00000nam 2200000za 4500 9.832348 CaOODSP 20221107145947 cr ||||||||||| 170717s2017 onc ob f000 0 eng d 978-0-660-07645-4 978-0-660-07647-8 CaOODSP eng n-cn-nk PS104-14/2017E-PDF PS104-14/2017 Fatal response [electronic resource] : an investigation into the preventable death of Matthew Ryan Hines : final report. Investigation into the preventable death of Matthew Ryan Hines : final report [Ottawa] : The Correctional Investigator Canada, 2017. 22, [3] p. 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." Includes bibliographical references. “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. Issued also in bilingual print format. gccst Correctional institutions gccst Inmates gccst Death gccst Investigations Canada. Office of the Correctional Investigator. Une réaction fatale (CaOODSP)9.832350 Fatal response : (CaOODSP)9.832351 PDF 2.74 MB https://publications.gc.ca/collections/collection_2017/bec-oci/PS104-14-2017-eng.pdf