Inside grey walls: unprepared for an aging inmate population
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* Jack Lawson

Inadequate infrastructure and health care to support aging prisoners is an emerging problem in federal penitentiaries, says the Office of the Correctional Investigator of Canada.

*An Investigation of the Correctional Service of Canada’s Mortality Review Process* recently issued by Howard Sapers focused on important quality-of-care issues, including a lack of follow-up on treatment recommendations, but also highlighted the particular difficulties inherent in caring for an aging prison population.

One in 5 of Canada’s 15 000 federal inmates is now over the age of 50, a rate destined to increase, given that the average life sentence lasts 28 years, says Sapers.

Fifty is not generally considered old, but in prison, the physiological age of prisoners is about 10 years older than their chronological age because they lead “rougher lives” and do not have the best nutrition, says Catherine Latimer, executive director of the John Howard Society of Canada.

An aging population makes managing medical problems in prisons increasingly expensive, adds Latimer. “There are a number of chronic problems, hepatitis C for example, and a strong belief that these sorts of chronic diseases are increasing in number.”

Older prisoners suffer from the same sort of health problems as the general population, including Parkinson disease, dementia and cancer, but the prevalence of some chronic diseases is much higher. According to a 2013 *CMAJ* article, older prisoners are more likely than people in the general population to have heart disease (30% v. 10%–20%) and hypertension (37% v. 1%–2%), for example. Hearing impairments are twice as likely.

Sapers identified staffing shortages and a lack of specialized geriatric care as a particular problem in caring for this population.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/186/6/E191/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/186/6/E191/F1)

One in 5 of Canada’s 15 000 federal inmates is now over the age of 50.

Image courtesy of © LOUOATES/iStock/Thinkstock

Kate Johnson, chaplain for the Pittsburgh Institution near Kingston, Ontario, from 2008 until 2013, echoed those concerns. The Pittsburg Institution houses 250 inmates over the age of 50 who have mobility issues and are at a low risk to reoffend.

“The facility was doing the best that it could, but it had gotten to the point where other inmates were taking care of [other inmates],” said Johnson. “Often this would work very well, but sometimes it wouldn’t, like when the other patients would steal their medication.”

Prison infrastructure also remains a problem, says Sapers. “Prisons simply aren’t designed for wheelchairs, canes and hospital beds. The infrastructure just isn’t there yet.” This is particularly problematic as prisons become more crowded. “The more double bunking you have, the greater chance you have of someone falling and hurting themselves.”

## A flawed system

The correctional investigator’s report, issued on February 17, examined 536 inmate deaths from 2003 to 2013 in federal penitentiaries, two-thirds of which were attributed to natural causes. Since 2006, the medical records of prisoners who succumb to natural causes have been reviewed at the Correctional Service Canada’s (CSC) national headquarters by a registered nurse.

“Mortality reviews consisted of little more than one person sitting at a desk in Ottawa, writing up the documents,” says Sapers. “There were no interviews, and no on-site analysis. We felt that these reviews weren’t thorough enough, and deserving of having an independent process.”

The report examined more than 100 reviews; 15 raised concerns about end-of-life care. The expert evaluation highlighted questionable diagnostic practices; incomplete medical documentation; concerns about the quality of information being shared among health care providers and correctional staff; and, delays and/or lack of appropriate follow-up on treatment recommendations.

Sapers also criticized the mortality review process for not generating a “single finding recommendation, lesson learned or corrective measure of any national significance.”

In addition, the reviews could take up to two years to complete.

One of the report’s most disturbing conclusions was that potentially preventable or premature deaths may have gone undetected simply because they were attributed to natural causes. Deaths ruled as unnatural, including those due to suicide, homicide, overdose or unknown causes, are investigated by a national board. However, 30% of the examined deaths from natural causes were deemed sudden or unexpected, but received no special attention. The report recommends that these be examined by the national board as well.

CSC’s mortality review process is “flawed and inadequate,” concluded Sapers in the report. “It is not carried out in a timely and rigorous manner as required by law. It fails to thoroughly establish, reconstruct or probe the factors that may have contributed to the fatality under review.”