What Does the Database Tell Us About Deaths in Custody Across Canada? Causes, Manner of Death & Use of Force

By: Alexander McClelland, Jeffrey Bradley, & Lindsay Jennings

Last year, 2023, on August 10th for Prisoners’ Justice Day, the Tracking (In)Justice project launched the first comprehensive online memorial of people who have died in custody across Canada. The memorial is one step to address a context where deaths in custody are not acknowledged, tracked or documented in a consistent way across Canada, leaving little information available to the public.

This year, 2024, our team is working to further address this gap in understanding, as we launch the first online, publicly available database of deaths in custody across Canada since the year 2000. We hope this new database enables communities, academics, journalists, advocates, and criminal justice workers to access information on deaths in custody in ways previously not possible, so we are collectively able to understand systemic issues and patterns, to help support calls for change, transparency and accountability. To watch our launch event hosted on August 9, 2024, click here.

As of Prisoners’ Justice Day 2024, the database currently includes 2,131 deaths in custody across Canada since the year 2000. Due to limited access to information, this is a bare minimum of the total number of deaths in custody over the past 24 years. As this is a living database, our team will update the data on an ongoing basis when more information about deaths becomes available. This is an initial analysis, which will be further developed over the coming months.

Interpreting these findings

Until more analysis can be conducted, we urge caution in interpreting the database findings as a real world understanding of deaths in custody across Canada. But as this is the largest dataset on deaths in custody ever created in Canada, and our data sources are mostly directly from government sources, we believe the data can give us a strong indication of potential trends which warrant further investigation.

Causes of death

Coroners classify deaths using five categories including Accidental, Homicide, Natural, Suicide, and Undetermined. These classifications may lack detail, which means we do not get a fulsome picture of the patterns of death. For example, overdoses are usually deemed either as accidental or suicides, depending on the circumstances, meaning the exact number of overdoses may be hard to track. To help address this, when information is available, our team has identified more detailed causes of death based on available information in coroners reports. To avoid stigmatizing the deceased people in the database, we do not make detailed information available about causes of death on the Explore the Data page. For more info on our process, see our data dictionary.

A vast number of the causes of death (44.6%, 950 deaths) are unknown to the public.

The causes of all known deaths in the database are:

Overdose (14%, 299 deaths);
Chronic conditions or illness that an individual had for a to be determined length of time prior to their death (whether known or diagnosed in the autopsy), this will include acute contagious illnesses and infections, such as pneumonia, influenza, and COVID-19 (12.7%, 270 deaths);
Hanging or asphyxia with a ligature (11.3%, 241 deaths);
Injury or trauma, which may be accidental, intentional, or indeterminate in nature (7.8%, 167 deaths);
Medical events that began at the time of, or shortly before a death, such as myocardial infarction, stroke, or a blood clot (6.8%, 145 deaths);
Asphyxia that is not due to hanging or another form of ligature around the neck (1.2%, 26 deaths);
Substance withdrawal (.6%, 13 deaths); and
Deaths that are undetermined in nature (.9%, 20 deaths)

Manner of death

We also documented coroner’s classifications of the manner of death, which is intended to describe the way in which a death occurred. Of all the deaths in custody in the database from 2000 to 2024, 615 of the deaths were deemed Natural (28.9%), 452 of the deaths were deemed to be Suicide (21.1%), 365 of the deaths were deemed Accidental (17.1%), 138 were Undetermined (6.5%), and 102 were Homicide (4.8%). We did not have a coroner’s determination of the manner of death in 459 (21.5%) of the deaths.

Based on coroners’ determinations of deaths where the Manner of Death is known, 37% (615 deaths) were deemed Natural and 8.3% (138 deaths) were deemed to be Undetermined. When Suicide, Accidental, and Homicide are combined as unnatural manners of death, they form a majority, or 54.7% (910 deaths). This means that for those when Manner of Death is known, a majority of the deaths were potentially preventable.

Natural deaths

The definition of a Natural death is one used by corners to classify deaths. Deaths that are deemed to have occurred from natural causes by a coroner do not require inquests in all provinces and territories except for British Columbia and Saskatchewan.

However, there are deaths that have been deemed “natural” in the database which seem far from natural. For example, there are 15 deaths in the database from the years 2001 to 2017, which involved various tactical interventions, including either one of a combination of restraints, chemical/inflammatory agents, sedating agents, and/or physical handling from corrections officers or police.

Furthermore, deaths by Medical Assistance in Dying (MAiD) are also deemed Natural by coroners. Based on access to information requests we received, there were 29 MAiD applications between 2017 to 2023 submitted by people in federal custody. Out of those, 11 people were granted approval and ended their lives through MAiD. A majority of granted MAiD applications were cancer related. Most of the MAiD deaths were completed in a hospital setting, and 1 was listed as being completed at a federal institution.

Tactical interventions

Tactical interventions are forms of force used by police and correctional officers before and/or during the death of the person in custody. For example, tactical interventions include, restraints (handcuffs, spit hoods, physical holds), pepper spray/foam, tasers, physical force, firearms, and medical sedating agents. These interventions are involved in a minority of cases of deaths in custody. In 62.9% of cases in the database (1340 deaths) our team does not have enough information on the death to determine the use of a tactical intervention. For the cases where there is information, such as details included in a coroner’s report, or inquest document, 31% of the cases (663 deaths) had no use of tactical intervention, and in 6% of cases (128 deaths), a tactical intervention was used in the context of a person dying in custody.

Of the 128 deaths that involved a known tactical intervention, 68 involved a combination of multiple tactical interventions simultaneously, such as deaths involving restraint equipment, and chemical/inflammatory agent and physical handling. Overall, in the database, currently, there are 80 deaths involving physical handling, 92 involved restraint equipment, 15 involved intermediary weapons, 14 involved chemical/inflammatory agents, 8 involved medical sedating agents, 7 involved a firearm, and 2 involved a K9.

How can people use the database?

People can search the database using the variables on our website’s Explore the Data page to create their own analysis. For example, to get a snapshot of how many people have died in each institution, you can search the deaths by institution in which they occurred. Or, to understand patterns over time, you can search by date, and manner of death, or other factors such as gender, or type of custody. Custom searches are available for download via the Excel or CSV file button function on the Explore the Data page.