Fatal response: PS104-14/2017E-PDF

an investigation into the preventable death of Matthew Ryan Hines : final report.

“This is the Final Report of my investigation into the death of Matthew Ryan Hines, age 33, who died unexpectedly in federal custody following a series of use of force incidents at Dorchester Penitentiary on May 26, 2015. An Interim Report containing my preliminary findings in this case was shared with the Commissioner of Corrections on August 26, 2016. In response, the Correctional Service of Canada (CSC) addressed a number of concerns and questions arising from my Interim Report including discipline of front-line staff members involved in this case, the use of inflammatory agents in federal corrections and the quality of health care provided to Mr. Hines. This information, which I received in early October 2016, has been helpful in completing my investigation. My Final Report […] contains my assessment of what went wrong in this case, the adequacy of the corrective measures that have been taken to date and how such events might be averted in the future. Based on the information that has been made available and reviewed by my Office to this point in time, it is my conclusion that Matthew Hines’ death while in the care and custody of the federal Correctional Service was preventable”--Introd., p. 1, 2.

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Department/Agency Office of the Correctional Investigator.
Title Fatal response
Subtitle an investigation into the preventable death of Matthew Ryan Hines : final report.
Publication Type Monograph
Language [English]
Other Language Editions [French]
Format Electronic
Electronic Document

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Note Issued also in French under title: Une réaction fatale : enquête sur le décès en établissement de Matthew Ryan Hines : rapport définitif. Cover title. "February 15, 2017."
Date 2017.
Number of Pages 22, [3] p.
ISBN 978-0-660-07645-4
Catalogue Number
  • PS104-14/2017E-PDF
Subject Terms Correctional institutions, Inmates, Death, Investigations