COURT FILE NO.: CR-13-0070

DATE: 2019-01-28

ONTARIO

SUPERIOR COURT OF JUSTICE

B E T W E E N:

HER MAJESTY THE QUEEN

Mr. T. Jukes and Ms. J. A. McGill, for the Crown

Mr. B. Whitehead and Ms. H. Evans for the Ministry of Community Safety and Correctional Services

Respondent

• and -

ADAM MARK CAPAY

K. Symes and A. Weaver, for the Defendant

Applicant

HEARD: July 31 and August 1 and 2, 2017, February 21 and 22, March 12, 13, 14, 15, 16, 21, 22, 23, May 9 and 10, 2018 in Thunder Bay, Ontario

Mr. Justice J.S. Fregeau

REASONS ON APPLICATION

Table of Contents

Introduction. 4

Background of the Accused. 5

Summary of the Evidence. 6

Segregation History. 6

Thunder Bay Jail 7

The Kenora Jail 8

Day-to Day life of the Accused in Segregation. 9

Renu Mandhane Chief Commissioner Ontario Human Rights Commission. 12

The Institutional Witnesses. 18

Thunder Bay Jail 18

Michael Lundy. 18

Melissa Boban. 20

Deborah McKay. 23

The Northern Region. 26

Richard McDaniel 26

Douglas Houghton. 27

Chronology of the Accused’s Court Appearances. 31

Provincial Law and Policy. 34

International Instruments. 37

The Expert Witnesses. 39

Professor Michael Jackson. 39

Professor Stephen Toope. 44

Professor Kelly Hannah-Moffat 47

Dr. John Bradford. 52

The Positions of the Parties. 66

The Accused. 66

The Crown. 84

Analysis. 88

Remedy. 116

Introduction

[1] On June 3, 2012, Adam Capay (the “accused”), a sentenced inmate at the Thunder Bay Correctional Centre (the “TBCC”) scheduled for release in August 2012, was placed in segregation following an assault on fellow inmate, Sherman Quisses. The accused is alleged to have stabbed Mr. Quisses twice in the neck.

[2] Mr. Quisses died as a result of the injuries he sustained. The accused is charged with first degree murder in relation to the death of Mr. Quisses.

[3] On June 4, 2012, the accused was transferred from the TBCC to the Thunder Bay Jail and placed in administrative segregation. Administration segregation (hereinafter “segregation”) is defined by the Ministry of Community Safety and Correctional Services as the separation of an inmate from the general population where the continued presence of the inmate in the general population would pose a serious threat to the health or safety of any person, to property or to the security or orderly operation of the institution.

[4] From June 4, 2012, until December 6, 2016, a period of four years, six months, and two days (1,647 days), the accused was continuously held in segregation in a cell by himself.

[5] The accused has brought an application pursuant to s. 24(1) of the Canadian Charter of Rights and Freedoms (the “Charter”) seeking a stay of proceedings as a remedy for alleged violations of his rights under ss. 7, 9, 12, and 15 of the Charter.

[6] The Crown concedes that the circumstances of the accused being held continuously in segregation between June 4, 2012, and December 6, 2016, violated the accused’s ss. 7 (retrospective application only) and 12 Charter rights. The Crown submits that ss. 9 and 15 of the Charter have no application in this case.

[7] The Crown submits that a stay of proceedings is not the appropriate remedy to redress these Charter violations.

Background of the Accused

[8] The accused is a 25 year old Indigenous man and a registered status member of the Lac Seul First Nation (“LSFN”), a First Nation community approximately 400 kilometres from Thunder Bay and 250 kilometres from Kenora. He is the oldest of seven children born to Glenda Brisket and Ransome Capay.

[9] The accused’s maternal grandmother and paternal grandparents attended residential schools. All became alcoholics. The accused’s parents both suffered sexual abuse and domestic physical violence while growing up. Both had very serious alcohol dependency issues with the result that the accused was exposed to parental alcoholism, marital discord, domestic violence, sexually promiscuous behaviour, and substance abuse throughout his life.

[10] The accused also suffered a number of significant traumas while growing up, including repeated childhood sexual abuse and physical assaults. When the accused was ten years old, his father attempted to solicit his assistance in committing suicide. While intoxicated, the accused’s father cut him with a knife. The accused’s father then put a loaded firearm either in his own mouth or to his own head and asked the accused to pull the trigger. The accused reports that he continues to have nightmares and flashbacks in relation to this incident.

[11] The accused’s parents have now overcome their dependency issues, are gainfully employed, and are very supportive of their son.

[12] The accused first drank alcohol at 7 years of age. He began using marijuana and inhaling solvents at 8 years of age. At 13 years of age, he began to experiment with hard drugs and became involved in the criminal justice system.

[13] The accused has only a Grade 7 or 8 education. His formal education ended when he was incarcerated for assaulting a teacher and police officer. He has never been employed but for a two week period at age 18 when he worked construction. He was terminated for being intoxicated on the job.

[14] The accused’s involvement with the criminal justice system has always been precipitated by the excessive consumption of alcohol. The accused maintains that he became addicted to drugs, including morphine and heroin, while incarcerated.

Summary of the Evidence

[15] The institutional record for the period of time that the accused spent in segregation and the evidentiary record on this application are both voluminous. The following is a summary of the evidence necessary to address the issues raised in the application.

Segregation History

[16] Between June 4, 2012, and December 6, 2016, the accused was held in segregation for a total period of 1,647 days, primarily at the Thunder Bay Jail (1,505 days) with the exception of four periods of time totaling 142 days when he was temporarily transferred to the Kenora Jail. Both facilities are Ontario correctional facilities operated by the Ontario Ministry of Community Safety and Correctional Services (the “Ministry”).

[17] During his time in segregation, the accused was housed in one of five blocks at the Thunder Bay Jail (Blocks 1, 2, 10, 11, and 12) and one of two blocks at the Kenora Jail, the isolation block (Cells “M” and “O”) and the South Basement.

Thunder Bay Jail

[18] The accused spent 847 days in Block 1 of the Thunder Bay Jail. Block 1 consists of a range of seven cells with a bunk bed in each cell. The cells are separated from each other by solid walls. Each cell has bars on the front of the cell with Plexiglas over the bars. The cells are situated within a slightly larger locked area that is enclosed by bars, known as the day area. There is a shower and two telephones in Block 1. There is no television or radio, and the lights are kept on 24 hours a day. On occasions when the accused was let out of his cell into the day area, he was always alone.

[19] The accused spent 53 days in Block 2 of the Thunder Bay Jail. Block 2 is very similar to Block 1 except that there are two televisions in Block 2 and the lights are turned down at night. On occasions when the accused was let out of his cell into the day area, he was always alone.

[20] The accused spent 237 days in Block 10 of the Thunder Bay Jail. Block 10 is a single cell in the isolation area. It is adjacent to Block 11 with the cells separated by a solid wall. Block 10 is encased in Plexiglas with a solid metal door beyond the Plexiglas. There is no day area, shower, television, or radio in Block 10. The toilet cannot be flushed from inside the cell, and the lights are kept on 24 hours a day.

[21] The accused spent 274 days in Block 11. Block 11 is also part of the isolation area. Each cell in Block 11 is encased in Plexiglas with a solid metal door beyond the Plexiglas. There is no day area. There is a shower located in the area between the Plexiglas and the solid metal door. Correctional officers take the inmates out of their cells one at a time to shower or to search the inmates’ cells. There is no fixed telephone in Block 11. Inmates use a telephone that is brought into their cells on wheels. There is no television or radio in Block 11. Inmates cannot flush the toilets from inside the cells in Block 11. The inmate must ask a correctional officer to flush the toilet as required. The lights are kept on 24 hours a day.

[22] The accused spent 94 days in Block 12, which consists of three cells with a bunk bed in each cell. The cells are separated by solid walls. Each cell has bars on the front that are encased in Plexiglas. There is a day area, a shower, a telephone, and a television. The lights are turned down at night. On occasions when the accused was let out of his cell into the day area, he was always alone.

[23] There is a separate yard at the Thunder Bay jail for inmates who are in segregation. The segregation yard is an outdoor area surrounded on all sides by concrete walls. Within that area there is a “caged in” space covered by a solid roof. There is no recreational or exercise equipment in the segregation yard. On occasions when the accused was let out of his cell into the segregation yard, he was always alone.

[24] The Thunder Bay Jail also has a multi-purpose room in the basement that is used for programming. The accused was only provided access to the multi-purpose room for sessions with Dr. P. Schubert, psychiatrist.

The Kenora Jail

[25] While at the Kenora Jail, the accused was held in two different blocks: the isolation blocks (cells “M” and “O”) and the South Basement.

[26] The accused spent 73 days in cells M and O, two of the four isolation cells at the Kenora Jail. The cells are separated from each other by solid walls. Each cell has double doors: the cell door and a second door that leads to the corridor. There is a shower and telephone for cells M and O, and each segregation cell has its own radio, which can only be operated by a correctional officer. There is no day area or television, and the lights are dimmed at night.

[27] The accused spent 69 days in the South Basement of the Kenora Jail, a range with five cells. The cells are separated from each other by solid walls. Each cell has bars on the front that are not encased in Plexiglas. There is a day area, a shower, a telephone, and a television. The lights in the South Basement are dimmed at night. On occasions when the accused was let out of his cell into the day area, he was always alone.

[28] Inmates in segregation at the Kenora Jail use the same yard as all other inmates. There is no recreational or exercise equipment in the yard. On occasions when the accused was let out of his cell into the yard area, he was always alone.

Day-to Day life of the Accused in Segregation

[29] Inmates in MCSCS facilities are served three meals per day as well as coffee or tea and an evening snack. Inmates in segregation at both the Thunder Bay Jail and the Kenora Jail are served and consume all meals and snacks inside their cell unless the inmate is in an area with access to a day area. In that case, the inmate eats in the day area, but only if the timing of the meal coincides with the inmate’s daily time out of his cell.

[30] While in segregation at the Thunder Bay Jail and the Kenora Jail, the accused was subject to regular searches pursuant to policy. He was generally strip-searched and subject to a cell search on a daily basis.

[31] When the accused was placed in segregation in the period immediately following June 4, 2012, his Offender Rating Sheet instructed correctional officers not to talk to the accused. During later periods of his time in segregation, the accused had lengthier and more involved discussions with correctional officers and managers.

[32] The accused had access to reading material for much of his time in segregation. When at the Thunder Bay Jail, he was generally restricted to one item of reading material at a time with limited opportunities to obtain new reading material in exchange for one he had completed. When at the Kenora Jail, the accused was allowed more than one item of reading material at a time and was allowed to exchange those materials on request.

[33] Of the 1,647 days the accused spent in segregation between June 4, 2012, and December 6, 2016, he had yard access on 108 days and was offered and declined yard access on 72 days.

[34] The accused was allowed “time outs” in various day areas, typically of one hour duration, to use the shower, phone, table and/or desk, television, or radio where available. Of the 1,647 days the accused spent in segregation, he had 794 time outs in the day areas, not including occasions he was allowed into the day areas solely for showering or cleaning the day area. The accused was always alone during these periods of time.

[35] The chaplain at the Thunder Bay Jail can meet with inmates at various locations. During the 1,505 days the accused was in segregation at the Thunder Bay Jail, he met with the chaplain eight times, all of which occurred while the accused was in his cell or cell block. The accused had no contact with the chaplains at the Kenora Jail while in segregation there.

[36] From May 2012 until May 30, 2016, the Thunder Bay Jail employed a single social worker who was also responsible for covering the duties of the classification officer. On May 30, 2016, the Thunder Bay Jail hired a second social worker.

[37] Between June 4, 2012, and December 6, 2016, the accused had contact with a social worker or classification officer on 31 occasions, 24 of which were in 2016. Of the 24 meetings in 2016, 21 occurred during October, November, and December 2016. The accused had no contact with either a social worker or classification officer while in segregation at the Kenora Jail.

[38] The accused did not have any documented access to Indigenous programming or services at the Thunder Bay Jail or the Kenora Jail in 2012, 2013, 2014, or 2015. In 2016, the accused was visited by a Native Inmate Liason Officer (“NILO”) on 13 occasions and participated in one pipe ceremony. Eleven of the NILO visits and the pipe ceremony occurred after Ms. Renu Mandhane, the Chief Commissioner of the Ontario Human Rights Commission, visited the Thunder Bay Jail and met with the accused on October 7, 2016.

[39] When the accused was placed in segregation on June 4, 2012, he had a documented history of suicide attempts, self-harm, and mental illness for which he was prescribed and received medication.

[40] Between June 4, 2012, and December 6, 2016, Dr. Michael Stambrook, a psychologist, saw the accused on three occasions. These three occasions occurred in 2012 and 2013, all at the Kenora Jail. All three meetings took place while the accused was in his cell, and over the course of the three meetings, the accused spent a total of approximately 80 minutes with Dr. Stambrook.

[41] Between June 4, 2014, and December 6, 2016, Dr. Peter Schubert, a psychiatrist, saw the accused on 31 occasions, all at the Thunder Bay Jail in the multipurpose room. The accused was handcuffed throughout these meetings. During this period of time, the accused refused to see Dr. Schubert on four occasions. During the 1,505 days the accused was in segregation in the Thunder Bay Jail, he spent a total of approximately nine hours with Dr. Schubert.

[42] As of September 24, 2015, Ministry policy required that Inmate Care Plans be created. A Care Plan was first created for the accused on September 22, 2016. It was updated once, on October 27, 2016.

[43] Between April 12, 2015, and December 6, 2016, the accused engaged in various self-harming behaviour, including pushing a pencil through his right cheek and through his foreskin, slashing his forearm with a razor blade, and banging his head against his cell door repeatedly causing himself to bleed.

[44] Between June 4, 2012, and December 6, 2016, Ministry policy required correctional officials to conduct segregation reviews for the accused in relation to his initial placement in segregation followed by 24 hour reviews, 5 day reviews, 30 day reviews at the institutional level, 30 day reviews at the regional level, and 30 day summaries prepared by the Regional Director, which the Regional Director was then required to forward to the Minister’s office.

[45] In 2012, there were 3 reviews done at the institutional level, none of which went to the regional office. In 2013, there were 30 reviews done at the institutional level, 6 of which went to the regional office. In 2014, 24 reviews were done at the institutional level, 11 of which went to the regional office. In 2015, 93 reviews were done at the institutional level, 24 of which went to the regional office. In 2016, 117 reviews were done at the institutional level, 20 of which went to the regional office.

Renu Mandhane Chief Commissioner Ontario Human Rights Commission

[46] Ms. Mandhane was appointed as the Chief Commissioner of the Ontario Human Rights Commission (the “OHRC”) in October of 2015. In January 2016, the OHRC provided a formal submission to a provincial segregation review then being undertaken by the Ministry. In conjunction with the filing of its submission, the OHRC requested data from the Ministry on the use of segregation in correctional institutions in Ontario and embarked on tours of various institutions.

[47] In an email to Yasir Naqvi, then Minister of Community Safety and Correctional Services, in advance of a March 24, 2016, meeting about the provincial segregation review, Ms. Mandhane requested the following information for the previous three months:

1. The number of prisoners admitted into segregation in each of Ontario’s jails;

2. The rationale for admission; and

3. The duration of segregation.

[48] Ms. Mandhane met with Minister Naqvi on March 24, 2016. One of the two issues discussed was the provincial segregation review. Ms. Mandhane testified that the Minister had received the OHRC’s submissions, was very interested in discussing them, and was very supportive of the commission continuing to do work on the issue. However, the OHRC did not receive the data it had requested from the Ministry until August of 2016 and then only after several follow up requests.

[49] On September 14, 2016, in anticipation of her tour of the Thunder Bay and North Bay correctional institutions, Ms. Mandhane sent an email to Aly Vitunski, Chief of Staff to David Orazietti. Mr. Orazietti was the successor to Yasir Naqvi as Minister of Community Safety and Correctional Services. Ms. Mandhane specifically requested that NILOs and social workers accompany her on the tours and that she be able to speak directly with prisoners in segregation.

[50] Prior to her tour of the Thunder Bay Jail, which she had publicized on social media, Ms. Mandhane was contacted by Michael Lundy, a correctional officer at the Thunder Bay Jail and the OPSUE local president at the time. Mr. Lundy asked to meet with Ms. Mandhane before her tour. Ms. Mandhane agreed to do so.

[51] At the conclusion of her meeting with Mr. Lundy, which she described as “a pretty typical conversation with a union representative,” Ms. Mandhane indicated to Mr. Lundy that her jail tours to date had been “pretty sanitized.” She asked him if there was anything in particular she should look into. Mr. Lundy suggested that she ask to meet with Adam Capay, an inmate who has been “in solitary” for four and one half years.

[52] Ms. Mandhane recalled that she did not believe Mr. Lundy because the data she had received from the Ministry in August of 2016 suggested that the longest period of time that an inmate had been in segregation in Ontario as of then was 939 days, approximately two and one half years. She skeptically made a note and proceeded on her tour of the Thunder Bay Jail.

[53] Ms. Mandhane was accompanied on her tour by Christine Danylchenko, Assistant Deputy Minister, Institutional Services; Douglas Houghton, Deputy Director, Northern Regional Institutional Services; Alex Sherba, Social Worker; Cathy Sky, NILO; and OHRC personnel. Following the formal tour, Ms. Mandhane met with inmates selected by the NILO, none of whom appeared to have any relevant concerns. Mr. Capay was not one of the inmates selected to speak with Ms. Mandhane, nor had he been in the segregation unit she had been taken through.

[54] Ms. Mandhane testified that when she asked to speak with the accused she was met with silence and surprise. The social worker told her that the accused did not really like to talk to people. Ms. Mandhane persisted, and the social worker left and returned, indicating that the accused was prepared to speak with Ms. Mandhane.

[55] Ms. Mandhane was taken down a set of stairs into a windowless “kind of…day room area…range” with “a kind of quiet, very quiet sort of feel to it.” Ms. Mandhane had a very clear independent recollection of her meeting with the accused, describing it as “unlike anything I had experienced before.” The accused was in Block 1, cell 4.

[56] Ms. Mandhane recalls the accused speaking “in a distinctive way, a very slow, labored sort of, like … when you’re struggling to find words.” According to Ms. Mandhane, the accused apologized for his manner of speech, saying that he could not speak properly because he had not talked to a lot of people since he had been placed in segregation in June 2012.

[57] The accused was candid with Ms. Mandhane about his charge, discussed his transfers to and from the Kenora Jail, and further apologized about his inability to recall dates, indicating that days and nights blended into each other because the light in his cell was on all the time. Ms. Mandhane asked the accused how often he was seeing a psychiatrist and was told once every couple of months for very short periods of time.

[58] According to Ms. Mandhane, the accused told her he was not getting enough food, was unable to access his “canteen” while in segregation, and had been seriously self-harming. Ms. Mandhane testified that she recalled the meeting being a “surreal experience” after which she “was actually angry. I was pretty upset about the whole thing and sort of didn’t understand how, you know we’d been working on this segregation issue for like years and that it seemed so incongruous with our conversations with the Ministry.”

[59] Ms. Mandhane recalled telling the accused that she would do whatever she could to help him, which she described as “significant” because her role as Chief Commissioner is not to advance individual cases. However, she recalled feeling very strongly that she had to do something about it – “I couldn’t as a human being, Chief Commissioner aside, that I couldn’t sort of abide by the state’s treatment of somebody like that.” Ms. Mandhane was visibly upset at this point in her testimony.

[60] Upon rejoining the tour group, Ms. Mandhane, in what she described as a “tone of anger,” expressed confusion, telling the group that Mr. Capay had just told her that he had been in solitary for four and one half years. She testified that “the man who was on the tour,” who I infer to have been Douglas Houghton, Deputy Director, Northern Region Institutional Services, replied “without skipping a beat” that that time estimate “sounds about right.”

[61] The group proceeded to a meeting room at which time Ms. Mandhane spoke directly to Ms. Danylchenko, asking her how this could have happened and whether she and the Minister had been signing off on reviews and continued segregation for the accused. Ms. Mandhane testified that Ms. Danylchenko would not answer her questions, but said that she would “try to figure that out.”

[62] Upon her return to Toronto, Ms. Mandhane immediately contacted Mr. Naqvi, now Attorney General, who put her in contact with Minister Orazietti. Ms. Mandhane outlined the OHRC’s concerns regarding the accused. She reiterated these concerns in a letter to the Minister on October 14, 2016.

[63] Ms. Mandhane explained that one of the reasons she sent the letter was because she had lingering concerns that her understanding of the duration and nature of the accused’s confinement may not have been entirely accurate. She wanted to provide the Ministry with an opportunity to correct any inaccuracies.

[64] In Ms. Mandhane’s October 14, 2016, letter to Minister Orazietti, she detailed her understanding of the conditions of the accused’s confinement, including:

• That he had been held on remand in continuous segregation since June 2012

• That he was housed in what appears to be the basement of the 90 year old jail, confined to his cell for at least 23 hours per day, with limited or no human contact

• That the lights in the cell are on 24 hours per day, 7 days a week

• That Plexiglas sheeting covers the entire perimeter of the windowless cell, with no fresh air circulation and irregular access to the yard and use of the shower

• That the accused was not being provided with regular or meaningful mental health treatment or any services responsive to his Indigenous status

[65] Ms. Mandhane further advised the Minister that many aspects of the accused’s treatment raised serious Human Rights Code issues and may constitute cruel and inhumane treatment contrary to the Charter. She further suggested that the circumstances of the accused demonstrated the inadequacy of the MCSCS’ internal segregation review processes and accountability mechanisms.

[66] Ms. Mandhane spoke with Deputy Minister Matt Torigan a few days after the letter was sent. According to Ms. Mandhane, the only inaccuracy in her letter noted by the Deputy Minister was that the accused was not being held in a basement, but a windowless area of the jail that is accessed by descending a staircase.

[67] When it became clear to Ms. Mandhane that the Ministry was not prepared to “do anything particularly substantive about the treatment” of the accused, after having been given "ample opportunity and advance warning,” the OHRC decided to make the conditions of the accused’s confinement public.

[68] On October 18, 2016, the OHRC publicly released their supplementary submission to the MCSCS’s Provincial Segregation Review. Within this submission, the OHRC commented on their October 7, 2016, tour of the Thunder Bay Jail and Ms. Mandhane’s meeting with “a prisoner who seems to have been held in continuous segregation for four years.” The OHRC did not release the accused’s identity.

The Institutional Witnesses

Thunder Bay Jail

Michael Lundy

[69] Mr. Lundy was a Correctional Officer at the Thunder Bay Jail from 2004 until September 2016. Mr. Lundy testified that he requested a meeting with Ms. Mandhane prior to her October 7, 2016, tour of the Thunder Bay Jail because of concerns about the segregation practices at the Thunder Bay Jail in general and in regard to the accused in particular.

[70] Mr. Lundy explained that Ontario Correctional Officers are trained at the Ontario Correctional Services College. His initial training consisted of a six week course, currently extended to an eight week course for new recruits. Within this six week course, Mr. Lundy received six hours of instruction on how to address the needs of Indigenous inmates and inmates with mental health issues, one three hour period for each. It was the opinion of Mr. Lundy that he and other correctional officers had not received sufficient training to deal with mentally ill inmates.

[71] Mr. Lundy testified that he had never seen an Inmate Care Plan for any inmate at any time during his employment at the Thunder Bay Jail.

[72] Commenting on the segregation units at the Thunder Bay Jail, Mr. Lundy testified that a correctional officer located at his post covering Blocks 10, 11, and 12 at the Thunder Bay Jail would not be able to hear inmates yelling at them from cells inside those blocks. He said that it was possible that inmates banging on the Plexiglas would be heard by the correctional officers. If not, the inmates would have to wait for an officer to make his rounds and then attempt to get his attention. According to Mr. Lundy, the Plexiglas inhibits an officer’s ability to both observe and communicate with inmates.

[73] When asked how he would respond to an unresponsive inmate in these blocks, Mr. Lundy indicated that he would first yell to get the inmate’s attention, call for an assisting officer, and enter the day area only when the assisting officer arrives.

[74] Mr. Lundy identified the Offender Rating Sheet for the accused with entries beginning June 4, 2012. This document indicated that the accused was transferred to the Thunder Bay Jail from the “TBCC” on June 4, 2012. At the top of the document is a handwritten entry stating,

“DO NOT ENTER INTO DISCUSSIONS WITH THIS OFFENDER.”

[75] Mr. Lundy recognized this entry to be the writing of Robert MacKenzie, a former sergeant at the Thunder Bay Jail. Mr. Lundy testified that he interpreted this entry as an order to correctional officers.

[76] Mr. Lundy testified that when the psychiatrist attends the Thunder Bay Jail to meet with inmates he does so in the multipurpose room with a correctional officer stationed outside the room. The Offender Rating Sheet is provided to the psychiatrist for the purpose of the meeting.

[77] According to Mr. Lundy, if the jail records indicate that an inmate “refused to see psychiatrist,” the inmate indicated that he did not want to attend the multipurpose room to visit with the psychiatrist. Mr. Lundy testified that he had seen the psychiatrist attend the cell of an inmate who refused to see him but that it was not a frequent occurrence.

[78] Mr. Lundy was present when Mr. Naqvi, then Minister of Community Safety and Correctional Services, toured the Thunder Bay Jail on January 13, 2016. He observed Mr. Naqvi interact with the accused during this tour. Mr. Lundy explained to Mr. Naqvi why the accused was segregated and advised him that he had been segregated for three and one half years at that point in time.

Melissa Boban

[79] Ms. Boban has been employed at the Thunder Bay Jail since 1999. She has been the Health Care Manager since 2002.

[80] Counsel referred Ms. Boban to a “Psychology Note” of Dr. M. Stambrook dated August 20, 2012. In this two page, comprehensive record of Dr. Stambrook’s meeting with the accused at the Kenora Jail on that date the psychologist concluded that the accused “will require a detailed forensic assessment. I have spoken to Sara Dias (a CAMH worker in Kenora) who has seen him on this.” This note was copied to the Kenora Jail Nursing/Medical Unit and Mr. S. Walker, Superintendent, Kenora Jail.

[81] Ms. Boban agreed that an inmate’s medical file follows him when he is transferred to another institution and that the accused’s health care records from Kenora would have gone to the Thunder Bay Jail. She did not recall seeing this particular note in regard to the accused.

[82] Ms. Boban testified that, while an inmate’s health care file is confidential, she has access to these files and shares relevant information with other institutional employees as required. One such instance of this is when Ms. Boban prepares health care administrative summaries for the purpose of segregation reviews.

[83] Ms. Boban confirmed that the Administrative Summaries which she provided for the segregation review process go to the Superintendent or his designate who determines the issue of ongoing placement in segregation. She agreed that the purpose of her summary is to provide accurate and current information from an inmate’s health care file to assist the superintendent in making that determination.

[84] Ms. Boban also acknowledged being aware that her Administrative Summaries form part of the package of information provided to the regional office for segregation reviews at the regional level.

[85] Ms. Boban agreed that an administrative summary for the purpose of a segregation review should ideally include the most current information on an inmate and the information most relevant to the issue of segregation. She also agreed that she would have reviewed Dr. Schubert’s notes from his meetings with Mr. Capay in order to prepare her administrative summaries.

[86] Counsel referred Ms. Boban to Dr. Schubert’s note of October 16, 2013, which reads in part, “Content no (suicidal ideation and homicidal ideation) as before. + Sadistic fantasies as above and as noted previously.” Counsel also referred her to Dr. Schubert’s note of December 11, 2013, which states, “mood restless, agitated sometimes ok. Affect normal, appears calm. Thought process normal content normal no (suicide ideation) no (homicidal ideation) no psychosis – history chronic (homicidal ideation)/fantasies however.”

[87] Ms. Boban agreed that Dr. Schubert was noting a history of chronic homicidal ideation or fantasies, not a current observation.

[88] Ms. Boban also acknowledged the following notes of Dr. Schubert in regard to the accused:

1. February 7, 2014 - “not suicidal or homicidal at this point”

2. April 4, 2014 – “he denies any (suicidal ideations/homicidal ideations or fantasies of violence/sexual nature of late”

3. May 27, 2014 – “Content. No (suicidal ideations) no (homicidal ideations) no psychosis”

4. July 23, 2014 – “low risk suicide/homicide at this time. Is segregated in Block 1”

5. September 5, 2014 – “denies any (homicidal ideations) today, not talking of any sadistic fantasies today”

6. October 28, 2014 – “normal content no (suicidal ideation) no (homicidal ideation) no talk of sadistic fantasies today. No violent fantasies reported.”

[89] Ms. Boban was next referred to her Administrative Summary dated December 17, 2014, which she prepared for the purpose of the accused’s December 22, 2014, 30 day segregation review. The document reads as follows:

Administrative Summary for Dec 2014

Adam Capay

DOB July 20/92

Otis# 1000849399

This Client remains in segregation.

He is currently awaiting court on charges for murdering another inmate at Thunder Bay Correctional Centre.

In July 2013 Dr. Schubert/Thunder Bay Jail Psychiatrist noted that client is a risk of harm to staff and inmates and there is a need for staff to be notified and procedures in place to protect others. This client has regular reviews and assessments with Psychiatrist. He is a low risk for suicide and very high risk for violence with sadistic paraphilia. He was last seen by Dr. Schubert on Oct 28^th 2014 and is for 8 week follow-up (end of December 2014)

[90] Ms. Boban agreed that she had failed to include in this Administrative Summary that Dr. Schubert had been noting, for in excess of one year, that the accused did not have suicide ideation, homicidal ideation, or sadistic or violent fantasies. She testified that “in looking back, I should have noted it or worded it differently.”

Deborah McKay

[91] Ms. McKay has been employed at the Thunder Bay Jail for 33 years. She was the Deputy of Operations from 2012 to 2014, Deputy of Administration from 2014 to 2016, and has been the acting Superintendent since February 2016.

[92] Ms. McKay explained the segregation review process in place at the Thunder Bay Jail in 2012. The Superintendent or designate conducts an initial review upon placing an inmate in segregation. The Superintendent or designate then conducts a segregation review at the institutional level every 5 days, repeated for each 5 day period of continued segregation. The Superintendent or designate also conducts a segregation review of an inmate who has been in segregation for 30 days, which is then repeated for each 30 day period of continued segregation. The institutional office then has to submit each 30 day review to the regional office.

[93] Ms. McKay did not recall there being any specific requirements in the segregation review process for mentally ill inmates in 2012 and years following.

[94] Ms. McKay identified the Segregation Decision/Review form used in 2012 and years following. This form includes sections to be completed upon an inmate’s initial placement into segregation, upon the 5 day review, upon 30 days at the institutional level, and upon 30 days at the regional level.

[95] The Regional Director Review section requires the Regional Director or designate to either “support” or “not support” continued segregation by checking a box and to provide comments. Ms. McKay testified that, in her experience, continued segregation has always been supported at the regional level. She was unable to recall whether there had ever been any comments added at the regional review level, such as recommendations for enhanced privileges or a psychiatric assessment. She acknowledged that, on occasion, regional employees would call with an informal request for more information about a particular inmate.

[96] Ms. McKay testified that, in hindsight, this had not been an effective review and tracking system.

[97] In 2014, Ministry policy in regard to the segregation review process changed such that more information was to be included for segregation reviews. Additional information concerned whether an inmate had a known or suspected mental illness, whether there was a treatment plan in place, and when the inmate had last seen a doctor or psychiatrist. The frequency of reviews and the forms used did not change at that time.

[98] The Segregation Decision/Review Form was amended in October 2015. It now includes sections to be completed upon initial placement in segregation, a 24 Hour Preliminary Review to be completed within 24 hours of the inmate being placed in segregation, a 5 Day Review section, a 30 Day Superintendent/Designate section, and a 30 Day Regional Director/Designate Review section. The amended form allows for a greater level of detail about inmates to be provided by those commenting. Ms. McKay reiterated that she could not recall an instance where the regional level refused to support a segregation review either before or after October 2015.

[99] Turning to the circumstances of the accused specifically, counsel referred Ms. McKay to an email dated February 21, 2013, which she sent to Mr. Daniel Smith, then Regional Director. She attached a Segregation Decision/Review for the accused. Ms. McKay explains in the email that this “may have slipped through the cracks” as the accused had been in segregation at the Thunder Bay Jail since August 2012. In fact, the accused had been in segregation continuously since June 4, 2012.

[100] Ms. McKay acknowledged that the reference to August 2012 is a reference to the date the accused was last transferred back to the Thunder Bay Jail from the Kenora Jail. This is an example of corrections “resetting” the segregation clock when an inmate in segregation is transferred between institutions. Ms. McKay acknowledged that this practice results in erroneous tracking of inmates’ time in segregation.

[101] Ms. McKay’s February 21, 2013, email to Mr. Smith confirms that the only segregation reviews conducted for the accused in 2012 occurred on August 29, September 3, and September 8, 2012. The reason stated for continued segregation was, “charged with the murder of an inmate while in custody at the TBCC.”

[102] The next documented segregation review is February 21, 2013. It was included on the form with the 2012 reviews sent to Mr. Smith. This review states that the “inmate advises psychiatrist that he has homicidal thoughts about other inmates. Remains segregated for protection of other inmates.”

[103] Mr. Smith replied to Ms. McKay the same day, asking whether the accused was receiving any regular mental health intervention. Ms. McKay replied that he was not because “he has refused any mental health intervention.” Mr. Smith thanked Ms. McKay, indicating that he was “just curious.” The accused had been in continuous segregation for approximately eight months at this point in time. Mr. Smith provided his approval of the continued segregation of the accused on February 27, 2013.

[104] Ms. McKay agreed that segregation reviews were sent to the region on a regular basis throughout 2013 with the accused’s disclosures to the psychiatrist being the rationale for his continued detention in segregation.

[105] The accused’s placement in segregation, and that of other segregated inmates, was the subject of a Correctional Services Oversight and Investigations (“CSOI”) Compliance Review dated December 21, 2015. The compliance review involved a random sample of 143 inmates who, in July 2015, were reported to have been in segregation for a continuous period of 30 days or longer. Ms. McKay testified that the result of this review was “positive.”

The Northern Region

Richard McDaniel

[106] Mr. McDaniel has been the Deputy Director, Northern Region Institutional Services, since March 2017. He has been employed in the Northern Region since 2012, performing what he described as “related, similar” duties, including participating in and tracking “segregation sign-offs.”

[107] Mr. McDaniel testified that he would not support continued segregation if the review documentation did not contain a plan for releasing an inmate from segregation. He also testified that it is not acceptable for an inmate to be held in indefinite segregation.

[108] According to Mr. McDaniel, he rarely failed to support continued segregation when conducting a regional review in which the superintendent had recommended continued segregation. Mr. McDaniel explained that:

A. Well for me to make that decision, I’m going to have to base that on something. So I would, it’s a very hypothetical thing for me, ‘cause I’m not going to, we’re a team, we’re not, like I have oversight onto them but we’re part of a team and they are doing good work and I rely on the social workers and everybody else that’s making these decisions to stay there. So why would I make a decision against that? So if that information’s not there, yes I would probably pick up the phone and say what’s going on here? But when you got social workers and psychiatrists and whoever else that’s indicated that this person is in segregation, whether they’re at their own will or because that’s the decision they’ve made, then I’m going to sign off on that. I don’t think it’s my decision to go against a social worker or a psychiatrist. I’ve reviewed it, I’ve seen the work was being done according to policy and I move forward with it.

Q. So in your experience, it’s never happened that the superintendent has recommended continued segregation and you’ve not supported that decision?

A. It may have happened. I may have picked up the phone and questioned but I don’t remember ever overriding the institution. I just, I don’t see it, no. I would work with them to try to get somebody out of segregation but to override and say you have to take that person out of segregation seems a bit heavy-handed for a person that’s sitting, could be 600 miles away or whatever. So I just go, I’m reviewing information, basing it on policy. I’m reviewing policy really and if that policy is meeting what the expectations are, you’re going to sign off on it. I think that’s our job.

Q. So do you know what the authority of part E is? If it’s, “if not supported” is checked and that’s sent back to the institution, what authority does that carry? Is that considered an order to the institution that the inmate be removed from segregation?

A. I suppose it could be.

Q. But that’s just in theory? Like in your practice do you….

A. I’ve never heard of it. I’ve never heard of that before. Like why would you do that? Why wouldn’t you work with the institution to find out what’s going on instead of trying to, me overriding a psychiatrist and social worker. I don’t think that’s my role to do that. I don’t think I’m authorized to do that. I can’t, a psychiatrist, if a psychiatrist is making a decision, I think I have to go with that decision.

Douglas Houghton

[109] Mr. Houghton began employment with the Ministry as a correctional officer in 1991. He was Deputy Director, Northern Region Institutional Services, from January 2015 to September 2017.

[110] Speaking generally, Mr. Houghton testified that he could not recall a single occasion where he failed to support the continued segregation of an inmate when conducting a segregation review.

[111] Mr. Houghton was also unable to recall ever having suggested alternatives to the accused’s continued segregation. He did recall discussing possibly transferring the accused from the Thunder Bay Jail to the Kenora Jail, “just to give him a break,” although the accused would remain in segregation there as well.

[112] Counsel referred Mr. Houghton to a 30 Day Regional Director Review for the accused, which Mr. Houghton signed on February 8, 2016. It notes the accused’s total days in segregation at 985. In the review, Mr. Houghton supported the accused’s continued segregation, commenting that, “the inmate poses a significant risk to himself, other inmates, staff members and the security of the institution.” Mr. Houghton acknowledged that there was nothing in place at the regional level to address the situations of inmates who had been in segregation for this length of time.

[113] Counsel next referred Mr. Houghton to a 30 day Regional Director Review for the accused, which Mr. Houghton signed on March 7, 2016. It notes the accused’s total days in segregation at 1,018. In response to the requirement on this review form that the Regional Director or his designate comment on any of the accused’s Human Rights Code needs, Mr. Houghton noted that “the inmate has mental health issues but does not require any type of accommodation.”

[114] The May 2, 2016, 30 Day Regional Director Review for the accused noted total days in segregation at that point in time to be 1,074 days. Mr. Houghton again supported the accused’s continued segregation on this review, and his comments regarding whether the accused had any Code related needs of the accused are identical to those on the previous review.

[115] Mr. Houghton was aware that the Thunder Bay Jail had a social worker, a NILO, and a psychiatrist available for inmates. He never suggested the accused have increased access to any of these services, nor did he inquire about the accused’s access to the yard, the canteen, educational materials, or time out of his cell.

[116] Mr. Houghton acknowledged being aware that the accused had been in continuous segregation for over 1,000 days at that point in time and that there was no plan in place to try to get him out of segregation. He agreed with the suggestion that he never recommended that the institution do anything different for the accused.

[117] In a March 21, 2016, email to Ms. McKay, Mr. Houghton sought detailed information about the accused’s circumstances in segregation. Mr. Houghton requested this information in order to provide it to the Assistant Deputy Minister’s office. In testimony, Mr. Houghton acknowledged that, in this email, he stated that the accused had been in segregation since June 2012. Counsel referred Mr. Houghton to a 30 Day Regional Director Review dated April 4, 2016. It notes the accused’s total days in segregation at 1,046. Mr. Houghton agreed that this was an obvious error that he did not notice at the time. Mr. Houghton supported the continued segregation of the accused on this review.

[118] Ms. McKay, in her March 22, 2016, reply to Mr. Houghton, attached an Administrative Summary and specifically stated that the accused has “a serious mental health condition diagnosed by a psychiatrist.” Mr. Houghton testified that this information was forwarded to Ms. Kinger, Regional Director, Northern Region, and from there to Ms. Vanessa Windgrove at the Assistant Deputy Minister’s office.

[119] On March 23, 2016, Ms. McKay further advised Mr. Houghton by email that the accused “has had minimal interactions with both the Chaplain and NILO.” Mr. Houghton forwarded this additional information to Ms. Windgrove the same day. Mr. Houghton did not receive a direct response from the Ministry.

[120] On October 7, 2016, immediately following Ms. Mandhane’s tour of the Thunder Bay Jail, Mr. Houghton again emailed Ms. McKay, stating: “ADM (Christina Danylchenko) and I were talking following the tour. Can you prepare a summary of i/m Capay? Include Care Plans, housing placements, info about his charges and court proceedings and anything else pertinent. Need it for Wed morning.”

[121] Mr. Houghton agreed that this information had never been previously requested by him when conducting regional reviews for the accused.

[122] On October 11, 2016, Ms. Danylchenko emailed Ms. Kinger asking for, among other things, “the summary regarding our management of the long-term inmate [the accused] in segregation that I will be using for my follow-up discussion with the Human Rights Commissioner this week.” Ms. Kinger forwarded this email to Ms. McKay who responded the next morning, attaching the relevant information. Mr. Houghton was copied on all emails.

[123] Mr. Houghton responded directly to Ms. McKay approximately 20 minutes later, requesting more information: “We need clinical information that supports this inmate having been in seg for over 1,100 days.” Mr. Houghton conceded that this email confirms that he had never before received or requested clinical information to support the accused having been in segregation for more than 1100 days.

[124] On October 13, 2016, Mr. Houghton emailed employees both at the Thunder Bay Jail and the Northern Regional office indicating that he had now confirmed that the accused “has been continuously segregated since his arrival at the TBJ on June 4, 2012. Which calculates to 1591 days. Please adjust the date … to reflect this correction.”

[125] Mr. Houghton agreed that the ongoing errors as to the accused’s total days in segregation resulted from “resetting” the segregation clock upon transfers between institutions, as referred to by Ms. McKay.

[126] Mr. Houghton was then referred to an email he sent to Ms. McKay dated October 20, 2016. In this email, Mr. Houghton suggested to Ms. McKay that they attempt to access additional mental health services for the accused. He concluded this email by stating, “The bottom line is we need to demonstrate we are trying to get him help.”

[127] Mr. Houghton agreed that he had never before, in the course of conducting 30 Day regional reviews for the accused over the span of four and one-half years, recommended that the accused have increased access to the psychiatrist who services the Thunder Bay Jail, let alone outside mental health care providers.

Chronology of the Accused’s Court Appearances

[128] The accused has not alleged a violation of his right to be tried within a reasonable time, as guaranteed by s. 11(b) of the Charter. However, the length of the accused’s pretrial custody is extraordinary and requires an explanation.

[129] Mr. S. George Joseph, an experienced and well respected Thunder Bay lawyer, represented the accused from June 4, 2012, until November 22, 2012. He first met with Mr. Capay on June 4, 2012. He received disclosure in regard to the first degree murder charge between September 23, 2012, and October 17, 2012.

[130] Prior to that time, the only information that Mr. Joseph received from the Crown was a one and a half page case file synopsis. Mr. Joseph was never informed that on August 20, 2012, Dr. Stambrook had recommended that the accused undergo a detailed forensic assessment.

[131] Mr. R. Amy, also an experienced and well respected criminal defence counsel from Winnipeg, Manitoba, represented the accused from the end of 2012 until August 23, 2016.

[132] The preliminary inquiry was completed on August 28, 2013. The Superior Court pretrial was conducted between November 22, 2013, and August 20, 2014. During the course of the pretrial, the case was scheduled for trial beginning September 22, 2014, approximately 27 months after the accused was charged with first degree murder. At the continuation of the pretrial on August 20, 2014, the trial was adjourned at the request of the accused to allow the accused to bring a Kokopenance application challenging the representativeness of the Thunder Bay jury panel.

[133] On October 30, 2014, a case management meeting was held. The Kokopenace application was scheduled to begin June 5, 2015, and the trial was scheduled to begin November 16, 2015. In due course, the Kokopenance application was dismissed and the November 16, 2015, trial date was confirmed.

[134] On November 16, 2015, at the start of jury selection, the accused requested and was granted an adjournment for the purpose of obtaining a psychiatric assessment. The record indicates that the “defence waived s. 11(b)” on this date.

[135] On February 22, 2016, the case was once again scheduled for trial beginning September 12, 2016. On August 23, 2016, the accused indicated to the court that he wanted to retain new counsel. Mr. Amy therefore brought an application to be removed as counsel of record, which was granted. The accused then requested an adjournment of his September 12, 2016, trial date, which was also granted.

[136] On October 25, 2016, at the request of recently retained counsel for the accused, the case was remanded to Assignment Court on November 28, 2016. On this date, defence counsel was advised that the March 2017 jury sittings were available for this trial to proceed. On November 28, 2016, this case was scheduled for trial beginning March 20, 2017, to be spoken to at Assignment Court on January 30, 2017.

[137] On November 29, 2016, an order was made for the accused to undergo an in-patient psychiatric assessment conducted by Dr. John Bradford at the Waypoint Centre for Mental Health Care in Penetanguishene, Ontario. On December 6, 2016, the accused was transferred from the Thunder Bay Jail to the Central North Correctional Centre in Penetanguishene and then on to Waypoint for the assessment.

[138] On January 16, 2017, the accused brought an application to have a case management judge assigned and indicated their intention to bring pretrial Charter applications on behalf of the accused. On January 30, 2017, I was appointed as case management judge and the March 20, 2017, trial date was vacated. The accused once again waived his s. 11(b) Charter rights.

[139] On February 22, 2017, the first case management conference was held. At this and subsequent case management conferences, hearing dates for this pretrial application were scheduled and re-scheduled throughout 2017 and early 2018.

[140] The hearing of this application was necessarily fragmented over this period of time as Crown, Ministry, and defence counsel worked diligently and cooperatively in assembling a very large volume of institutional records, organizing these records into a coherent and comprehensive evidentiary record, and then scheduling the necessary lay and expert witnesses. Final submissions were heard on May 8 and 9, 2018.

[141] Since December 6, 2016, the accused has remained in custody. A portion of this period of time was spent undergoing the assessment at Waypoint. Once the assessment was completed, the accused was transferred to the Algoma Treatment and Remand Center in Sault Ste. Marie.

[142] In April 2018, the accused was transferred to the St. Lawrence Valley Correctional and Treatment Centre in Brockville for treatment. As of October 5, 2018, the accused had completed all available programming offered at this facility. He was then transferred to the Kenora Jail, at his request, so that he could be closer to his family.

Provincial Law and Policy

[143] General, R.R.O. 1990, Reg. 778 (“Regulation 778”) under the Ministry of Correctional Services Act, R.S.O. 1990, c. M.22, governs the use of segregation in provincial correctional facilities. Section 34 of Regulation 778 provides as follows:

34. (1) The Superintendent may place an inmate in segregation if,

(a) in the opinion of the Superintendent, the inmate is in need of protection;

(b) in the opinion of the Superintendent, the inmate must be segregated to protect the security of the institution or the safety of other inmates;

(c) the inmate is alleged to have committed a misconduct of a serious nature; or

(d) the inmate requests to be placed in segregation.

(2) When an inmate is placed in segregation under clause (1)(c), the Superintendent shall conduct a preliminary review of the inmate’s case within twenty-four hours after the inmate has been placed in segregation and where the Superintendent is of the opinion that the continued segregation of the inmate is not warranted, the Superintendent shall release the inmate from segregation.

(3) The Superintendent shall review the circumstances of each inmate who is placed in segregation at least once in every five-day period to determine whether the continued segregation of the inmate is warranted.

(4) An inmate who is placed in segregation under this section retains, as far as practicable, the same benefits and privileges as if the inmate were not placed in segregation.

(5) Where an inmate is placed in segregation for a continuous period of thirty days, the Superintendent shall report to the Minister the reasons for the continued segregation of the inmate.

[144] Pursuant to s. 32(2)(1) of Regulation 778, disciplinary segregation pursuant to s. 34(1)(c), referred to as “close confinement,” is only available where the Superintendent has determined that the inmate has committed a misconduct of a “serious nature.” Sections 32(2)(1) and (2) provide that close confinement can be imposed for a definite or indefinite period, but in either case for no more than 30 days.

[145] In contrast to the case of disciplinary segregation, Regulation 778 does not set any limit on the duration of administrative segregation imposed pursuant to ss. 34(1)(a), (b), or (d).

[146] Segregation is also subject to Ministry policy, particularly the policy on Placement of Special Management Inmates (“PMSI”) found in the Institutional Services Policies and Procedures Manual. This policy was amended during the period of time the accused was held in segregation. The version initially in effect was dated March 2011 (the “March 2011 PMSI policy”). The amended version came into effect on September 24, 2015 (the “September 2015 PSMI policy”).

[147] Pursuant to the March 2011 PSMI policy, initial and continued placement in segregation was governed by the following procedure:

• When an inmate is placed in segregation, he or she will be advised by the superintendent or designate of the reasons, status, and duration of the segregation, of any changes in these conditions, and of the right to make a submission to the superintendent in writing or in person within five days of being segregated. A “Segregation Decision/Review” is prepared.

• Within five days of the inmate’s placement in segregation, the superintendent or designate reviews the full circumstances of the case, including any submission by the inmate, to determine whether the inmate’s continued segregation is warranted.

• The superintendent or designate must review the circumstances of each inmate in segregation at least once every five days to determine if continued segregation is warranted.

• When an inmate is in segregation for a continuous period of 30 days, the appropriate section of the “Segregation Decision/Review” is completed and submitted to the Regional Director within three business days of the inmate’s 30^th day in segregation. Before the report is completed, the inmate is provided an opportunity to make submissions either in writing or in an interview with the superintendent or designate. If the inmate makes a written submission, it is retained in the inmate’s file and a copy forwarded to the Regional Director with the “Segregation Decision/Review.”

• The Regional Director reviews the “Segregation Decision/Review” and discusses any concerns with the superintendent. A copy of the report, including the Regional Director’s comments, is retained in the Regional Office. The original form is returned as soon as possible to the superintendent for inclusion in the inmate’s file.

• At the end of each subsequent 30 days, the superintendent makes an entry on the original form in the designated space. Before the entry is made, the inmate must again be permitted to make a written or personal submission. The superintendent then forwards the form to the Regional Director for review. The Regional Director makes a corresponding entry in the designated space, retains a copy to replace the earlier one, and returns the original form for inclusion in the inmate’s file.

[148] In September 2015, the provisions of the PMSI policy governing the placement of special management inmates were substantially revised. The September 2015 PSMI policy included definitions and specific requirements for both inmate Care Plans and Treatment Plans. A Care Plan was defined as a “written document that guides a consistent approach for inter-professional tram members on how to meet care goals and support needs.” A Treatment Plan was defined as a “written document which outlines the medical strategies and treatment goals for a patient.”

[149] The September 2015 PSMI policy required that, when an inmate suffering from mental illness was placed in segregation, a physician or psychiatrist was required to assess the inmate’s mental health prior to each 5 day review to determine if changes were required to the inmate’s Treatment and/or Care Plan.

[150] With respect to the review of segregation, the September 2015 PSMI policy required that an inmate in segregation be given the opportunity to make submissions, in writing or in person, at each 5 and 30 day institutional review. Any submissions made were required to be considered at each 5 day review and to be attached to or summarized in the Segregation Decision/Review Form provided to the Regional Director.

International Instruments

[151] Canada has ratified or acceded to three international treaties that set out limits on the use of segregation and the standards for the conditions to which segregated inmates may be subjected.

[152] The United Nations General Assembly adopted the International Covenant on Civil and Political Rights 999 UNTS 171 (“ICCPR”) on December 16, 1966, which Canada acceded to on August 19, 1976.

[153] Article 7 of the ICCPR provides that “no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” Article 10 provides that “all persons deprived of their liberty shall be treated with humanity and with respect for the inherent dignity of the human person.”

[154] The United Nations General Assembly adopted the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment 1465 UNTS 85(“CAT”) on December 10, 1984, which Canada ratified on July 24, 1987. CAT prohibits torture and cruel, inhuman, or degrading treatment or punishment and imposes on each state party affirmative obligations to prevent such acts in any territory under its jurisdiction.

[155] Article 2 of CAT requires that each state party shall “take effective legislative, administrative, judicial or other measures to prevent acts of torture” and provides that “no exceptional circumstances whatsoever … may be invoked as a justification of torture.” Article 16 further provides that each State party shall “undertake to prevent in any territory under its jurisdiction other acts of cruel, inhuman or degrading treatment or punishment which do not amount to torture … when such acts are committed by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.”

[156] The United Nations General Assembly adopted The Convention on the Rights of Persons with Disabilities GA. Res. 61/106 (“CRPD”) on December 13, 2006, which Canada ratified on March 11, 2010. Article 14 of the CRPD provides that State parties should ensure that “the existence of a disability shall in no case justify a deprivation of liberty” and that persons with disabilities who are deprived of their liberty “shall be treated in compliance with the objectives and principles in the present Convention, including by provision of reasonable accommodation.”

[157] The General Assembly adopted the current standards of the United Nations Standard Minimum Rules for the Treatment of Prisoners, GA. Res 70/175, known as the “Mandela Rules,” on December 17, 2015. The Mandela Rules are designed to provide legal guidance to decision makers in relation to the treatment of prisoners. The Ontario Superior Court of Justice has held that the Mandela Rules “represent an international consensus of proper principles and practices in the management of prisons and the treatment of those confined”: Corporation of the Canadian Civil Liberties Association v. Her Majesty the Queen, 2017 ONSC 7491, 140 O.R. (3d) 342, at para. 61.

The Expert Witnesses

Professor Michael Jackson

[158] Professor Jackson was qualified as an expert witness in the following areas:

1. International correctional law, policy, and practice;

2. Historical and current Canadian correctional law, policy, and practice, with specific expertise in the use of segregation in Canadian prisons; and

3. Aboriginal peoples within the criminal justice and correctional system.

[159] Professor Jackson has taught at the University of British Columbia since 1970 and is currently a Professor Emeritus. As part of his ongoing research into the Canadian correctional systems, with a focus on the incarceration of Aboriginal offenders, Professor Jackson estimated that he has personally visited over 50 percent of the segregation units in the Canadian federal correctional system, with regular visits to segregation units in British Columbia. He has also toured segregation units at the Alberta and Edmonton Remand Centres and two remand centres in British Columbia for the purpose of preparing expert reports.

[160] Professor Jackson explained that historically there was no distinction in the treatment of Aboriginal inmates within the federal correctional system. Beginning in the 1980’s major developments began to take place, including the passing of the Corrections and Conditional Release Act, S.C. 1992, c. 20, (the “CCRA”), declared in force November 1, 1992, which is the most comprehensive reform of the federal correctional landscape in a century and partially inspired by the enactment of the Charter.

[161] Federal corrections legislation was amended to include specific provisions requiring federal correctional authorities to provide special programs responsive to the needs of Aboriginal people, to recognize Aboriginal spirituality, and to recognize the role of Elders in providing services within the federal correctional system. Concurrently, it became correctional best practice to explore and place an Aboriginal inmate’s personal criminal history into the larger context of their Aboriginal social history.

[162] According to Professor Jackson, the federal correctional system embraced the concept of utilizing a different approach to the administration of sentences for Aboriginal offenders before the Supreme Court of Canada interpreted the relevant remedial sentencing provisions of the Criminal Code, R.S.C., 1985, c. C-46 in R. v. Gladue, 1999 CanLII 679 (SCC), [1999] 1 S.C.R. 688. However, Professor Jackson noted that there has been considerable difficulty in the actual implementation of the relevant law and policy into federal correctional decision making.

[163] Professor Jackson was of the opinion that Gladue principles are particularly applicable in the context of segregation decisions involving Aboriginal inmates due to their over-representation in the prison system generally and in segregation in particular. Professor Jackson opined that the proper application of Gladue in the correctional system would:

1. Take into account and accommodate the rights, interests, and needs of Aboriginal offenders;

2. Provide the necessary contextualization and understanding of an Aboriginal inmate and the behaviour that has brought them into custody through a consideration of their unique systemic and background factors; and

3. Provide greater opportunities for rehabilitation and mitigation of risk and amelioration of the most damaging effects of imprisonment through the utilization of culturally appropriate procedures or sanctions that reflect the Aboriginal perspective.

[164] Professor Jackson suggested that the Aboriginal cultural relationship to the land and the deep connections between Aboriginal people and the natural world in general resulted in segregation being a more difficult experience for Aboriginal people.

[165] Turning to the circumstances of the accused, Professor Jackson was asked to consider whether the above, or in fact any, Gladue analysis was applied to the accused’s confinement in segregation in regard to the initial assessment process, segregation review decisions, access to Aboriginal programming and services, and mental health interventions.

[166] The Level of Service Inventory – Ontario Revision (“LSI-OR”) is a tool utilized in the provincial correctional system for risk assessment, prison placement, treatment, and recidivism prediction.

[167] The LSI-OR completed for the accused on April 20, 2012, prior to his placement in segregation, contained no information addressing his Aboriginal background.

[168] Professor Jackson explained that this document comprehensively listed the accused’s numerous risk and need factors, but failed entirely to contextualize these same factors into the accused’s Aboriginal background. On the LSI-OR, the accused’s social history, including substance abuse, family violence, sexual abuse, and community and family dysfunction, is not linked in any way to the cumulative and inter-generational impacts of colonialism and residential schools. According to Professor Jackson, under a Gladue analysis, contextualization of the accused’s systemic and background factors was a necessary requirement to identify any Aboriginal programming that may have been available to address his needs and mitigate risk in a culturally appropriate manner.

[169] Professor Jackson was of the opinion that this initial assessment of the accused “contains no Gladue analysis whatsoever.” According to Professor Jackson, the failure of the LSI-OR to recognize and contextualize Gladue factors in regard to the accused “is of great significance” because this assessment tool tracked the accused during his incarceration in the provincial correctional system and informed decision making throughout. In a Gladue context, this document did nothing more than state that the accused was a “19 year old native Canadian male recidivist from Lac Suel First Nation.”

[170] In regard to segregation review decisions, Professor Jackson explained that the federal correctional system requires that an inmate’s Aboriginal social history, mental health, and health care needs be taken into account in segregation reviews. Professor Jackson was unable to locate any provincial law or policy that mandates a Gladue analysis in segregation decisions for Aboriginal inmates.

[171] Professor Jackson read all of the accused’s segregation review documents in preparing his report. He testified that the initial June 4, 2012, segregation placement decision for the accused did not contain any consideration of his Aboriginal background. His reading of subsequent segregation review forms confirmed that they did not contain any consideration of the accused’s Aboriginal status or any Gladue analysis.

[172] Pursuant to his review of the segregation documentation in this case, Professor Jackson concluded that there simply was not any Gladue analysis attempted for the accused throughout his four and one half years in segregation. Professor Jackson opined that some understanding of the accused’s Aboriginal social history could have contextualized his anger and self-harming behaviour, part of the underlying rationale for his continued segregation.

[173] Professor Jackson suggested that, if this had been done, it logically should have been complimented by a consideration of whether there were any culturally appropriate measures - intensive interventions by the NILO or an Elder, participation in spiritual activities - that could have been utilized to mitigate the accused’s perceived risk in an attempt to move him out of segregation.

[174] Professor Jackson reviewed the institutional records from the Kenora Jail and the Thunder Bay Jail for the period June 4, 2012, to October 26, 2016. It was not until March 2016 that he found any reference to visits offered or occurring with the NILO or Elders, nor any participation in Aboriginal spiritual practices or programs. He also confirmed that no Care/Treatment Plan was in place for the accused until September 2016. The Health Care Administrative Summaries were found to be “typically…very brief and make no reference to Mr. Capay’s Aboriginal history.”

[175] Based on his review of the evidence, Professor Jackson was of the opinion that the accused did not have any meaningful access to the NILO until October 2016, nor was he offered any Aboriginal programming or cultural practices until that point in time. Professor Jackson suggested that the provision of “culturally appropriate supports” could have mitigated the accused’s perceived risk and contributed to his removal from segregation.

[176] Professor Jackson was also asked to consider whether correctional staff involved in the treatment of the accused contextualized his mental health treatment within a Gladue framework and whether they considered culturally appropriate interventions in their decision making and treatment of him. He concluded that no Gladue analysis had ever been conducted during the course of any mental health assessments that were performed on the accused.

[177] Professor Jackson emphasized that conducting a Gladue analysis for the accused would not have precluded the implementation of standard mental health treatments, suggesting that they could have complimented a culturally appropriate Care/Treatment Plan.

Professor Stephen Toope

[178] Professor Toope is a Professor of International Law and Vice-Chancellor at the University of Cambridge. Between 2015 and 2017, he was a Professor of Law and Director of the Munk School of Global Affairs at the University of Toronto. From 2006 to 2014, he was the President and Vice-Chancellor at the University of British Columbia.

[179] Professor Toope was qualified as an expert witness on international law and standards relating to the use of segregation in prisons. His testimony addressed this topic generally and its application to the facts of the accused’s confinement in segregation between June 2012 and December 2016.

[180] As referenced in paras. 152-155 of these reasons, two major international treaties govern the treatment of prisoners: the CAT and the ICCPR. Canada ratified the CAT on July 24, 1987, and acceded to the ICCPR on August 19, 1976, and is therefore legally bound to the terms of both, according to Professor Toope.

[181] In general terms, the CAT defines “torture” as the intentional infliction of severe pain or suffering, mental or physical, on a person for a specific purpose. Parties to the CAT are subject to affirmative obligations to prevent acts of torture. Parties to the CAT are also obligated to prevent acts of cruel, inhuman, or degrading treatment or punishment which do not amount to torture when such acts are committed by or with the consent or acquiescence of a public official. Articles 7 and 10 of the ICCPR collectively create an obligation to ensure that prisoners are protected against torture and cruel, inhuman, or degrading treatment or punishment.

[182] Professor Toope explained that the Mandela Rules provide detailed guidance on how to interpret and apply legal obligations established by international treaty obligations. The Mandela Rules were most recently revised in 2016. According to Professor Toope, they reflect an evolution in international law and practice concerning the treatment of prisoners and in particular reflect contemporary international norms concerning the use of segregation.

[183] The Mandela Rules include specific minimum requirements concerning conditions of confinement, including access to natural light and fresh air, access to clothing and bedding, minimum provision of health care services, contact with the outside world, and access to books and news. According to Professor Toope, “strong authority exists for the proposition that anyone suffering from mental illness should not be subjected to solitary confinement. At the very least, solitary confinement should not be resorted to if the prisoner’s mental illness might be exacerbated.”

[184] Professor Toope testified that segregation or solitary confinement is most commonly understood as the physical and social isolation of individuals for 22 hours or more a day. Prolonged segregation is typically defined as any period of solitary confinement in excess of 15 consecutive days. The Mandela Rules explicitly prohibit indefinite and prolonged segregation.

[185] Professor Toope noted that the Mandela Rules specifically contemplate situations where it is required that prisoners be subjected to segregation from the general prison population. However, they also make clear that minimum standards relating to “light, ventilation, temperature, sanitation, nutrition, drinking water, access to open air and physical exercise, personal hygiene, health care and adequate personal space, shall apply to all prisoners without exception.”

[186] Applying international law and standards to the accused’s continuous segregation from June 4, 2012, to December 6, 2016, Professor Toope concluded that this was “prolonged” segregation and “cruel, inhuman and degrading treatment, amounting to torture.” Further, the prolonged periods of confinement without access to natural light and being subject to artificial light for 24 hours a day also amounts to cruel, inhuman, and degrading treatment under international law.

[187] Professor Toope went on to consider the application of international law to other aspects of the accused’s time in segregation, including:

• Irregular access, less than one hour in duration per visit, to the segregation yard, an enclosed and roofed area without an outside view and with no equipment;

• No access to recreational or educational programming, newspapers, the internet, and extremely limited access to television and radio;

• No access to meaningful human contact weeks and months on end;

• Very little ability to connect with his family, either by way of in person visits or by telephone; and

• No access to regular and meaningful mental health treatment or advice for prolonged periods of his confinement.

[188] Professor Toope’s conclusion was that the length, indeterminacy, and conditions of the accused’s segregation constitute cruel, inhuman, and degrading treatment amounting to torture under international law.

[189] On cross examination, Professor Toope agreed that torture, pursuant to international law, requires the intentional infliction of severe pain or suffering, physical or mental, on a person for a specific purpose. He acknowledged that his conclusion that the treatment of the accused amounted to torture was arrived at by imputing the required intent due to multiple breaches of international standards over an extended period of time.

[190] On re-examination, Professor Toope testified that absent the imputation of the necessary intent, the conditions of the accused’s confinement “clearly breached the international obligation to prevent cruel and unusual treatment or punishment.”

Professor Kelly Hannah-Moffat

[191] Professor Hannah-Moffat is a Vice-President at the University of Toronto and a former director of the Centre of Criminology and Sociolegal Studies. She worked as a policy advisor on the Arbour Commission and testified as an expert witness for the Office of the Ontario Coroner in the Ashley Smith inquest.

[192] Professor Hannah-Moffat was qualified as an expert in regard to human rights, corrections and penal reform, risk assessment and classification within correctional institutions, and the use of segregation and alternatives for mentally ill inmates.

[193] In the course of her professional studies, Professor Hannah-Moffat has toured a wide range of correctional facilities and segregation cells in the United States, the United Kingdom, and Canada, including federal and provincial institutions.

[194] Speaking generally, Professor Hannah-Moffat explained that, over the last two decades, academic research, inquiries, and inquests have produced a vast body of literature that consistently documents the negative effects of segregation on inmates. According to Professor Hannah-Moffat, this literature establishes that segregation exacerbates prior mental health problems and can lead to the development of previously undetected mental health problems. Inmates with a history of trauma or violence or any form of sexual or physical abuse will often experience a re-traumatization in segregation as the isolation triggers emotions from the past, resulting in a wide range of reactions.

[195] Responding to a question about the relationship between the duration of segregation and the effects on inmates’ mental health, Professor Hannah-Moffat digressed and responded as follows:

It’s not particularly clear…this case [the accused] far exceeds…the definition of long term…it’s much more excessive than anything I’ve seen and it would be akin to some of the most egregious conditions that you’ve seen in…undeveloped countries or in the United States in some of their super max’s…it’s beyond the pale of anything I’ve ever seen…in terms of long term segregation, I don’t think I’ve seen anything this long and this, you know badly documented and managed context in my career and I’ve seen a lot of it in this country. Like this has got to be the worst case I’ve ever seen.

[196] Professor Hannah-Moffat was asked to comment on the physical condition and the configuration of the segregation cells in which the accused was confined between 2012 and 2016.

[197] For 2012 and 2013, the accused was held primarily in Blocks 10 and 11 at the Thunder Bay Jail. She described these cells as “quite antiquated by comparison to a lot of the conditions of confinement that I’ve seen. [T]he inability to flush your (toilet) is unusual and only typically done when somebody has been plugging a toilet or flooding an area or behaving in a particular way.”

[198] Asked to comment on a photograph of a cell in Block 11 at the Thunder Bay Jail, a block where the accused was segregated for 274 days, Professor Hannah-Moffat testified as follows: “I’ve not seen anything this bad in any of the international institutions that I’ve been or in any of the Canadian institutions. It’s actually, it’s filthy, it’s disgusting, it’s of ill repair, it’s dirty. [T]here’s a lot that could be done and like a good cleaning would be a good place to start.”

[199] Professor Hannah-Moffat was asked her opinion about the information provided and considered in the reviews of the accused’s continued placement in segregation. Generally speaking, she described it as inconsistent with an absence of a documented rationale or justification for the continuation of segregation and without any clear plan for how to end the accused’s segregation.

[200] In 2012, officials reviewed the accused’s segregation only three times (August 29 and September 3 and 8) with the reasons for continued segregation simply listed as “protective custody,” “institutional security,” or “charged with the murder of an inmate while in custody.” Professor Hannah-Moffat was uncertain what this actually meant or how this in and of itself justified continued segregation.

[201] Commenting on the 2013 reviews, Professor Hannah-Moffat testified that there should have been approximately 70 5 day reviews and 12 30 day reviews but that these were not evident in the file. She also found that the explanations for continued segregation often consisted of just a simple one or two line comment repeating the limited information listed at the previous review. She found that overall both the 5 and 30 day reviews did not occur in a regimented manner and contained very little information other than the reiteration of previous generic reasons for continued segregation.

[202] Professor Hannah-Moffat found similar issues with the 2014 reviews. She testified that the Health Care Administrative Summaries attached to the 2014 reviews noted mental health issues but did not provide any sort of a treatment plan. The professor found this completely inexcusable:

It’s clear to me that there’s demonstrated need in this area at this point in time. [W]e’re getting on to three years and again there’s inconsistent documentation and if somebody’s been in that long you’d think you’d have an accumulated amount of information. You’d try things. You would see alternatives. You would see evidence of alternatives.

[203] Professor Hannah-Moffat testified that there was no change in the quality of the 2015 segregation reviews:

It just seems to … get a little bit more egregious and shocking as you’re reading through it because you still keep expecting to see a discussion of alternatives and you keep expecting to see an escalation of this, beyond the institution to a higher level where someone’s talking about … mitigating the circumstances of segregation, making sure that there are educational opportunities, Elders, psychiatric staff … and you don’t see any evidence of that.

[204] For 2016, Professor Hannah-Moffat concluded that the accused’s continued placement in segregation was reviewed regularly at 5-day and 30-day intervals and within 24 hours when transferred between institutions. However, once again, few changes appear in the information provided in these reviews.

[205] In the opinion of Professor Hannah-Moffat, the reviews of the accused’s continued placement in segregation failed to provide “any meaningful oversight.” Demonstrably exasperated when testifying at this point, she once again commented on the conditions of the accused’s confinement in segregation:

They’ve got to be the worst that I have seen in 25 years of going in institutions and recently being in L.A. County Jail, I’ve seen units of individuals who are seen as the most difficult to manage in congregated spaces with therapy programs being led with a lot of security around so there are alternatives. [A]s far as I’m concerned, this does get to the level of torture, definitely cruel and unusual, completely unacceptable when you’re talking about pretrial custody and by all standards inhumane and I don’t know of any western democracy or in many of the countries in Europe and even South American institutions and some places that are more developed that would tolerate this for … protracted periods of time.

[206] Professor Hannah-Moffat outlined some relatively simple measures that can be taken to alleviate the negative effects of segregation, from both a procedural perspective and in terms of the physical design and condition of segregation cells.

[207] Procedurally, mandated reviews should be completed in a timely and consistent manner and audited at the institutional level and outside the institution. She explained that meaningful review outside the institution is important because officials inside an institution “can get caught up in group think when you have somebody in a particular circumstance for a long time.” In her opinion, another level of review and another level of thinking about a particular case is necessary.

[208] Professor Hannah-Moffat further explained that the design and condition of segregation cells can also reduce the negative effects of segregation. Access to daylight or the ability to see a clock to provide an inmate with some concept of the time of day, reading material, radios, television, reasonable ventilation, and the ability to turn cell lights on and off were cited as examples of simple measures that can be taken to provide segregated inmates a small measure of autonomy, dignity, and self-respect in order to reduce the disorienting effects of solitary confinement.

[209] Professor Hannah-Moffat was of the opinion that the segregation cells in which the accused was confined did not have any of the mitigating features she described. She referred to them as “quite antiquated by comparison to a lot of the conditions of confinement that I’ve seen…they’re not anywhere near the level that you would be thinking about as mitigating.”

Dr. John Bradford

[210] Dr. Bradford is currently a Professor Emeritus at the University of Ottawa, a Professor at McMaster University, and a forensic psychiatrist at St. Joseph’s Healthcare in Hamilton.

[211] Dr. Bradford has testified extensively as an expert in forensic psychiatry, including approximately 100 times in dangerous offender applications and approximately 200 times in criminal responsibility hearings. He has testified in notorious cases involving extreme sexual violence against adult females, adult males, or a combination of the two.

[212] Dr. Bradford was qualified as an expert and allowed to provide opinion evidence in forensic psychiatry and the psychiatric effects of institutional segregation.

[213] On December 8, 2016, the accused was admitted to Waypoint Centre for Mental Health Care in Penetanguishene, Ontario, for a court-ordered psychiatric assessment to be conducted by Dr. Bradford. The purpose of the assessment was two-fold: first, to evaluate the mental state of the accused at the time of the alleged offence under s. 16 of the Criminal Code; and second, to evaluate the effects of the accused’s prolonged subjection to segregation.

[214] The second prong of the assessment was to be the subject of a separate report dealing exclusively with the effects of segregation, which was to be provided to the court, the Crown, and defense counsel for the purposes of this application. As will be seen, Dr. Bradford found it impossible to neatly separate these two issues.

[215] Dr. Bradford reviewed a very large volume of documents in the preparation of his report, including the accused’s institutional health care records, psychiatric and psychological notes, his criminal record, education records, and a Gladue report. He personally met with the Gladue writer on a number of occasions, and sat in with the Gladue writer on at least one occasion when she was interviewing the accused.

[216] Dr. Bradford summarized the content of the accused’s institutional health care records for the six month period prior to June 3, 2012. He noted repeated references to self-harming and suicidal behaviour, suggesting to him the possibility of the accused having suffered from a mood disorder, possibly depression and/or posttraumatic stress disorder at that time.

[217] Dr. Bradford reviewed the conditions of the accused’s confinement at the Thunder Bay Jail during the eight week period between June 4, 2012, when the accused was placed in segregation, and July 31, 2012, when he was first transferred to the Kenora Jail. He also reviewed the conditions of the accused’s confinement at the Kenora Jail between July 31, 2012, and August 20, 2012, when the accused was first seen by Dr. Michael Stambrook, a psychologist at the Kenora Jail.

[218] Dr. Bradford described the accused’s confinement over this 12 week period as follows:

Essentially it’s … almost total isolation. Very little social contact or communication and we know from studies that this can have a profound effect on a person. We also know that for every day in isolation it’s cumulative. [T]he effects become worse day by day, so over this period of eight weeks you’ve got in my opinion an accumulating problem of social isolation and the effects on this individual.

[219] Dr. Bradford explained, in general terms, that as a result of this degree of social isolation:

People become anxious, depressed or both. They undergo cognitive disturbances. [T]hey [have] difficulties with memory and [time] orientation. [Y]ou can’t tell day or night. [T]hey lose track of time. They’re not sure whether they’ve been in this total isolation for a day, a week or weeks. So the cognitive effects can be quite profound. [Y]ou get various perceptional disturbances. [Q]uite often they are visual hallucinations. [I]t can be auditory hallucinations.

[220] Dr. Bradford summarized a substantial body of research literature documenting the effects of segregation on inmates’ physical and psychological health. He explained that it has consistently been shown that the mental and physical health effects of segregation are significant and profound. Pre-existing mental disorders are aggravated. It can cause what he referred to as “segregation psychosis” or “jail psychosis” in inmates who have not been psychotic before.

[221] Dr. Bradford explained that segregation is also associated with elevated incidences of self-harming behaviour and increased risk of suicidal behaviour. The negative effects of segregation can be enhanced for individuals with personality disorders and/or attention deficit, hyperactivity disorders. Because social isolation is very stressful, individuals who have experienced previous trauma, such as being the victim of childhood sexual abuse or who suffer from PTSD, experience a compounding effect when placed in segregation.

[222] Dr. Bradford explained that the extent of psychological damage suffered by inmates in segregation depends on a number of factors, including the physical conditions, the duration of the segregation, and uncertainty as to the duration of segregation. In the case of the accused and his initial 12 week period of “just about total isolation,” Dr. Bradford testified that “the effects would have been profound.” Further, indefinite or indeterminate segregation, as experienced by the accused, is generally accepted to be more harmful than segregation with an identified endpoint.

[223] Moving on to the circumstances of the accused, Dr. Bradford was referred to Dr. Stambrook’s notes from his meeting with the accused on August 20, 2012. This was the accused’s first interview with a mental health professional following his placement in segregation and 12 weeks of almost total isolation.

[224] Dr. Bradford noted that Dr. Stambrook had previously seen the accused as a teenager and summarized his history as including a major depressive disorder, poly substance abuse, and possible borderline traits. Dr. Bradford reviewed Dr. Stambrook’s report of the accused’s two year history of homicidal ideation, his thoughts of harming correctional officers, and his incongruous affect – smiling while talking about violent topics. Dr. Bradford described this as “a classic hallmark of psychosis.” Dr. Bradford further noted Dr. Stambrook’s opinion that the accused required a “detailed forensic assessment.”

[225] Dr. Bradford emphasized that it was essential, when assessing the effects of segregation on the accused, to bear in mind that he already carried a very heavy trauma load when placed in segregation in June 2012. Significant traumatic events in his past included the incident where his father attempted to have the accused (at age ten) pull the trigger of a loaded gun, the barrel of which the accused’s father had put in his own mouth or to his own head, and very serious childhood sexual abuse, the latter being so emotionally charged that the accused could not discuss it with Dr. Bradford.

[226] In Dr. Bradford’s opinion, segregation, particularly the initial 12 week period of almost total isolation, was a further trauma that compounded the earlier traumas and caused the accused to relive them. Dr. Bradford believed that the accused likely had PTSD when placed in segregation. Dr. Bradford had no doubt that the accused had severe PTSD when he assessed him, either pre-existing and exacerbated by his time in segregation or triggered by it.

[227] During the assessment, the accused was tested for Fetal Alcohol Spectrum Disorder (FASD) and Attention Deficit Hyperactivity Disorder (ADHD). He exhibited manifestations of ADHD, but did not show the typical cognitive presentation of FASD. Testing also indicated the accused suffered from antisocial personality disorder. These results, together with the accused’s history of trauma prior to placement in segregation, led Dr. Bradford to conclude that the accused “likely experienced more severe effects of segregation than many other inmates would have.”

[228] Dr. Bradford found that the accused suffered from cognitive impairments, including memory impairment and placing events in temporal sequence, which he felt were “most likely a result of segregation.” The accused had also experienced auditory and visual hallucinations, the former being most significant during the early period of more intense isolation.

[229] Dr. Bradford noted the reports of the accused experiencing sadistic, violent, and paraphilic fantasies while in segregation, first disclosed to Dr. Stambrook on August 20, 2012, at which point in time the accused had been in near total isolation for about 12 weeks. These fantasies, including fantasies of pedophilia, necrophilia, and violence to guards, continued to be reported until October 2013.

[230] Dr. Bradford explained that the period in which these fantasies were reported coincides with the period in which the accused experienced the most profound and at times near total isolation and absence of mental stimulation. After the fall of 2013, the accused was generally housed in cells with a day area and provided with daily time out of his cell and some limited interaction with other inmates.

[231] Dr. Bradford testified that in his opinion, based on this history, there is a strong possibility that the accused was delusional between August 2012 and the fall of 2013 consistent with the documented effects of severe forms of isolation. In his report, Dr. Bradford indicates that, if he is correct in this assessment, “then the violent and sadistic fantasies that appear to have been a significant part of the rationale for continuing Mr. Capay’s detention in segregation were in fact, at least in part, effects of that segregation.”

[232] Dr. Bradford acknowledged that neither Dr. Stambrook nor Dr. Schubert diagnosed the accused as suffering from psychosis. However, Dr. Bradford noted that the accused was prescribed an antipsychotic – Seroquel – in November 2013 and, after the Seroquel was discontinued, another antipsychotic – Risperodone – in April 2014. Dr. Bradford observed that the accused’s treatment with antipsychotics was also closely associated in time with him ceasing to endorse violent and sadistic fantasies, which in his opinion, lends additional support to the view that these fantasies were delusional.

[233] Dr. Bradford further opined that the accused was “likely experiencing multiple disturbed thought processes while in segregation.” Dr. Bradford testified that explaining this opinion required him to refer to matters relevant to the assessment of criminal responsibility and the accused’s mental state at the time of the offence.

[234] Dr. Bradford was fully cognizant of the requirement that his report and evidence on the effects of segregation on the accused were to be separate from his report on criminal responsibility. He endeavoured to keep the two distinct as much as possible and to avoid providing, in the former, his opinion with respect to the issue of criminal responsibility.

[235] However, in Dr. Bradford’s opinion, matters relevant to and arising from the assessment of criminal responsibility were also relevant to assessing the effects of segregation, and at the same time, the effects of segregation also have an impact on the assessment of criminal responsibility. He proceeded to review and discuss matters relevant to the assessment of criminal responsibility that he felt were also related to the effects of segregation.

[236] Dr. Bradford had read the transcripts from the accused’s preliminary hearing which provided him with the observations of correctional officers and other inmates as to the accused’s behaviour and demeanour prior to and at the time of the offence.

[237] Gary Mihichuk, a correctional officer, was familiar with the accused prior to June 2012. Dr. Bradford felt that his comments must be given some weight because of his experience in observing disturbed behaviour while a correctional officer.

[238] About a month prior to the incident, the accused came into Mr. Mihichuk’s office after lights out. The accused told Mr. Mihichuk that he was having disturbing thoughts, including suicidal thoughts and thoughts of hurting somebody. Mr. Mihichuk placed the accused in the segregation area overnight where he would be alone and subject to 20 minute checks.

[239] Dr. Bradford noted that other inmates were consistent in their observations of the accused in the days leading up to the incident, at the time of the incident, and following the assault. Dr. Bradford explained that these were people in the dormitory with the accused who knew him over a period of time. They describe, in different ways, a change in the accused’s demeanour – “it wasn’t the same Adam,” “his behaviour had changed.”

[240] With respect to the incident itself, Mr. Bruyere, a fellow inmate, was woken up by the accused when he saw the accused under his own bed. The accused was wearing an orange rag on his head and stated that he was on a mission. Mr. Bruyere next saw the accused start hitting Mr. Quisses and heard the accused say that he was “Carlos” to the guard who broke it up. Mr. Ross, an inmate who was sleeping in the bunk next to the accused, saw and heard the accused being taken away by the guards. He observed that “it wasn’t the Adam that I remembered meeting. [H]e seemed to have been in … like a trance. [H]e seemed to be in a trance. And I remember him saying that he was Don Corleone.” Mr. Harrison, another inmate sleeping two beds away from the accused, heard the accused state after the assault, “I’m Carlos Cardone and I don’t give a fuck.”

[241] Mr. McClendon, a correctional officer, ordered the accused away from Mr. Quisses. Asked about his observations of the accused, Mr. McClendon stated, “I noticed that he was not displaying any emotion. His face was very, very blank and emotionless. He was not breathing hard or, or anything. He was just emotionless and quiet.” Mr. Ulmer, another correctional officer, escorted the accused out of the dorm. He asked the accused what was going on. The accused responded, repeatedly, “Roger Rodriguez – that’s who I am,” or something similar to that. Mr. Ulmer described the accused as “just calm and relaxed.”

[242] Mr. Mihichuk, the correctional officer who had interacted with the accused approximately one month before, was also present that night. He stated that the accused was very compliant, but “it’s just that his demeanour did not seem, it did not seem that it was normal to me. I don’t know how else I can explain it. Regarding what had just transpired.”

[243] Dr. Bradford explained the significance of these eyewitness reports. From his experience, in dealing with the mentally ill, it is very important to listen to and review layperson’s observations because, “I think they can be very powerful.” He noted that a number of people familiar with the accused noticed a change in his demeanour in the period immediately prior to the incident. The observations of his behaviour at the time of and immediately after the assault were also consistent – that he was in a trance and using false, Spanish names.

[244] In Dr. Bradford’s opinion, the accused was described as “being in an altered state of mind in layman’s terms. [A]ssuming these observations are correct, they are supportive of Mr. Capay being in some form of altered state of mind at the time of the homicide, and therefore most likely suffering from a mental disorder prior to and at the material time of the alleged offence.”

[245] Dr. Bradford was unable to opine more specifically on whether the altered state of mind was a psychosis (possibly drug induced), a substance induced state including perceptual disturbances, or an altered state of consciousness also possibly related to drug intoxication.

[246] The accused advised Dr. Bradford that he became addicted to opiates while incarcerated at the TBCC. Dr. Bradford testified that, if in fact the accused was abusing opiates while receiving prescribed medications, including antidepressant drugs, there would have been a significant drug interaction which could have led to an altered state of consciousness.

[247] In his report, Dr. Bradford explained that the accused’s background, the presence of depression and PTSD, and the fact that he was on antidepressants for the treatment of a major depression, could have resulted in him becoming psychotic as part of a substance induced psychosis. He was of the opinion that the description of the accused’s behaviour by lay witnesses supports a significantly disturbed state of mind typically seen in psychosis or a drug induced intoxicated state.

[248] Dr. Bradford further noted that the attack on the victim appeared to have been unprovoked and without a logical or consistent motivation. According to Dr. Bradford, this unprovoked attack on Mr. Quisses, “which is seen as a classic hallmark of a psychotically driven act of violence, remains a strong possibility. If accurate, this would also be consistent with the result of a disturbed state of mind, with the behaviour being driven by internal perceptions rather than being in response to external reality.”

[249] Dr. Bradford carefully considered the fact that neither Dr. Schubert, who saw the accused two weeks prior to the alleged offence and numerous times thereafter at the Thunder Bay Jail, nor Dr. Stambrook suggested that the accused suffered from a psychotic condition. He suggested that Dr. Schubert’s visits with the accused were brief, consistent with the demands of an institutional setting. He further suggested that the accused felt that Dr. Schubert was largely responsible for his ongoing segregation.

[250] Dr. Bradford was of the opinion that this resulted in the accused not being fully forthcoming with Dr. Schubert, limiting Dr. Schubert’s ability to fully appreciate the accused’s condition and reach a complete diagnosis. Dr. Bradford, on the other hand, felt that he had been able to develop a rapport with the accused over the course of a lengthy inpatient assessment.

[251] Dr. Bradford reviewed some of his observations of the accused together with nursing observations which informed his assessment.

[252] Shortly after his December 2016 admission to Waypoint for the assessment, the accused was observed to be responding to hallucinations. He talked about hearing voices and having an alien in his head that talked to him.

[253] Dr. Bradford described an incident which occurred on March 12, 2017. While in the dining area, the accused jumped up with his tray in his hand and, entirely unprovoked, hit another patient on the head five times. Dr. Bradford noted that this was quite similar to the attack on Mr. Quisses. When Dr. Bradford later discussed this incident with the accused, the accused explained that he had been hearing voices and that it was because of these voices that he attacked the other patient. The voices stopped when he carried out the attack.

[254] Dr. Bradford felt that these auditory/command hallucinations, common in psychotic conditions, may have been precipitated by medication adjustments made to treat the accused’s adult ADHD. He suggested that this would be consistent with past experiences of some level of psychotic breakdown associated with a substance induced psychotic state.

[255] Dr. Bradford diagnosed the accused as having a psychosis NOS – not otherwise specified. He explained that “it’s not typical of schizophrenia. It’s not typical of schizoid effective disorder. It’s not typical of bipolar disorder or any of the organic psychosis, a brain disorder leading to psychosis, but he certainly has had psychotic symptoms.” Dr. Bradford was careful to explain that he “was not exactly sure because of his drug history and all the other things we talked about, but it was sufficient to make a diagnosis of psychosis.”

[256] Dr. Bradford began to treat the accused with a moderate dosage of an antipsychotic drug. The accused began to respond within a few days and told Dr. Bradford that the auditory hallucinations had started to become less intense.

[257] Dr. Bradford’s assessment and treatment of the accused, together with his review of the institutional record, led him to conclude that, while the accused was in segregation, he was experiencing at least three distinct but possible overlapping and/or interactive forms of disordered thinking: auditory hallucinations associated with a pre-existing condition (possibly schizoaffective); other auditory and visual hallucinations; and delusional fantasies of a sadistic and paraphilic nature. He was of the opinion that the pre-existing auditory hallucinations may well have been exacerbated by the accused’s time in segregation. The latter two forms of disordered thinking are likely due in significant measure to the effects of segregation itself, according to Dr. Bradford.

[258] Dr. Bradford testified that the challenge of assessing criminal responsibility for an offence that occurred four years previously had been “significantly increased” by the effects of segregation, in particular, on the accused’s memory and as a result of the unavailability of information and observations that would ordinarily be considered in an assessment.

[259] Dr. Bradford’s review of the testimony of correctional officers and other inmates present at the time of the accused’s attack on Mr. Quisses suggested to him that the accused may have been in an altered state of mind at the time of the offence such that a forensic evaluation was warranted at that time.

[260] Dr. Bradford testified that, if the accused had been promptly assessed following the June 3, 2012, assault, biochemistry results would have been available to determine the level of prescribed and non-prescribed medication in his system, professional mental status observations would have been recorded, and neurological testing could have been done. In his report, Dr. Bradford explained that:

In Mr. Capay’s case, he was placed in complete isolation for several months following the offence, thus severely limiting the opportunity for observation and interaction. I am advised that during this initial period, institutional staff were specifically instructed not to engage Mr. Capay in conversation, creating a complete vacuum of evidence relating to his mental health status during that period of time. Mr. Capay was not seen by any mental health professional until more than two months after the offence, during which he was in seclusion. By the time he was seen by a mental health professional, there is a strong possibility that his presenting mental health status had been significantly altered by his total seclusion.

The absence of physiological data and contemporaneous psychiatric observation and assessment, or even the opportunity for laypersons to interact with Mr. Capay and to observe his interactions with others, is a significant constraint on any assessment of criminal responsibility today.

[261] Dr. Bradford elaborated on the impact the absence of contemporaneous evidence had on his assessment of criminal responsibility: “Well, I think it’s very difficult … even without some of the complexities that Mr. Capay presents whether it be difficult four years afterwards, with what he presents within segregation it’s very difficult, impossible I would say.”

[262] Dr. Bradford testified that the best alternative to the missing physiological data and contemporaneous psychiatric observation would be the accused’s memory of the events leading up to the incident and his subjective state of mind at the time. While this would be difficult to obtain from anyone four years after the fact, Dr. Bradford testified that the difficulty is increased in the accused’s case because his memory has been profoundly impaired by his time in segregation, in particular because of the intense isolation in the period immediately following the offence.

[263] Dr. Bradford noted improvements in the accused’s current functioning while under his care, but he saw no evidence of improvement in his memory for past events, specifically his time in jail prior to and following the offence. Dr. Bradford was of the opinion that the memory impairment that the accused experienced as a result of the segregation is permanent.

[264] In conclusion, Dr. Bradford reiterated that the accused experienced an extremely impaired medical and social background, including exposure to alcohol in utero, most likely resulting in a level of cognitive impairment resulting in ADHD. During childhood, the accused suffered a number of significant traumas, including sexual abuse, physical assaults, repeated head injuries, parental alcoholism and marital discord, substance abuse, and violence. Dr. Bradford opined that these childhood experiences left the accused with a basis for a personality disorder and that he presented with a moderate antisocial personality disorder.

[265] Dr. Bradford further concluded that the accused’s time in segregation, particularly the initial period of near-total isolation, almost certainly had a more serious effect on him than it would on many other individuals given the accused’s ADHD, antisocial personality disorder, history of depression, self-injurious behaviour, and suicidality. Dr. Bradford felt that the accused’s time in segregation also resulted in perceptual disturbances and violent and sadistic fantasies.

[266] Dr. Bradford was also of the opinion that the further trauma of segregation compounded the past traumas the accused had suffered and either exacerbated pre-existing PTSD or triggered its development, which is now both chronic and severe. Dr. Bradford opined that this PTSD would persist as a lasting effect of the accused’s prolonged segregation.

[267] Dr. Bradford concluded that the accused’s prolonged segregation has resulted in significant cognitive impairments, in particular, permanent serious impairment of the accused’s memory of events leading up to his time in segregation.

[268] Dr. Bradford advised the court that all of the above has had a significant impact on the assessment of the accused’s mental state at the time of the offence. Dr. Bradford reported that there is “considerable evidence” that the accused was in a “seriously altered or disturbed state of mind, which would support a finding that he was not criminally responsible, or at the very least, [would] have a substantial impact on his culpability short of that finding.”

[269] Dr. Bradford concluded, in his report, that “the effects of segregation, in particular, on Mr. Capay’s memory, impair the ability to determine today the etiology, nature and severity of the altered or disturbed state of mind that the evidence indicates he was in at the time the offence was committed.”

[270] Dr. Bradford’s opinions and conclusions were not challenged on cross examination.

The Positions of the Parties

The Accused

[271] The accused is seeking a stay of proceedings pursuant to s. 24(1) of the Charter as a remedy for alleged violations of his rights under ss. 7, 9, 12, and 15 of the Charter.

Section 7

[272] The accused submits that the circumstances of his continuous detention in segregation between June 4, 2012, and December 6, 2016, have violated his s. 7 Charter rights, retrospectively and prospectively.

[273] Retrospectively, the accused contends that the four and one-half years that he was held in segregation deprived him of liberty and security of the person and that this deprivation was inconsistent with the principles of fundamental justice. The Crown has conceded that the evidence on this application establishes a retrospective violation of the accused’s s. 7 Charter rights.

[274] Prospectively, the accused submits that he faces a prolonged deprivation of liberty if convicted of first degree murder. The accused submits that the effects of segregation have prejudiced his ability to make full answer and defence and his right to a fair trial, such that the prospective deprivation of his liberty cannot be in accordance with the principles of fundamental justice.

[275] The accused submits that Dr. Bradford’s unchallenged evidence is that the accused’s memory of his June 3, 2012, assault on Mr. Quisses and of the events leading up to it have been permanently lost as a result of the impact of segregation on the accused. Dr. Bradford further explained that objective information and observations of the accused’s mental health status immediately following the offence, which would ordinarily be fundamental in an assessment of criminal responsibility, are not available because of the accused’s detention in near total isolation in the months immediately following the assault. According to Dr. Bradford, both factors exacerbate the already significant challenge of assessing the criminal responsibility of an accused for an offence that occurred over four years earlier.

[276] The accused submits that his loss of memory and the unavailability of timely objective observations of him, both as a result of state conduct, prejudice his ability to make full answer and defence and his right to a fair trial.

[277] The accused submits that fault for the fact he was not assessed soon after the offence lies with corrections. It is suggested that the accused’s psychiatric history, of which the corrections was aware, together with his bizarre behaviour at the time of the offence, should have prompted efforts to have him assessed by a mental health professional immediately following the offence. In the alternative, the accused submits that the state had an obligation to alert the court, the Crown, and/or defence counsel of the accused’s mental health issues promptly following the offence.

[278] The accused submits that this was not done and that he was immediately segregated in conditions of near total isolation, which had profound psychological effects on him and altered his psychological profile from what it was at the time of the offence. The isolation of the accused following the offence also prevented any contemporaneous observations of the accused’s demeanour by correctional officers or others.

[279] The accused notes that he did not see a mental health professional until his meeting with Dr. Stambrook on August 20, 2012, more than two months after he had been placed in segregation. At this time, Dr. Stambrook directed that the accused required a “detailed forensic assessment.” The accused suggests that Dr. Stambrook’s direction was communicated to a mental health worker in Kenora and shared with the nursing department and the Superintendent at the Kenora Jail. It also became known to the medical staff at the Thunder Bay Jail. The accused contends that none of these parties did anything to have him forensically assessed. The accused further submits that Dr. Stambrook’s direction was never shared with the court, the Crown, defence counsel or the accused himself.

[280] Counsel for the accused submits that the State’s failure to act on Dr. Stambrook’s direction and to take reasonable steps to have the accused assessed – or at a minimum the failure to share available information to allow the court, Crown or defence counsel to make informed decisions as to an assessment – was contrary to the duty of correctional institutions to provide treatment and living conditions to inmates that respect the inmate’s right to a fair trial. It has resulted in the loss of relevant evidence, according to the accused, and the accused submits that the state has therefore prejudiced his ability to make full answer and defence.

[281] Counsel for the accused suggests that Dr. Bradford’s evidence establishes that the accused’s time in segregation has permanently impaired his ability to recall the events leading up to his assault on Mr. Quisses and his state of mind at the time of the offence, hindering his ability to raise a viable not criminally responsible defence.

[282] However, the accused submits that the prejudice to his right to a fair trial caused by his loss of memory is not limited to his ability to advance a not criminally responsible defence. The accused submits that this loss of memory also impairs his ability to properly instruct counsel and to respond to evidence called by the Crown.

[283] The accused cites as an example the statement that he is alleged to have made immediately before the assault – “I’m on a mission, watch this.” The accused suggests that this is vital incriminating evidence in a first degree murder case in which the only issue is his mental state at the time of the offence.

[284] According to the accused, as a result of his loss of memory, he would be unable to instruct counsel or testify in any way as to this evidence. Did he in fact make this exact statement? If so, what did he mean by it? What was the mission referred to?

[285] The accused submits that similar constraints resulting from his loss of memory would apply to all fact witnesses that would be called at trial. The accused suggests that it would also have a significant impact on his ability to testify in his own defence.

[286] The accused acknowledges that trials proceed all the time when an accused has no memory of the events in question. However, counsel for the accused submits that in this case it was state conduct in breach of the accused’s Charter rights that caused his memory loss and which has impaired his ability to make full answer and defence.

Section 9

[287] The accused’s submits that a person’s s. 9 Charter right not to be arbitrarily detained or imprisoned encompasses both the existence of constitutionally adequate standards prescribed by law for detention or imprisonment and the application of and compliance with those standards by state actors. Included within this s. 9 Charter guarantee, according to the accused, is the right to prompt and regular reviews of segregation to determine whether a lawful basis for continued segregation exists. The accused submits that a remedy may be sought under s. 24(1) of the Charter where state actors fail to meet constitutionally compliant standards.

[288] The accused submits that the evidence clearly establishes that the practice followed by correctional authorities in the ongoing reviews of the accused’s segregation violated his right to procedural fairness under s. 7 of the Charter. The Crown has conceded this point in acknowledging the s. 7 breach. However, the accused submits that the right to prompt review of the substantive basis for continued segregation is a right guaranteed by s. 9, distinct from the right to a procedurally fair review process guaranteed by s. 7 of the Charter.

[289] The accused submits that two aspects of the mandated review process violated his s. 9 rights: first, the absence of prompt and timely reviews of the accused’s detention during the initial period of segregation; and, second, the absence of a lawful basis for continued segregation upon review of the accused’s detention in segregation thereafter.

[290] The accused submits that the specific facts as to his detention during the initial period of segregation are central to the s. 9 breach analysis.

[291] The accused was first detained in segregation on June 4, 2012. Counsel submits that the accused was detained in isolation cells at the Thunder Bay Jail and subject to near total isolation from June 4, 2012, to July 31, 2012. During this period of time, the accused’s Offender Rating Sheet at the Thunder Bay Jail prohibited correctional officers from speaking with him. During this same eight week period, the accused was out of his cell for a total of eight hours.

[292] Between July 31, 2012, and August 29, 2012, the accused was segregated in isolation cells at the Kenora Jail. He was returned to segregation at the Thunder Bay Jail on August 29, 2012, and again placed in isolation cells where he remained until December 5, 2012.

[293] Subsequent to December 5, 2012, the accused was detained for 11 weeks in Block 1 of the Thunder Bay Jail. For the balance of 2013, the accused was again detained in isolation cells in either the Thunder Bay Jail or the Kenora Jail, but for three three-day periods of time.

[294] The accused contends that correctional officials were legally required to review his detention in segregation on a regular and consistent basis - by the superintendent or designate every five days and 30 days following June 4, 2012, and by the Regional Director every 30 days. The accused contends that his segregation was not reviewed at the institutional level until August 29, 2012. Corrections conducted 5 day reviews were conducted on September 3 and 8, 2012. There was no further review of the accused’s segregation at the institutional level until February 21, 2013, a period of more than five months.

[295] The accused submits that between June 4, 2012, and July 31, 2012, corrections was legally required to have reviewed his detention in segregation 13 times, 12 times at the institutional level and once at the regional level. Thirteen legally mandated reviews did not occur during the first two months of the accused’s segregation, a period of time during which he was held in near total isolation, according to the accused.

[296] The accused was transferred to the Kenora Jail on July 31, 2012, and remained there until August 29, 2012. Corrections was required to conduct five 5 day reviews at the institutional level and two 30 day reviews, one at the institutional level and one at the regional level, during this period of time. None were conducted.

[297] The accused was returned to segregation at the Thunder Bay Jail on August 29, 2012. Corrections conducted two 5 day reviews on September 3 and 8, 2012, which the accused suggests indicates at least an awareness of the requirement to conduct segregation reviews. However, the accused submits that there was not a single review of his detention in segregation between September 8, 2012, and February 21, 2013, a period of five and one-half months, and that corrections was required to conduct 33 5 day reviews at the institutional level and five 30 day reviews at both the institutional and regional levels.

[298] The accused submits that this pattern continues thereafter, with 30 day reviews being conducted at the institutional level on February 21, 2013 and at the regional level on February 27, 2013, and the next regional review not occurring until July 16, 2013.

[299] The accused submits that his detention in segregation for almost three months initially and then subsequently for in excess of five months without any of the mandated reviews at the institutional and regional levels occurring was contrary to Ministry policy, unlawful and therefore arbitrary.

[300] The accused submits that s. 9 of the Charter encompasses the right to prompt review of any detention by the state and that the conditions under which he was detained during the initial period following June 4, 2012, represented an extraordinary form of detention. The accused contends that the constitutional requirement of prompt review consistent with the applicable law is that much more vital and pressing in the particular circumstances of this case.

[301] The accused submits that the repeated and ongoing failure to undertake segregation reviews prescribed by law to determine the lawfulness and validity of his ongoing detention in segregation was a prolonged and repeated violation of his s. 9 Charter guaranteed right against arbitrary detention.

[302] The accused alleges that his s. 9 Charter rights were further violated as a result of his continued detention in segregation absent a lawful basis for it, beginning in 2013.

[303] The accused submits that the Ministry policy in regard to Special Management Inmates required that decisions regarding housing special management inmates be based on “reliable information and objective criteria” and be consistent with “the principle of placing inmates in the least intrusive or lowest level of security possible…and [which] ensures the safety of all persons and the security of correctional institutions.”

[304] The accused submits that s. 34(1) of Regulation 778 authorizing administrative segregation provides three grounds for that form of detention, two of which are relevant to this analysis:

(a) in the opinion of the Superintendent, the inmate is in need of protection; or,

(b) in the opinion of the Superintendent, the inmate must be segregated to protect the security of the institution or the safety of other inmates.

[305] The accused submits that the only 5 day segregation reviews performed in 2012 were two 5 day reviews conducted in September of that year by Ms. McKay, Superintendent at the Thunder Bay Jail. In these reviews, Ms. McKay identified the reason for segregation as “charged with the murder of an inmate while in custody as the TBCC.” Ms. McKay testified that this meant that the accused was in segregation for his own protection because he would be targeted by other inmates.

[306] The accused suggests, however, that there was nothing in the institutional record to suggest that he had been the target of threats or retaliation from other inmates. The accused contends that the circumstances of his offence and the exercise of common sense by experienced correctional staff, in and off itself, do not meet the policy threshold of “reliable information and objective criteria.” The accused submits that there was an insufficient evidentiary basis to ground Ms. McKay’s opinion that the accused had to remain segregated during this time for his own protection.

[307] The accused contends that while he was segregated at the Kenora Jail in August 2012, a period of time during which there should have been five 5 day reviews and two 30 day reviews, no reviews were conducted and there was therefore a complete absence of any consideration as to whether grounds for continued segregation existed.

[308] The accused submits that, beginning in 2013, the apparent rationale for his continued segregation became the protection of other inmates and the security of the institution. According to the accused, beginning in July 2013, segregation review forms at both the institutional and regional levels indicated that the accused had expressed thoughts to the psychiatrist of harming staff and other inmates. This rationale is suggested to have been used on review forms up to and including October 2016.

[309] The accused referred the court to the review form dated October 4, 2016, which noted that “offender discloses ongoing pervasive thoughts to seriously harm or kill staff or other offenders. Segregation requested by institutional psychologist” as the reason for continued segregation.

[310] Counsel acknowledge that the accused did express sadistic fantasies and homicidal ideation to both Dr. Stambrook and Dr. Schubert between August 2012 and October 2013. The accused submits that Dr. Schubert’s notes, however, indicate that he had ceased to report any homicidal ideation as of October 2013 and consistently denied such thoughts after that point in time.

[311] In conducting segregation reviews, correctional officials, due to privacy concerns, rely on health care administrative summaries to inform their segregation decisions. At the Thunder Bay Jail, these summaries were prepared by Melissa Boban, the Health Care Manager. The accused suggests that Ms. Boban was aware of the need to provide current, accurate information on all matters relevant to a segregation review.

[312] The accused points out that Dr. Schubert’s notes from his October 16, 2013, interview of the accused include the entry, “Content. No (suicide ideation) + (homicidal ideation).” The accused submits that the health care administrative summaries provided by Ms. Boban for his segregation reviews never included the information that the accused had ceased to report any homicidal ideation as of October 16, 2013. The accused further submits that essentially all of the summaries prepared by Ms. Boban concluded with the statement that the accused continued to be a high risk for violence and a low risk for suicide.

[313] The accused submits that the health care administrative summaries prepared by Ms. Boban for the purpose of segregation reviews did not provide current, accurate, reliable information with respect to Dr. Schubert’s observations of the accused. As such, these summaries, which were the basis of the ongoing decision to keep the accused in segregation, were manifestly unreliable, according to the accused.

[314] The accused submits that his ongoing segregation from mid-2013 to the fall of 2016, in the absence of a proper evidentiary basis for the conclusion that he posed a risk to other inmates, staff, or the security of the institution, was unlawful, and his detention in segregation was therefore arbitrary and in breach of s. 9 of the Charter. The accused submits that, during this period of time, there was an insufficient and unreliable evidentiary basis to allow a decision maker to form the opinion that he was a current risk or danger to other inmates or staff.

[315] The accused submits that s. 9 of the Charter is in fact engaged in relation to his prolonged segregation and was breached, first, during the period of time he was detained in segregation without review and, again, when he thereafter was held in segregation for three years without a substantive basis for such detention.

Section 12

[316] The Crown has acknowledged that the accused’s s. 12 Charter rights have been violated as a result of the duration and conditions of his detention in continuous segregation between June 4, 2012, and December 6, 2016.

Section 15

[317] The accused submits that s. 15 of the Charter protects substantive equality and therefore provides protection from both direct and indirect discrimination. The accused contends that a law, regulation, or state practice that does not directly discriminate on its face may nonetheless violate the s. 15 guarantee of substantive equality if in its application it has a disproportionately negative impact on particular persons.

[318] The accused suggests that detention in segregation has a disproportionately negative impact on persons with mental illness and/or who are Indigenous. The accused suggests that inmates in Canada who are mentally ill or Indigenous or both are more likely to be placed in segregation and are also more vulnerable to the effects of segregation.

[319] The accused submits that Professor Hannah-Moffat and Professor Jackson testified as to the disproportionately negative effects of segregation on Indigenous people given that Indigenous culture and spirituality place such importance on maintaining relationships with the natural world. The accused contends that the disproportionately negative effects of segregation on mentally ill inmates is now notorious.

[320] The accused, an Indigenous inmate with mental health issues, suggests that the disproportionate impact of segregation on mentally ill and Indigenous persons imposed a positive obligation on the state to provide him with deferential treatment, accommodation, or mitigating measures during his time in segregation to satisfy the substantive equality requirements of s. 15 of the Charter. The accused suggests that this duty entailed, on the facts of this case, nothing more than the consideration of alternatives to ongoing segregation or the implementation of measures directed at mitigating the effects of segregation on the accused, including adequate and appropriate supports short of undue hardship.

[321] The accused submits that the Ministry did absolutely nothing to discharge this duty during the four and one-half years that he was in segregation.

[322] The accused submits that he had no access to any form of Indigenous programming, services or spiritual activities in 2012, 2013, 2014, or 2015, but for the provision of a Christmas bag by a NILO on December 24, 2015. In 2016, there were only two occasions prior to October when the accused was allowed to speak with a NILO. Throughout this period of time, as a result of his segregation, the accused suggests that he was not permitted to engage in any communal spiritual activities. The accused submits that this establishes the lack of even an attempt on the part of the Ministry to accommodate his needs as an Indigenous person in segregation.

[323] With respect to his mental health needs, the accused submits that Dr. Schubert, the institutional psychiatrist at the Thunder Bay Jail, met with him for approximately nine hours in total between June 4, 2012, and December 6, 2016, - approximately two hours per year of segregation. During the same time period, the accused submits that he made 19 written requests to see a psychiatrist in response to which he was told he would be put on a waiting list or that he was on a waiting list. Assessments required by Ministry policy were not conducted for the purpose of five-day reviews. The Thunder Bay Jail did not even employ a mental health nurse until June 2015; the Kenora Jail did not do so until November 2015. Ironically and more troubling, according to the accused, is that his mental illness was listed as the primary reason for his continued segregation on multiple segregation review forms.

[324] In contrast to the four and one-half years that the accused spent in segregation without any attempt on the part of the Ministry to accommodate or mitigate the disproportionate effects of the segregation, the accused submits that a number of measures intended to mitigate the effects of segregation were quickly implemented after Ms. Mandhane’s October 2016 visit to the Thunder Bay Jail. These included increased yard time, more time out of his cell each day, meetings with the mental health nurse, more frequent visits with the social worker and NILOs, pipe ceremonies, and educational supports.

[325] The accused submits that all such measures could have and should have been implemented well prior to October 2016. The accused suggests that none were even considered, let alone provided. The accused submits that the Ministry’s failure to consider alternatives to segregation and to provide appropriate available accommodation or to implement any measures in an attempt to mitigate the effects of segregation on him constitutes a violation of his rights under s. 15 of the Charter.

[326] The accused acknowledges that the statutory objective which must be balanced against his s. 15 Charter equality rights in this analysis is the protection of inmates’ safety and institutional security. However, he contends that the severity of the interference with his Charter protections was exceptional and extreme. The accused suggests that there was a complete absence of any regard for the severity of the impact of prolonged and highly restrictive segregation on his Charter rights, much less any attempt to balance that impact against the statutory objective. The accused submits that, throughout his time in segregation, maintenance of safety and security was the only consideration given weight by Ministry staff. The disproportionately negative impact of segregation on him never entered into the equation, according to the accused.

Remedy

[327] The accused submits that the Charter violations in this case have prejudiced his right to a fair trial and undermined the integrity of the justice system.

Trial Fairness

[328] The accused concedes that he caused the death of Mr. Quisses. He is to be tried by a judge and jury on the charge of first degree murder. The accused submits that the issue for the jury will be his mental state at the time of the offence. The accused submits that there has been irreparable prejudice to his right to a fair trial on this issue as a result of state misconduct.

[329] The accused submits that state misconduct has impaired his ability to present a defence of not criminally responsible. The accused further contends that state misconduct has caused the loss of his memory, both of the offence and the circumstances surrounding it, which he suggests will impact every aspect of a trial.

[330] The accused suggests that no remedy other than a stay of proceedings is capable of redressing the prejudice to his right to a fair trial.

[331] The actions of the state in violation of a number of the accused’s Charter rights are suggested to have stripped the accused of his memory of the events of June 3, 2012. The accused submits that his memory of the offence and the period of time immediately before the assault is such a significant source of potential evidence, given the facts of this case, that it is obvious that he could not have a fair trial.

[332] The accused submits that his memory loss is permanent and that the shortcomings in Dr. Bradford’s ability to assess his mental status at the time of the offence are irreparable. The accused suggests that the prejudice to trial fairness has been compromised to such an extent that the appropriateness of a stay of proceedings is manifest at the pre-trial stage.

[333] The accused submits that Dr. Bradford’s evidence establishes that the inability of the accused to remember the events of June 3, 2012, and his state of mind at the time of the offence impair the accused’s ability to raise a defence of not criminally responsible, to properly instruct counsel as to his defence, to respond to evidence called by the Crown, and to testify in his own defence. The accused submits that the court is presently in a position to assess the effect this will inevitably have on trial fairness.

[334] The accused submits that, in the particular circumstances of this case, the prejudice to trial fairness is irremediable such that a stay is the only available remedy.

[335] The accused disputes that the prejudice to trial fairness in this case could be alleviated by Dr. Bradford attempting to explain to the jury the limitations on his opinion regarding the accused’s mental state at the time of the offence coupled with a curative jury instruction.

[336] According to the accused, explanations as to the limitations on Dr. Bradford’s opinion and the accused’s memory loss would necessarily include the fact that the accused has spent years in solitary confinement. The accused submits that this is highly prejudicial information that a jury would never receive under normal circumstances. The accused submits that, in this scenario, the state misconduct would further prejudice his right to a fair trial by essentially forcing him to introduce highly prejudicial evidence before a jury.

[337] The accused contends that, if this prosecution continues, the Crown would benefit from the frailties in Dr. Bradford’s assessment and his lack of memory, both of which are said to be the direct result of the state’s misconduct. The accused submits that this would result in the Crown benefitting from its own misconduct.

[338] The accused submits that this court cannot be seen to condone the mistreatment of an accused person which has the effect of prejudicing his ability to make full answer and defence. If this case was allowed to proceed, the accused submits that the Crown would benefit from the accused’s lack of memory and the frailties in Dr. Bradford’s assessment, both a direct result of the state’s violations of the accused’s Charter rights.

[339] The accused submits that the facts of this case are so extreme and the prejudice to trial fairness so pervasive that there should be no uncertainty over whether a stay is warranted.

The Integrity of the Justice System

[340] The accused submits that the state conduct in this case has irreparably prejudiced his right to a fair trial and is so offensive to societal notions of fair play and decency that proceeding with a trial in the face of that conduct would be harmful to the integrity of the justice system.

[341] The accused suggests that a stay of proceedings is a prospective remedy meant to prevent the perpetuation or aggravation of past conduct. The accused submits that the court must be concerned about the possibility of the state conduct in this case being repeated in the future. The accused also submits that this is an exceptional case where the state’s past conduct was so egregious that allowing the prosecution to proceed in light of that conduct is offensive to society’s sense of fair play and decency.

[342] The accused submits that his detention in segregation for 1,647 days – 109 times in excess of what is deemed acceptable by international standards - in conditions described as shocking and appalling by experts in the field must offend society’s sense of justice.

[343] The accused notes that Professor Jackson, an expert in the field of corrections, found the particular physical conditions of the accused’s segregation, including 24 hour light, no natural light, no access to radio or television, and an inability to flush the cell toilet, shocking and as bad as he has ever seen or read about. Professor Jackson compared the segregation cells used to detain the accused as comparable to segregation cells 50 years ago.

[344] The accused submits that Professor Hannah-Moffat, also an expert in the field of corrections, opined that both the physical conditions and the length of the accused’s detention in segregation were as bad as she had ever seen in Canada and internationally –“akin to some of the most egregious conditions…in undeveloped countries or in the United States in some of their super max’s.”

[345] The accused suggests that Ms. Mandhane also testified that the conditions that were imposed on him were the worst she had ever witnessed.

[346] The accused submits that this case goes beyond simple state misconduct. The accused suggests that the state misconduct established by the evidence on this application is the worst state misconduct ever encountered by expert witnesses with decades of experience in the field. The accused submits that a stay is warranted in these circumstances even absent a consideration of whether the misconduct is likely to continue in the future.

[347] However, when considering the appropriate remedy, the accused also submits that this court should be concerned about this type of state conduct being repeated. The accused submits that the evidence heard on this application indicates that the mistreatment he suffered is not isolated, but part of a pattern of disregard for policy and procedure endemic within the Ontario correctional system. As of January 31, 2017, there were four other inmates who had been held in segregation continuously for longer than 939 days. The accused submits that there have been no apparent consequences for any of the Ministry employees involved in the systemic failure in this case, including Superintendent McKay; Dr. Schubert, psychiatrist at the Thunder Bay Jail; Ms. Boban, Health Care Manager at the Thunder Bay Jail; Mr. McDaniel, Regional Director; and Mr. Houghton, Regional Director.

[348] The accused contends that the fact that he, an inmate with clearly diagnosed mental health issues, was in continuous segregation for four and one-half years was known at the institutional, the regional, and the provincial levels of the Ministry. In addition, according to the accused, the reviews that corrections conducted were pro forma, perfunctory, and meaningless.

[349] The accused submits that a stay of proceedings is the only remedy capable of redressing the prejudice caused by his mistreatment and the only remedy capable of adequately denouncing the state’s misconduct.

[350] The accused suggests that a reduction of sentence is not an available remedy in this case for two reasons.

[351] First, a conviction for first degree murder carries with it a mandatory sentence of life imprisonment without the possibility of parole for 25 years. The accused submits that this court does not have the jurisdiction to reduce this mandatory sentence to remedy the Charter breaches.

[352] Second, the accused submits that no reduction in sentence could be an adequate remedy for the state misconduct in this case. The accused contends that he spent four and one-half years in deplorable conditions and has suffered permanent psychological harm as a result. The accused submits that the segregation he endured for four and one-half years was highly punitive and much more severe than a court could sentence him to serve if convicted.

[353] The accused submits that this is one of the rare cases in which the state misconduct is so egregious and the appropriateness of a stay so compelling that they could not possibly be overtaken by society’s interest in having a trial on the merits.

The Crown

[354] The Crown accepts that the circumstances of the accused being held in continuous segregation for 1,647 days between June 4, 2012, and December 6, 2016, violated his retrospective s. 7 Charter rights and his s. 12 Charter rights. The Crown further concedes that the s. 7 and s. 12 breaches are significant and systemic.

[355] The Crown submits that ss. 9 and 15 of the Charter are not engaged in this case and that the facts as to the alleged ss. 9 and 15 Charter violations are more appropriately analyzed within the ambit of s. 7 and s. 12 of the Charter.

Section 7– Prospective Violation and Trial Fairness

[356] The Crown agrees that the issue at trial will be the state of mind of the accused at the time of the offence. The Crown does not challenge the evidence of Dr. Bradford as to accused’s loss of memory of events at the time of and leading up to the offence. The Crown accepts that the accused’s memory loss was caused by the state treatment of the accused in violation of his ss. 7 and 12 Charter rights.

[357] The Crown concedes that the accused’s loss of memory has “impeded and impaired” his ability to call evidence at trial as to his mental state at the time of the offence. However, the Crown submits that it is speculative to now conclude that the trier of fact will ultimately reject Dr. Bradford’s opinion and therefore speculative to conclude on this application that the accused cannot receive a fair trial.

[358] The Crown submits that Dr. Bradford had access to a broad range of material and observations during the course of his assessment of the accused, including a comprehensive Gladue report, the medical and psychiatric records of the accused, correctional log books, the preliminary hearing transcripts, and an extensive and prolonged in-person assessment. The Crown submits that, given this background, a trier of fact may very well give sufficient weight to Dr. Bradford’s opinion to make the trial fair for the accused.

[359] The Crown submits that the accused is entitled to a trial which is fundamentally fair. The Crown suggests that Dr. Bradford’s evidence, even given its limitations as a result of the accused’s memory loss, would nevertheless enable the accused to advance all available defences at trial such that his trial would be fundamentally fair.

Section 9

[360] The Crown submits that s. 9 of the Charter does not address the nature or duration of detention or imprisonment, but the adequacy of standards prescribed by law for a detention or imprisonment, which are not in issue in this application. The Crown contends that any alleged Charter violations resulting from a deficient segregation review process are more appropriately analyzed in the context of s. 7 of the Charter.

Section 12

[361] The Crown accepts the opinion of Professor Toope that the conditions of the accused’s confinement in segregation amount to cruel, inhuman, and degrading treatment under international law. The Crown does not accept the opinion of Professor Toope that these same conditions amount to torture as understood in international law. The Crown submits that the evidence heard on this application does not allow the court to conclude that correctional authorities intentionally inflicted pain and suffering on the accused.

[362] The Crown submits that the treatment of the accused was the result of a “systemic failure” consisting of, in part, an insufficient segregation review process and the failure to meaningfully consider any possible accommodations or alternatives to segregation.

[363] In any event, the Crown concedes that correctional officials subjected the accused to cruel and unusual treatment or punishment between June 4, 2012, and December 6, 2016, in violation of his s. 12 Charter rights.

Section 15

[364] The Crown does not dispute that the accused is Indigenous and suffered from mental illness throughout his time in segregation. The Crown submits that Ministry employees acted upon information suggesting that the accused was a danger to correctional officers and other inmates when placing and retaining him in segregation. The Crown suggests that correctional actions were guided by concerns for inmate and institutional safety and not by any of the s. 15 enumerated grounds. In these circumstances, According to the Crown, s. 15 of the Charter is not engaged.

Remedy

[365] The Crown submits that there are compelling reasons, as set out above, for the trier of fact to accept Dr. Bradford’s expert opinion as to the accused’s state of mind at the time of the offence. The Crown contends that determining the true impact of the Charter violations on trial fairness is speculative unless and until Dr. Bradford’s opinion is rejected by the trier of fact.

[366] The Crown disputes the accused’s submission that his right to a fair trial would be prejudiced as a result of Dr. Bradford having to explain that the limitations of his opinion are the result of the accused’s prolonged detention in segregation. The Crown suggests that an appropriate jury instruction could alleviate any potential prejudice in this regard.

[367] In the alternative, the Crown submits that any potential prejudice to trial fairness could be mitigated by this court ordering the Attorney General to consent to a judge alone trial pursuant to s. 473(1) of the Criminal Code. The Crown acknowledges the significance of the accused’s right to be tried by a judge and jury. However, if the Attorney General is ordered to consent to a judge alone trial, the accused would have the option of trial by judge alone or judge and jury. The availability of trial by judge alone, according to the Crown, would mitigate any potential prejudice to trial fairness.

[368] The Crown accepts that the violations of the accused’s ss. 7 and 12 Charter rights implicate the integrity of the justice system, thus requiring this court to balance the interests in favour of granting a stay against society’s interest in a trial on the merits. The Crown suggests three alternative remedies to redress the Charter violations in this case short of a stay of proceedings.

[369] First, the Crown submits that the court could order a sentence reduction for the accused. The Crown submits that s. 24(1) of the Charter provides this court with jurisdiction to reduce a sentence outside statutory limits as a remedy for state misconduct in violation of an accused’s Charter rights. The Crown concedes that this remedy may not be, in practical terms, available if the accused is ultimately convicted of manslaughter, given that the accused has been in pretrial custody for six years and eight months, the equivalent of 10 years for sentencing purposes.

[370] Second, the Crown submits that the court could, under s. 24(1) of the Charter, award damages to the accused as a remedy for any Charter violations. The Crown acknowledges that this has, to date, never been done. The Crown submits, however, that superior criminal courts have jurisdiction to award monetary damages under s. 24(1) of the Charter.

[371] The third alternative remedy proposed by the Crown is a judicial declaration denouncing abusive state conduct in violation of the Charter.

[372] The Crown submits that, when balancing the interests in favour of a stay against society’s interest in a trial on the merits, the alternative remedies, short of a stay of proceedings, can and will serve to preserve the integrity of the justice system. The Crown reminds this court that the accused stands charged with the first degree murder of another inmate in the care of correctional authorities. The correctional authorities had a duty to protect other inmates, correctional staff, and the accused himself. The Crown submits that breaches of the accused’s Charter rights occurred in this context, not as a result of malice toward the accused. Balancing all interests engaged in this application militates against a stay of proceedings, according to the Crown.

Analysis

[373] The accused is seeking a stay of proceedings pursuant to s. 24(1) of the Charter as a remedy for alleged violations of his rights under ss. 7, 9, 12, and 15.

Section 7 of the Charter

Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.

[374] The Crown has properly conceded that the accused’s detention in continuous segregation for four and one-half years was in violation of the accused’s s. 7 Charter rights retrospectively. The nature and extent of this breach has to be established for the purpose of determining an appropriate remedy.

[375] It has long been recognized that incarcerated persons retain a residual liberty interest and that placement in segregation constitutes a significant reduction of that interest. In R. v. Miller, 1985 CanLII 22 (SCC), [1985] 2 S.C.R. 613, at p. 641, the Supreme Court stated that:

Confinement in…administrative segregation…is a form of detention that is distinct and separate from that imposed on the general inmate population. It involves a significant reduction in the residual liberty of the inmate.

[376] Segregation has been described as the “the most onerous and depriving experience that the state can legally administer in Canada”: Annual Report of the Office of the Correctional Investigator 2014-2015, at p. 31, cited in British Columbia Civil Liberties Association v. Canada (Attorney General), 2018 BCSC 62, [2018] B.C.J. No. 53, at para. 1 (“BCCLA”).

[377] It is obvious that the accused’s prolonged detention in segregation severely impaired his residual liberty interests.

[378] In New Brunswick v. G. (J.), 1999 CanLII 653 (SCC), [1999] 3 S.C.R. 46, at para. 58, the Supreme Court confirmed that the right to security of the person protects both the physical and psychological integrity of the individual. The court described the nature of the protection of psychological integrity included in the right to security of the person at para. 60:

For a restriction of security of the person to be made out, then, the impugned state action must have a serious and profound effect on a person’s psychological integrity. The effects of the state interference must be assessed objectively, with a view to their impact on the psychological integrity of a person of reasonable sensibility. This need not rise to the level of nervous shock or psychiatric illness, but must be greater than ordinary stress or anxiety.

[379] Dr. Bradford has provided comprehensive expert evidence describing the effects of segregation on the psychological integrity of the accused. His evidence has been summarized and need not be repeated. Dr. Bradford’s opinion has not been challenged and, given his qualifications, it is entitled to considerable weight. The effects of segregation on the psychological integrity of the accused, and therefore on his personal security interests, are very serious, profound, and far exceed the established threshold.

[380] Administrative decisions which affect individual rights must be made in a procedurally fair manner. The requirements of procedural fairness are determined by context. In Charkaoui v. Canada (Citizenship and Immigration), 2007 SCC 9, [2007] 1 S.C.R., at para. 20, the Supreme Court stated that:

Section 7 of the Charter requires not a particular type of process, but a fair process having regard to the nature of the proceedings and the interests at stake. The procedures required to meet the demands of fundamental justice depend on the context. Societal interests may be taken into account in elucidating the applicable principles of fundamental justice. [Citations omitted.]

[381] Factors to be considered in determining the content of procedural fairness in a particular context include the nature of the decision being made and the process to be followed in making it, the nature of the statutory scheme, and the importance of the decision to the affected individual: Baker v. Canada (Minister of Citizenship and Immigration), 1999 CanLII 699 (SCC), 1999 SCC 699, [1999] 2 S.C.R. 817, at paras. 23-27.

[382] It is well established that, in the segregation context, the content of the duty of procedural fairness includes a mechanism for meaningful and independent review. The British Columbia Supreme Court addressed this requirement in BCCLA, at para. 391:

There is, as well, a feature specific to administrative segregation that further demands independent adjudication: the open-ended nature of placements. In circumstances where an inmate remains in segregation until the warden determines he or she should be released, it is especially important that the statutory criteria for segregation be rigorously applied. An independent adjudicator is best placed to ensure that robust inquiry occurs at segregation reviews and that institutional staff and administrators make the case for segregation by demonstrating that there are no reasonable alternatives.

[383] Provincial law and Ministry policy provide a mechanism for independent and impartial review of the accused’s detention in segregation, including 5 day and 30 day reviews at the institutional level and 30 day reviews external to the institution and institutional decision makers at the regional level. The requirements of the March 2011 and September 2015 PMSI policies are set out at paragraphs 147-150 of these Reasons.

[384] Segregation reviews at the regional level are obviously intended to provide independent, meaningful oversight of segregation review decisions made at the institutional level. In general terms, in conducting a 30 day segregation review the Regional Director or designate is required to review, among other things, the regulatory basis for segregation, the specific reasons for segregation, the alternatives that have been explored and rejected, what accommodations could be implemented to mitigate the negative effects of segregation and maximize integration, and whether the inmate has a mental illness.

[385] A Regional Director conducting a 30 day segregation review is required to indicate to the institution whether continued segregation is supported or not supported, which presumably empowers the Regional Director to direct the institution to more thoroughly consider alternatives, accommodations, mitigation, or removal of the inmate from segregation.

[386] The unchallenged evidence as to quality of the segregation review process during the four and one-half years the accused was detained in continuous segregation has been reviewed at length. It is obvious that the segregation review process in the case of the accused was meaningless at the institutional and regional levels.

[387] Professor Jackson and Professor Hannah-Moffat, experts in Canadian correctional law and policy, both commented on the quality of the review process in this case. Professor Jackson testified that:

When you look at these reviews and you see from month to month, from year to year, they’re exactly the same. There may be a handwritten notation a little bit different, but there’s no change in the risk. There’s no change in the reasons why he’s there. There’s no recognition that he’s getting better, that he’s getting worse. A few notations that he’s harming himself, that he’s hearing things, but you have a sense that in June 2012 until sometime in 2016, time stopped. He was kind of trapped in a place and a space that never changed and you get – you almost can kind of go like that with these seg reviews and there’s nothing there. There’s, you know, people are filling out forms. They’re checking boxes, but it’s as if Adam Capay’s disappeared.

[388] Professor Hannah-Moffat found that the explanations for continued segregation set out in the reviews that were conducted consisted of only a simple one or two line comment reiterating generic reasons noted on the previous reviews. Professor Hannah-Moffat observed that there was no change in the quality of the reviews between 2013 and 2015, despite the accused having been in segregation for almost three years. She found it to be “egregious and shocking” that these reviews contained no discussion of alternatives or measures that corrections could have attempted in order to mitigate the impact of segregation, such as Indigenous programming, psychiatric treatment, or educational opportunities. Professor Hannah-Moffat opined that the reviews of the accused’s segregation over a period of four and one-half years provided no “meaningful oversight” of his continued detention in segregation.

[389] The opinion of Professor Hannah-Moffat on this issue is amply supported, in my view, by the testimony of Deborah McKay, Deputy of Operations at the Thunder Bay Jail from 2012 to 2014 and Deputy of Administration from 2014 to 2016, and by the testimony of Douglas Houghton and Richard McDaniel both Deputy Directors, Northern Region Institutional Services.

[390] Ms. McKay testified that, to the best of her recollection, continued segregation had never been “not supported” at the regional level. Ms. McKay was further unable to recall the regional office even commenting on the circumstances of continued segregation they supported, such as enhanced privileges or mental health treatment.

[391] Mr. Houghton was obviously aware that there were social workers, NILOs and mental health professionals at the Thunder Bay Jail. He never considered, let alone suggested, that the accused be granted increased access to these readily available services. Mr. Houghton never inquired about the accused’s access to the yard, canteen, or reading material, and he was unable to recall any specific discussions with staff at the Thunder Bay Jail about any form of mitigation or alternative placement for the accused. Mr. Houghton never recommended that the accused receive increased psychiatric services, either from inside or outside the institution.

[392] Mr. Houghton was unable to recall a single time that he failed to support the continued segregation of an inmate when conducting a segregation review.

[393] Mr. McDaniel testified that he would not support continued segregation if the review documentation did not contain a plan for moving an inmate out of segregation and that it was unacceptable for an inmate to be held in indefinite segregation. However, in later testimony, he did not appear to understand or appreciate his supervisory responsibility when conducting reviews at the regional level:

Like I have oversight onto them but we’re part of a team and they are doing good work and I rely on the social workers and everybody else that’s making these decisions to stay there. So why would I make a decision against that…When you got social workers and psychiatrists and whoever else that’s indicated that this person is in segregation…then I’m going to sign off on that. I don’t think it’s my decision to go against a social worker or psychiatrist.

[394] Mr. McDaniel testified that he did not “remember ever overriding the institution” when conducting a segregation review at the regional level.

[395] Mr. Houghton’s and Mr. McDaniel’s evidence on this point was consistent with that of Ms. McKay who had never seen continued segregation not supported on a regional review.

[396] To suggest that the regional reviews of the accused’s prolonged detention in segregation lacked the “robust inquiry” standard described by the British Columbia Supreme Court in BCLA is a gross understatement.

[397] I accept the submission of the accused that, notwithstanding that the Ministry appreciated their duty of procedural fairness in relation to segregation as reflected in the March 2011 and September 2015 versions of the PMSI policy, in practice, the accused’s continuous segregation for four and one-half years was devoid of any meaningful oversight or review.

[398] I find that the accused’s detention in segregation between June 4, 2012, and December 6, 2016, was a serious, prolonged, and profound violation of his retrospective s. 7 Charter rights.

Section 12 of the Charter

Everyone has the right not to be subjected to any cruel and unusual treatment or punishment.

[399] The Crown has conceded that the accused’s s. 12 Charter right not to be subjected to cruel and unusual treatment or punishment has been breached. Once again, the nature and extent of the breach has to be considered for the purpose of the s. 24(1) analysis.

[400] The conditions of the accused’s detention in segregation between June 4, 2012, and December 6, 2016, have been comprehensively reviewed and need only be summarized at this juncture:

• 847 days (2.3 years) alone in Block 1 of the Thunder Bay Jail, without radio or television and with lights on 24 hours a day;

• 53 days alone in Block 2 of the Thunder Bay Jail, with two televisions in the block and lights dimmed at night;

• 237 days alone in Block 10 of the Thunder Bay Jail, a single cell encased in Plexiglas in the isolation area, without a day area, shower, television, or radio, with lights on 24 hours a day, and without the ability to flush the toilet from inside the cell;

• 274 days alone in Block 11 of the Thunder Bay Jail, in a cell encased in Plexiglas, without a day area, television, or radio, without the ability to flush the toilet from inside the cell, and with the lights on 24 hours a day;

• 94 days alone in Block 12, with a day area, a shower, and a telephone and with lights dimmed at night;

• 73 days alone in isolation cells at the Kenora Jail, with a shower, telephone, and radio controlled by the correctional officers, without a day area or television, and with lights dimmed at night;

• 69 days alone in the south basement of the Kenora Jail, with a day area, shower, telephone, and television and with lights dimmed at night;

• The accused had yard access on 108 days of the 1,647 days he was in segregation. He declined yard access on 72 days;

• The accused had “time outs,” typically one hour long, 794 times of the 1,647 days he was in segregation, excluding time in day areas for showering or cleaning.

[401] The record confirms that the accused suffered from mental illness upon his admission to and throughout his detention in segregation and that correctional officials were aware of his mental health issues. Between June 4, 2012, and December 6, 2016, Dr. Stambrook spent approximately 80 minutes with the accused at the Kenora Jail and Dr. Schubert spent approximately nine hours with the accused at the Thunder Bay Jail.

[402] In my opinion, the very limited time that Dr. Stambrook and Dr. Schubert were able to devote to the accused over the four and one-half year period that he was detained in segregation precluded them from providing the accused with any meaningful therapeutic mental health treatment.

[403] I recognize that institutional demands place significant limits on the ability of mental health professionals to provide meaningful treatment to inmates. However, when a mentally ill inmate is placed in segregation and the institutional mental health records document that the inmate’s mental health is deteriorating during a prolonged detention in segregation, it is incumbent on the Ministry to provide meaningful mental health treatment and to invoke measures designed to mitigate the impact of segregation.

[404] The evidence establishes that the correctional officials did not consider any mitigating measures to alleviate the impact of segregation on this mentally ill accused. The evidence also establishes that correctional officials did not consider obtaining therapeutic mental health services for the accused from outside the institution at any point in time prior to Ms. Mandhane’s October 2016 visit to the Thunder Bay Jail.

[405] One could easily conclude that correctional officials were simply oblivious to the accused’s mental health condition during his time in segregation, but for the fact that it was used as a rationale to continuously detain him in segregation. The effect that prolonged segregation had on this mentally ill accused has been confirmed by the unchallenged expert evidence of Dr. Bradford.

[406] Dr. Bradford was of the opinion that the accused’s time in segregation, especially the initial period of near total isolation, had a more serious effect on the accused than it would on many other individuals given his pre-existing conditions, including ADHD, antisocial personality disorder, and history of depression and anxiety.

[407] Dr. Bradford testified that segregation compounded past traumas the accused had suffered and either exacerbated pre-existing PTSD or triggered its development, resulting in the accused having “chronic and severe” PTSD that “will persist over time as a lasting effect of Mr. Capay’s prolonged segregation.”

[408] Dr. Bradford explained that segregation also resulted in the accused developing “significant cognitive impairments,” including the permanent loss of memory with respect to the period of time prior to and during the initial period of segregation.

[409] Dr. Bradford opined that while in segregation the accused was experiencing “at least three distinct but possibly overlapping and/or interactive forms of disordered thinking,” including auditory hallucinations, visual hallucinations, and delusional fantasies of a sadistic and paraphilic nature. He felt that the auditory hallucinations were pre-existing and exacerbated by the segregation and that other auditory and visual hallucinations and the delusional fantasies were “likely due in significant measure to the effects of segregation itself.”

[410] Based on the prolonged and indefinite nature of the accused’s segregation, his mental illness, and the conditions of confinement, Professor Toope was of the opinion that the accused had been subjected to cruel, inhuman, or degrading treatment or punishment, amounting to torture, pursuant to international standards.

[411] Professor Toope conceded that for treatment to amount to torture pursuant to international standards, there must be an intentional infliction of severe pain or suffering, physical or mental, for a specific purpose. Professor Toope agreed that he came to the conclusion that the treatment of the accused amounted to torture under international standards by imputing the necessary intent for this finding to correctional officials as a result of the length and particular conditions of the accused’s segregation. I decline to impute that intent on the facts of this case and therefore do not accept Professor Toope’s opinion that the accused’s detention in segregation amounted to torture according to international standards.

[412] Professor Hannah-Moffat was extremely blunt in her assessment of the treatment of the accused. That assessment is set out at paragraphs 195-205 of these Reasons. The length of time the accused was in segregation, the egregious conditions of his confinement, the lack of any meaningful oversight or review, and the lack of any attempt to mitigate the negative effects of segregation led her to conclude as follows:

As far as I’m concerned, this does get to the level of torture, definitely cruel and unusual, completely unacceptable when you’re talking about pre-trial custody and by all standards inhumane and I don’t know of any western democracy or in many of the countries in Europe and even South American institutions…that would tolerate this for…protracted periods of time.

[413] The test to establish a violation of s. 12 is the same for cruel and unusual treatment as it is for cruel and unusual punishment: Ogiamien v. Ontario (Community Safety and Correctional Services), 2017 ONCA 667, 335 C.C.C. (3d) 41, at para. 7. The test or threshold is gross disproportionality: R. v. Nur, 2015 SCC 15, [2015] 1 S.C.R.733, at para. 39. To be considered grossly disproportionate, the treatment must be so excessive as to outrage standards of decency and disproportionate to the extent that Canadian society would find the treatment abhorrent or intolerable: R. v. Ferguson, 2008 SCC 6, [2008] 1 S.C.R. 96, at para. 14.

[414] The accused, a young, mentally ill, Indigenous man, was detained in continuous segregation in deplorable conditions for 1,647 days. He was confined to his cell for more than 23 hours per day for extended periods of time. He was subjected to near total isolation during the initial three month period of segregation during which time his mental health deteriorated dramatically. The accused received no substantive mental health treatment or Indigenous programming or support during the four and one-half years that he was in segregation.

[415] The treatment of the accused was, in my opinion, outrageous, abhorrent, and inhumane. It is a shocking and intolerable violation of s. 12 of the Charter.

Section 7 of the Charter and Trial Fairness

[416] The accused stands indicted of first degree murder in the death of Mr. Quisses. If convicted he is subject to a mandatory life sentence. The liberty interests of the accused are obviously engaged in this prosecution.

[417] Section 7 of the Charter provides that the accused cannot be deprived of his liberty except in accordance with the principles of fundamental justice. The principles of fundamental justice include the right to make full answer and defence and the right to a fair trial.

[418] The accused submits that his right to make full answer and defence and his right to a fair trial have been breached because the psychological damage he has suffered due to the conditions and length of his detention in segregation have compromised Dr. Bradford’s ability to provide a definitive opinion as to his criminal responsibility.

[419] Dr. Bradford’s evidence has been extensively summarized at pages 53-65 of these Reasons. I reiterate only his conclusions relevant to the prospective application of s. 7 of the Charter.

[420] Dr. Bradford found that the accused’s prolonged segregation has resulted in significant cognitive impairments, including permanent serious impairment of his memory of the period of time leading up to his assault on Mr. Quisses and of the assault itself.

[421] The accused was segregated in almost complete isolation for several months following June 3, 2012. Dr. Bradford placed significant emphasis on this fact. He concluded in his report that the absence of physiological data and contemporaneous psychiatric observation and assessment, or even the opportunity for laypersons to interact with the accused and to observe his interactions with others, is a “significant constraint on any assessment of criminal responsibility today.”

[422] Testifying on this point, Dr. Bradford explained that the total absence of this crucial information, compounded by the accused’s memory loss, renders an assessment of criminal responsibility four years after the offence “very difficult, impossible I would say.”

[423] In Dr. Bradford’s opinion, there is considerable evidence that the accused was in a “seriously altered or disturbed state of mind” at the time of the offence which would support a finding that he was not criminally responsible or that would have a “substantial impact on his culpability short of that finding.” Dr. Bradford further concluded that the effects of segregation, particularly on the accused’s memory, have impaired his ability to now determine the “etiology, nature and severity of the altered or disturbed state of mind that the evidence indicates he was in at the time the offence was committed.”

[424] If this first degree murder case proceeds to trial, the only issue will be the accused’s criminal responsibility for the offence. The accused is presumed to be criminally responsible for the death of Mr. Quisses. At trial, the accused will allege that he is not criminally responsible for the death of Mr. Quisses because of mental disorder. Given the totality of Dr. Bradford’s evidence, the accused may advance alternative defences, such as intoxication, which could impact his degree of responsibility for the death of Mr. Quisses short of being found not criminally responsible.

[425] The accused will be required to prove on a balance of probabilities that he is not criminally responsible for the death of Mr. Quisses. He has been extensively assessed by Dr. Bradford. We know now what Dr. Bradford’s evidence at trial will be. Dr. Bradford will testify that there is considerable evidence that the accused was not criminally responsible on June 3, 2012, but that it is very difficult or impossible for him to provide a definitive opinion on the issue.

[426] In my opinion, the equivocal nature of Dr. Bradford’s expert opinion on this vital issue significantly inhibits the accused’s ability to advance a defence of not criminally responsible. The shortcomings in Dr. Bradford’s opinion are a result of the state’s treatment of the accused, which has been found to be in violation of ss. 7 (retrospectively) and 12 of the Charter. The accused’s state of mind will be the only issue at trial.

[427] On this application, the accused is required to establish on a balance of probabilities that his constitutional guarantee of a fair trial has been compromised because of the limitations of Dr. Bradford’s opinion in regard to his criminal responsibility.

[428] As recognized by McLachlin J., as she then was, in R. v. O’Connor, 1995 CanLII 51 (SCC), [1995] 4 S.C.R. 411, at para. 194, “the Canadian Charter of Rights and Freedoms guarantees not the fairest of all possible trials, but rather a trial which is fundamentally fair…what the law demands is not perfect justice, but fundamentally fair justice.”

[429] I accept the submission of the accused that the issues of his right to make full answer and defence and of trial fairness are not limited to the issue of criminal responsibility.

[430] Dr. Bradford opined that the accused has suffered significant cognitive impairments, including the permanent loss of his memory of the events occurring within the time period surrounding the June 3, 2012, assault on Mr. Quisses. These are a direct result of segregation, in particular, the initial period of almost complete isolation.

[431] As a result of his memory loss, the accused is unable to testify about the events of June 3, 2012, including about the comment attributed to him by a witness, “Watch this. I’m on a mission.” The accused’s ability to instruct counsel as to all Crown witnesses anticipated to be called at trial has been compromised by his loss of memory. The accused’s ability to advance alternative defences to the charge of first degree murder, short of establishing he was not criminally responsible, has also been impaired.

[432] I am persuaded on a balance of probabilities that the accused’s right to make full answer and defence and his right to a fundamentally fair trial have been breached. This breach is a result of his inability to fully and fairly advance a defence of not criminally responsible or alternative defences to the first degree murder charge.

Section 9 of the Charter

Everyone has the right not to be arbitrarily detained or imprisoned.

[433] Section 9 of the Charter guarantees freedom from arbitrary detention. The Supreme Court has described the s. 9 guarantee as one of “the most fundamental norms of the rule of law. The state may not detain arbitrarily, but only in accordance with the law.” Charkaoui, at para. 88.

[434] As previously noted in paragraph 375 of these Reasons, the Supreme Court in Miller found the confinement of an inmate in administrative segregation to be a form of detention that is “distinct and separate” from that imposed on the general inmate population, which involves a significant reduction in the inmate’s residual liberty. The Court in Miller, at para. 35, described administrative segregation as a “new detention of the inmate, purporting to rest on its own foundation of legal authority.”

[435] In R. v. Grant, 2009 SCC 32, [2009] 2 S.C.R. 353, at para. 54, the Supreme Court recognized the s. 9 guarantee to be a manifestation of the general principle, enunciated in s. 7, that a person’s liberty is not to be curtailed except in accordance with the principles of fundamental justice. The Grant court confirmed that a lawful detention is not arbitrary within the meaning of s. 9 unless the law authorizing the detention is itself arbitrary and that, conversely, a detention not authorized by law is arbitrary and in violation of s. 9. In Charkaoui, at para. 91, the Supreme Court held that the s. 9 guarantee against arbitrary detention “encompasses the right to prompt review of detention under s. 10(c) of the Charter.”

[436] The Supreme Court has described ss. 7 to 14 of the Charter as a “scheme of interconnected legal rights”: R. v. Malmo-Levine, 2003 SCC 74, [2003] 3 S.C.R. 571, at para. 160. Sections 8 to 14 address specific deprivations of the right to life, liberty, and security of the person in breach of the principles of fundamental justice, and as such, violations of s. 7. They are designed to protect, in a specific manner and setting, the right to life, liberty, and security of the person set forth in s. 7: Re B.C. Motor Vehicle Act, 1985 CanLII 81 (SCC), [1985] 2 S.C.R. 486, at para. 28.

[437] I accept the submission of the accused that deficiencies in the segregation review process may amount to a distinct breach of the s. 9 guarantee against arbitrary detention while at the same time violating the s. 7 right not to be deprived of life, liberty, and security of the person except in accordance with the principles of fundamental justice.

[438] The law authorizing administrative segregation and establishing the review process for inmates in segregation in Ontario is contained within Regulation 778 under the Ministry of Correctional Services Act and reflected in the Ministry PMSI. During the period of time the accused was in segregation the March 2011 and the September 2015 versions of this policy were in effect.

[439] Under s. 34(1) of Regulation 778, segregation is by law restricted to inmates:

(a) In need of protection;

(b) Who must be segregated to protect the security of the institution or the safety of other inmates;

(c) Who are alleged to have committed a misconduct of a serious nature; or

(d) Who request to be placed in segregation.

[440] Segregation is required to be reviewed on a preliminary basis by the superintendent or designate within 24 hours of an inmate being placed in segregation. Within five days of an inmate being placed in segregation, the superintendent or designate is required to “review the full circumstances of the case” to determine whether the inmate’s continued segregation is warranted. The superintendent or designate is also required to ensure that a review of the reasons for continued segregation has been conducted when an inmate has been in segregation for a continuous period of 30 days, to be repeated each 30 days.

[441] Further, at each 30 day mark, the regional director or designate is required to ensure that the Segregation Decision/Review Form and related Occurrence Reports are reviewed and “any concerns are discussed with the superintendent or designate.”

[442] The accused has not challenged the Charter compliance of the statutory framework governing the segregation review process in Ontario. The accused’s position is that Ministry officials and employees failed to comply with the law in regard to segregation reviews in the case of the accused between June 4, 2012, and October 2016, such that his detention in segregation during this period of time was unlawful and therefore arbitrary and in violation of s. 9.

[443] The Crown has acknowledged that correctional authorities breached the accused’s s. 7 Charter rights when they failed to comply with provincial law and policy in regard to the accused’s segregation reviews. The accused takes the position that the right to prompt segregation reviews based on objective and reliable information is a distinct right guaranteed by s. 9. I agree.

[444] Following his placement in segregation on June 4, 2012, the accused was held in what Dr. Bradford described as conditions of almost complete isolation for the months of June, July, and August of 2012. I accept the accused’s submission that the constitutional requirement of prompt review consistent with the applicable law is heightened in the case of a mentally ill inmate being segregated in these conditions.

[445] Between June 4, 2012, and August 29, 2012, the accused’s placement in segregation was legally required to have been reviewed 20 times, 18 times at the institutional level and twice at the regional level. Incomprehensibly and contrary to law, the accused’s detention in segregation was not reviewed a single time between June 4, 2012, and August 29, 2012. A review on August 29, 2012, appears to have been an initial placement review.

[446] Corrections conducted 5 day reviews at the institutional level on September 3 and 8, 2012. Between September 8, 2012, and February 21, 2013, the accused’s placement in segregation was legally required to have been reviewed 43 times, 33 5 day reviews at the institutional level and five 30 day reviews at both the institutional and regional levels. During this five and one-half month period, the accused’s detention in segregation was not reviewed on a single occasion.

[447] On February 21, 2013, Ms. McKay emailed Mr. D. Smith, Regional Director, and attached the Segregation Decision/Review form for the accused, explaining to the Regional Director that this review “may have slipped through the cracks” as the accused had been in segregation at the Thunder Bay Jail since the beginning of August 2012. Neither Ms. McKay, Deputy of Operations at the Thunder Bay Jail at the time, nor the Regional Director twigged to the fact that the accused had been in continuous segregation since June 4, 2012.

[448] This segregation review form, provided to the Regional Director for the purpose of oversight and review of the institution’s position that segregation be continued, confirmed that the only segregation reviews conducted for the accused to this point in time occurred on August 29, September 3, and September 8, 2012. The Regional Director should have recognized this as an egregious and unacceptable breach of policy, both at the institutional and regional levels. Mr. Smith failed to do so. The extent of Mr. Smith’s review and oversight at this point was to ask, out of “curiosity,” if the accused was receiving any regular mental health services. He was advised that the accused had refused mental health intervention.

[449] Mr. Smith unconditionally approved the continued segregation of the accused on February 27, 2013. There is nothing in the record before me to suggest that Mr. Smith, in his supervisory role as Regional Director, even commented on the fact that in excess of 60 mandated segregation reviews had not been carried out at that point in time.

[450] Institutional reviews were conducted on a somewhat regular basis between February 27, 2013, and July 2013. All supported continued segregation. However, these institutional reviews were conducted without regional oversight as no regional reviews were conducted between February 27, 2013, and July 16, 2013, a period of time during which Ministry policy mandated five reviews at the regional level.

[451] For nine months following the placement of a young, mentally ill, Indigenous man in segregation, his placement in segregation was reviewed at the institutional level only three times. Further, for in excess of one year following the accused’s placement in segregation, it was not reviewed at all at the regional level in any substantive or meaningful way.

[452] The March 2011 version of the PSMI policy required that placement decisions regarding special management inmates be based on “reliable information and objective criteria” and be consistent with placing inmates in the lowest level of security possible.

[453] The 2012 segregation reviews that were completed for the accused noted “charged with the murder of an inmate while in custody at the TBCC” as the reason for continued segregation. Beginning in mid-2013, the segregation review forms at the institution and regional levels begin to note that the reason for continued segregation was the security of the institution and the safety of other inmates and that the accused had or continued to express thoughts to the psychiatrist of wanting to harm staff and other inmates.

[454] A review of the segregation review forms from 2013, 2014, 2015, and up to October 2016 indicates the same reasons were recorded to support continued segregation throughout these years. For example, the Segregation Decision/Review Form dated October 4, 2016, lists the following reasons for segregation:

34(1)(a) – Offender is in need of protection. Offender was self-harming and needed to be placed in restraint chair on Sept. 22;

34(1)(b) – Safety and security. Offender discloses ongoing pervasive thoughts to seriously harm or kill staff and other offenders. Segregation requested by Institutional psychologist.

[455] Dr. Stambrook’s notes from his August 20, 2012, meeting with the accused confirm, among other things, that the accused expressed “ideation” in regard to stabbing people and harming correctional officers at that time. Dr. Stambrook properly recommended continued segregation at that time. Dr. Stambrook followed up with the accused on March 11, 2013. He diagnosed the accused as having an anti-social personality disorder with psychopathy combined with sadistic paraphilia, a “dangerous combination where there is a high risk” according to Dr. Stambrook. Dr. Stambrook recommended that the accused not be in a dorm situation at that time. In a March 25, 2013, follow-up note, Dr. Stambrook saw no change and specifically noted that the accused expressed sadistic, violent, and murderous ideation toward staff. He recommended that the accused be treated with extreme caution.

[456] Dr. Schubert’s notes up to the fall of 2013 are consistent with those of Dr. Stambrook. On July 5, 2013, Dr. Schubert noted that the accused has had intermittent thoughts and dreams of killing people and that he was a “very high risk individual for violence.” Dr. Schubert noted that he had talked with correctional and nursing staff about the accused’s risk of harm to staff and other inmates. Dr. Schubert’s September 6, 2013, note indicates that the accused “remains extreme risk of violence – jail aware precautions in place.”

[457] Thereafter however, the contents of Dr. Schubert’s notes changed in a material and relevant manner and included the following:

December 11, 2013 – no suicidal ideation, no homicidal ideation, no psychosis – history chronic homicidal ideation/fantasies however

February 7, 2014 – not suicidal or homicidal at this time

April 4, 2014 – denies any suicidal ideation/homicidal ideation or fantasies of violence/sexual nature

May 27, 2014 – no suicidal ideation no homicidal ideation no psychosis

July 23, 2014 – low risk suicide/homicide at this time

September 5, 2014 – denies any homicidal ideation today, no talk of any sadistic fantasies today

October 28, 2014 – no suicidal ideation no homicidal ideation no talk of sadistic fantasies today. No violent fantasies reported.

December 31, 2014 – thought process: normal content no suicidal ideation no homicidal ideation no psychosis

March 25, 2015 – thought process normal content normal no suicidal ideation no homicidal ideation no psychosis not talking of violent fantasies today

April 15, 2015 – thought process normal content no suicidal ideation no homicidal ideation no psychosis

May 20, 2015 – no suicidal ideation no homicidal ideation no psychosis

August 12, 2015 – no suicidal ideation no homicidal ideation no psychosis

September 23, 2015 – no suicidal ideation no homicidal ideation – but I suspect he still harbours thoughts of violent nature – should remain in cell by self

October 21, 2015 – no suicidal ideation no homicidal ideation

November 6, 2015 – denies any homicidal ideation or suicidal ideation – I am still of the opinion requires own cell

January 13, 2016 – denies suicidal ideations and homicidal ideations – currently in my opinion can be managed at lower levels of observation

January 20, 2016 – denies any suicidal ideation or homicidal ideation – would benefit from increased privileges, from a psychological perspective

August 31, 2016 – thought process normal content no suicide ideation no homicide ideation, stable at this time given history will recommend administrative segregation with own cell

September 28, 2016 – no suicidal ideation no homicidal ideation

October 26, 2016 – denies suicidal ideation denies homicidal ideation

[458] Dr. Stambrook’s and Dr. Schubert’s notes were not available to the correctional officials conducting the segregation reviews. The Health Care Manager, Ms. Boban, was required to review the accused’s medical file and prepare health care administrative summaries for the purpose of the segregation reviews. Ms. Boban testified that she knew that her health care summaries formed an integral part of the segregation review process at both the institution and regional levels and that it was required that they include the most accurate and current information available about inmates undergoing segregation review.

[459] It is clear that the health care administrative summaries prepared by Ms. Boban concerning the accused were deficient and contained inaccurate information for the three year period between October 2013 and October 2016. Ms. Boban failed to include in her summaries that the accused stopped reporting homicidal ideation or suicidal ideation after October 2013. Ms. Boban failed to accurately convey the information contained in Dr. Schubert’s notes, as set out above, including the notes from January 2016, to the effect that the accused could be managed at lower levels of observation and that he would benefit from increased privileges.

[460] From the fall of 2013 to the fall of 2016, the continued segregation of the accused was supported by institutional and regional staff on the basis of protecting the security of the institution or other inmates. The health care administrative summaries used in the reviews for this period of time provided them with the grounds for doing so. However, as of the fall of 2013 the accused’s psychiatric records were not being accurately reflected or summarized in these health care administrative summaries.

[461] I accept the accused’s submission that the ongoing decisions to detain the accused in segregation after the fall of 2013 were not based on reliable information and objective criteria as required by Ministry policy. I find that the segregation of the accused during this period of time was therefore contrary to Ministry policy and unlawful.

[462] During the first 13 months that the accused was held in segregation, numerous segregation reviews which corrections was required to conduct at the institutional level did not take place. Regional oversight during the same period of time was non-existent.

[463] For the three years that the accused was held in segregation between 2013 and 2016, segregation review decisions were based on inaccurate and unreliable information as to the accused’s psychological status.

[464] Continuously detaining the accused in segregation without adhering to the segregation review policy and in the absence of a proper evidentiary basis that the accused was a risk to the safety or security of the institution or other inmates was unlawful and therefore arbitrary. I accept the submission of the accused that this represents a separate and distinct breach of his s. 9 [Charter](https://www.canlii.org/en/ca/laws/stat/schedule-b-to-the-canada-act-1982-uk-1982