and recommendations were then discussed and produced, in draft form, followed by briefings with managers and stakeholders.

To ensure all relevant evidence was assessed, in the IO’s opinion, the BOI timelines were appropriate. All electronic and verbal communications presented as professional, and timely.

I am not aware of any breaches in confidentiality, and the communications were forthright and transparent.

I noted that during the interviews the BOI was consistently flexible in scheduling to meet the needs of the interviewees and from the BOI’s processes, investigative activities were conducted in a timely manner.

The IO noted that advance information packages were forwarded to all interviewees, inclusive of: an Introductory Statement referencing the reason for the investigation and why they have been identified as a witness; the importance of full cooperation in order to obtain a complete and accurate understanding of what happened and why, with the intent to try and prevent similar incidents in the future; the protections afforded under Article 13 of the Inquires Act and the Duty to Act Fairly; the management and storage of information under the Access to Information and Privacy Acts; the option for interviews to be conducted under the language of choice under the Official Language Act; and the opportunity of having a support person including Union representation. This information was further reinforced directly at the start of every interview.

Additionally, interviewees were encouraged to provide suggestions or recommendations at the conclusion of their interviews further reinforcing that the intent of the investigation is to prevent similar situations or occurrences in the future.

These actions presented as helpful to interviewees in order for them to better understand the process and they appeared to help put the majority of the interviewees at ease and reduce any potential concerns the interviewees may have.

One local manager interviewed had expressed concerns to the BOI in relation to a request for a second interview. The follow up interview was requested to obtain clarity on related information that the BOI obtained after the initial interview. The BOI Chair listened to the interviewee’s concerns and effectively explained the importance of a thorough investigation and why there was a need for a second interview. It is the IO’s opinion this was done in a respectful and professional manner.

The IO also noted that the BOI Chair, during interviews, monitored interviewees’ emotional responses and re-emphasized the importance of identifying a support person and/or seeking assistance to help cope with any stress the incident may have caused them.

It is the IO’s observation and opinion that interviews and written communications were conducted both in a respectful and timely manner.

Ensure that all BOI members follow the Values and Ethics Code for the Public Sector

The Values and Ethics Code for the Public Sector came into force on April 2, 2012. It was developed in consultation with public servants, public sector organizations and bargaining agents. The Code outlines the values and expected behaviours that guide Canadian public servants in all activities related to their professional duties. It is intended to follow these values and adhering to the expected behaviours, public servants strengthen the ethical culture of the public sector and contribute to public confidence in the integrity of all the public institutions.

During the course of the investigation, the IO did not detect any breaches of the Values and Ethics Code by the BOI members.

Key findings and recommendations

Key findings

• The IO found the investigation was consistent with the parameters set out in the March 6, 2024, Terms of Reference and directions set out by the Convening Order and Commissioner’s Directive 041 – Incident Investigations (September 8, 2020)
• The IO found the observations, findings and recommendations produced by the BOI were supported by the evidence reviewed in the investigation including documents and the recollection and perceptions of those interviewed
• The IO found that all interviews and verbal and written communications with stakeholders were conducted in a professional, respectful and timely matter
• The IO found that there was no prejudice or bias in the findings of the investigation and that the investigation was guided solely based on the evidence

Recommendations

No recommendations were identified.

Conclusion

The BOI in this matter was convened by the CSC under the authority of the Commissioner’s Convening Order. Boards of investigation can be convened when a preliminary review of an incident reveals questions as to whether the law, policies or the duty to act fairly were respected.

The BOI was comprised of three people, including an external community board member who, in addition to participating as an investigator, was also mandated to certify the integrity of the process. The other two members were CSC employees: one, a National Investigator, who served as the BOI Chair; and the other, a Correctional Manager. I was appointed to act as an Independent Observer to ensure the investigation was conducted in a “thorough, impartial and professional” manner.

The purpose of the BOI was to identify any areas of systematic concern that must be addressed, such as any potential gaps and or compliance with existing laws, policy and procedures, any potential training or communication gaps. Management follows up on the recommendations formulated by the BOI by analyzing and bringing any potential amendments and clarifications to policies and practices to reduce the likelihood of such incidents in the future. Boards of investigation are administrative investigations that allow for a thorough review of actions taken by CSC. They are not criminal or disciplinary investigations.

In conclusion, as the IO in this matter, I am satisfied that the investigation was conducted in a manner that was thorough, impartial and professional. I am satisfied that their report accurately reflects the findings based solely on the evidence heard and verified. I am also satisfied with their recommendations, based on the findings, that they reflect reasonable answers and solutions to issues identified during the investigative process.

References

• Commissioner’s Directive 041 – Incident Investigations (September 9, 2020)
• Corrections and Conditional Release Act, sections 19, 20, 21, 97, 98
• Values and Ethics Code for Public Service
• National BOI Convening Orders
• Independent Observer Mandate
• BOI Responsibility Letter

In addition to the foregoing, the IO had access to all documentation and recordings utilized by the BOI during the course of their investigation and in preparation for their final report.

Appendix A: Mandate

Independent Observer mandate

National Board of Investigation into the death of an inmate that occurred at Millhaven institution (maximum) on February 4, 2024

Background

On February 4, 2024, at approximately 1542 hours, a Social Programs Officer attended inmate Taran Morrison’s [redacted] cell in [redacted] Mr. Morrison did not respond to the officer; therefore, the Correctional Manager was alerted. A radio transmission for assistance and a call for Emergency Medical Services (EMS) were placed. Once the cell door was opened, it was noted that Mr. Morrison [redacted] and Mr. Morrison was placed onto the floor and cardiopulmonary resuscitation (CPR) was initiated. Paramedics arrived at approximately 1600 hours and assisted with the administration of CPR. At 1618 hours, paramedics directed life-saving measures to be stopped and the inmate was pronounced deceased.

In response to this incident, the Commissioner, Correctional Service of Canada (CSC), by virtue of Sections 19 and 20 of the Corrections and Conditional Release Act, has convened a national investigation, for which the terms of the investigation are described as per the attached Convening Order.

Stemming from a recommendation made by the Correctional Investigator of Canada and an Independent Review Committee into non-natural deaths in custody, as part of this investigation, CSC is also appointing an Independent Observer (IO) whose role and responsibilities are described as per the following Terms of Reference.

Terms of reference

1. The IO will assess whether the work of the Board of Investigation (BOI) is thorough, impartial and professional.
   1. Thorough will be understood as the adherence to the parameters set out in the Convening Order, as well as the consistent application of a rigorous established investigation process, as defined under Commissioner’s Directive 041, Incident Investigations, as well as the guidelines, norms, and standards as established by the Incident Investigations Branch
   2. Impartiality will be understood as an absence of prejudice or bias, actual or perceived, in the outcome of the investigation that will be guided solely by the evidence; and
   3. Professional will be understood as assessing that all interviews, verbal, and written interactions/communications with involved parties and stakeholders, are carried out in a respectful and timely manner
2. Throughout the course of all activities, the IO is expected to make observations and/or recommendations on any issues related to his or her mandate. The observations and recommendations may be made to the BOI, or in the event the observations and recommendations relate to the BOI or at the preference of the IO, to the CSC Senior Deputy Commissioner (SDC). This includes identifying potential concerns and proposing solutions for the resolution of such concerns.
3. The IO will provide a final report of their observations and conclusions by January 10, 2025, following the conclusion of the investigative process. The format of such report shall be determined by the IO and the report could be made public by CSC.
4. The IO will liaise with the chair of the BOI to obtain access to all the information and documents he or she deems necessary.
5. The IO will also liaise with the Director General, IIB, for assistance regarding any procedural or administrative matter related to the conduct of the investigation.
6. CSC shall provide the IO office supplies and material (for example, CSC laptop).
7. The IO shall maintain document security, including respecting the need-to-know principle, as dictated by the Government of Canada Security Policy.
8. The IO will respect the provisions of the Privacy Act as they relate to personal information.
9. The IO will inform the SDC of any media or government requests for engagement, as soon as possible.
10. The IO will be reimbursed for any necessary travel and disbursements in accordance with Government of Canada Policy.

In consideration of the foregoing and in accordance with the Terms of Reference set out above, I agree to act as the Independent Observer in this matter.

Assented to this 10th day of May at Ottawa, Ontario.

Original signed by: Michelle Maureen Duncan