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Introduction
The principle that prisoners are entitled to the same level of health care as that provided to the wider community is accepted in an enlightened society and within enlightened prison systems. Since many prisoners in Canada come from marginalized society and also originate from other countries where there is inadequate health care and therefore high rates of disease like that of hepatitis, HIV and tuberculosis. Without health care for these inmates the diseases would spread throughout the jail and consequently into society upon their release. There are three different types of prison systems in Canada. Federal penitentiaries (housing people sentenced to 2 or more years) and provincial prisons (housing people sentences less than 2 years) and police cells (short stays around time of arrest). In Canada the crude rate of death among male inmates was 420.1 per 100,000 in federal institutions and 211.5 per 100,000 in provincial institutions. The death of inmates is taken no lighter than that of the civil population and therefore in Ontario, like most provinces, a coroner’s inquest is mandatory for any death of a person in custody. This is to ensure public examination of the circumstances leading to the death and to allow comparison of deaths in different settings. In all three types of custodial systems the deaths of all persons are subjected to a mandatory corners inquest. This is conducted with a jury of five citizens who are therefore responsible for making the finding or facts and recommendations via medical records and psychiatric files. By the end of the coroners examination as well as the jury’s must questions as to how the inmate died along with when, where and possibly even who should be answered, furthermore any ideas on how to prevent avoidable deaths if dubbed accidental or suicidal should be included within this report. The six critical components of a comprehensive suicide prevention policy for inmates include, staff training, intake screening/assessment, housing, levels of supervision, intervention and administration review, touched on through this document. In regards to staff there are 700 nurses employed by Correctional Cervices Canada (CSC)who play a large role in providing health care to offenders serving time in Canadian prisons. Many of these nurses are working in one of Canada’s 53 federal penitentiaries taking care of long term inmates who may not have previously sought out health care. Together these nurses represent the largest group of health-care professionals within the correctional system. Custodial authorities and ongoing public scrutiny as well as concern are necessary to continue improving health care in Ontario prisons.

The CSC
Correctional Services Canada, also known as CSC states in their legislative Mandate that they are to provide health services to federal offenders under the Corrections and Conditional Release Act (CCRA). This act indicates that the CSC is responsible for providing, “every inmate with essential health care and reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration in the community". The CSC strives to improve offender health to contribute to the safety of Canadians; this is accomplished by providing offenders with efficient, effective health care and services that encourage individual responsibility promote healthy reintegration; and Contribute to safe communities. Furthermore, section 86 of the Corrections and Conditional Release Act states that the CSC “shall provide every inmate with essential health care and non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community and that the provision of health care shall conform to professionally accepted standards”. From 2011-2011 the CSC has stated that their priorities are Essential Health Services (focus on the quality and consistency of essential health service delivery, including patient safety), Vulnerable Populations (improve capacity to address the health needs of Aboriginal offenders and offenders with mental health disorders), Health Information (improve evidence-based decision-making by collecting and analyzing health information), Workforce/Workplace ( strengthen a sustainable health workforce in a healthy workplace) and lastly Partnerships (strengthen internal and external partnerships).

History
Historically sequestration of offenders from society was possible; one could do more than incapacitate offenders. Thus, it was believed offenders could be reformed by punishment and that penitence might rectify inmates thereby allowing them to eventually enter main-stream life. The belief was that a steady and ascetic regimen in prison could reinstate virtue, penitence, and redemption among convicts. Furthermore a convict was not seen as inherently deprived, but the victim of an upbringing that had failed to provide protection against the vices at loose in society. Because of this it was believed that a well-ordered institution could successfully re-educate and rehabilitate him. 1959 was the first opportunity for prison authorities to be able to provide clinical care; psychiatric facilities were operational in federal penitentiaries but comprised only a single wing with the provision of one psychiatrist at Kingston Penitentiary.

Modern
Modern counterpart to the reformation perspective in prisons mentioned above is the treatment perspective. Treatment is described as an intentional method of improving offenders by therapeutic techniques rather than by fear or incapacitation. “Treatment is an attempt to effect a change of some deviation in the person treated whether this be the remission of an illness or of a mood, or a new attitude toward the conduct that we want to alter.” Inmates are now subjected to a wide range of tests to ascertain their degree of abnormality.

Kingston Prison for Women
Kingston Prison for Women had many names, such as the limestone fortress or even simply referred to as P4W. “P4W cells had no hot water. By day the clang and hum of electrically operated metal doors was constant. At night, wind rattled through doors and windows. Even more alarming for the prisoners were the chilling sounds that travelled through the antiquated vents: the screams of women housed in the prisons segregation unit.” Prisoner committee filled an official complain about excessive use of segregation by prison administration as the inmates were incapable of handling the pressure and this would result in slashing. It was even said that psychological damage done to the women in segregation is beyond punishment of the prison sentence, “...it is straight torture for any human person to be subjected to cages such as these.” Jan Heney worked on this official complaint. When the report was compiled it was concluded that the institutions way of handling women who slashed was likely to escalate rather than reduce the rate of self mutilation and suicide among prisoners. “Isolation increases rather than decreases suicide tendencies” and recommended an immediate end to the use of segregation on women who slash. Just four years after the prison opened and the Archambeault committee further investigating the penal system and recommended that the women's prison be shut down. Since 1968, no fewer than 13 government studies and nongovernment reports have reaffirmed that P4W should be closed and that decentralized facilities should be established closer to women's homes. In 1978, Solicitor General Jean-Jacques Blais announced that the prison would be closed within a year but instead in the early 1980’s; a new 18-foot-high concrete wall was placed around the prison at a cost of $1.4 million. Later in 1985 a target date announced by the federal government for dispersing the women, but that date also passed without any action being taken. Since then CSC has taken some emergency measures to try to make the conditions more tolerable as long as the Kingston Prison remains open, this includes hiring a second full-time psychologist and a sexual-abuse education program for inmates and staff. As well as a part-time aboriginal elder, a spiritual resource for the native population, a full-time native councilor and an instructor for native studies.

Treatment:
The problem of inadequate treatment exists in both federal and provincial penitentiaries yet the failure to provide adequate treatment may increase the burden of ill health later on. As a result increase the cost of the health care system all together as ultimately any disease will spread to the greater community as well. There is a wealth of evidence that indicates that emergency services for medically ill inmates have been, and continue to be, inadequate. Fundamental factors such as staff and client support for clinical services, informed consent of clients, and the benign nature of treatment are often unmet in penal context. This lack of available treatment could be due to a lack of funding, political will or public indifference, but most likely is a combination of all three. In addition, the failure of prison administrates to provide adequate clinical facilities in prisons have been set back by the reluctance of the civilian sector to admit prison-referred inmates, resulting in a reliance on the prison authorities to provide adequate clinical care for their prisoners. Clinical programs that do exist in prisons can be divided into two categories first being, emergency services for prisoners experiencing a minor crisis or disorientation (ex. Clinical response to life threatening acts by inmates) and secondly, a range of therapeutic services for inmates who wish to participate (ex. Individual or group psychotherapy). Also proven as an effective treatment is the “psyche-saving” importance of family visits to prisoners as well as a correspondence and personal belongings, basic elements of life can be crucial within prison. Changes in inmates are predicted based on effective treatment, accurate diagnoses and an appropriate match with treatment techniques as well as the improvements in psychological well being. Although since prisoners do not voluntarily enter prison it could be hypothesised that inmates are likely to regard imprisonment as a deprivation rather than an opportunity for growth. Therefore prisoners are more likely to undertake rehabilitation courses that address pragmatic issues such as budgeting, securing social assistance as well as clinical intervention for the disoriented and suicidal, but will reject those that are directed toward character flaws. It is believed that these treatments are not only beneficial to the inmates well being but also provide a diversion from the monotony life within prison, and may also improve their chances of making parole.

Health issues
The chaotic lifestyle of inmates outside of prison and the common association with drug use usually results in limited contact with the health care system; because of this diseases within prisons reach levels usually found in developing countries. Wendy Wobeser and her colleagues presented an analysis of mortality rates and causes of death among people in involuntary confinement in Ontario from 1990-1999. In total there were 308 inmate deaths of which 291(283 males, 8 women) are described in detail. Rates of death by poisoning, suicide homicide and natural causes in custody exceed the rates in the general population aged 25-49 by far. While death by accidental intoxication (such as drug overdose) was 20 times more common in provincial custody and 50 times more common in federal. Respectively suicide by strangulation was 10 and 4.5 times more frequent. According to CSC about 80 percent of federal inmates have a form of substance abuse problems and the crude rate of death among male inmates was 420.1 per 100,000 in federal institutions and 211.5 per 100,000 in provincial institutions. For many inmates, the need for care goes beyond that of chronic illness and addiction. There is an overwhelming amount of inmates with reported mental illness, which is actually three times for common in Canadian prisons than among the general public’s population. The CSC reports that 13 percent of male offenders in federal custody presented mental health problems when they were admitted in 2008, which is up 86 percent from 1997. For women, this figure reaches 24 percent of offenders which is an increase of 85 percent over the same period of time. In the general prison population, those with a mental illness are at risk for abuse by other inmates and suicide especially around the time of arrival and sentencing, which is a known watch phase by clinical staff for suicide attempts among inmates who are unable to adapt to the change. Furthermore, because punishment and segregation can drive mentally ill and even an average inmate to drastic measures it is important to remember that human rights, the rights of fair process, the right to counsel, the guarantee against unreasonable search and the fundamental obligation still apply to inmates. .This is to ensure that punishment does not approach “cruel and unusual” because it is excessive or inhumanely harsh. .

Suicide
Research into suicide in prison needs to be directed toward the exploration of preventative factors. Researching how to reduce the probability of suicide and environmental factors that could influence suicidal behaviour such as Prison regimes and prisoners social networks. Many suicides in the prison population occurred shortly after arrest and around the time of sentencing, which is a well-documented danger period. Prisoners who commit suicide are more likely to be young and more likely to be serving sentences over 10 years. They were also more like to have committed offenses involving theft, robbery and homicide and they are also more likely to be placed in higher security prison upon arrival into federal custody. Yet several people in custody had been identified as suicide risks and had killed themselves either while under “suicide watch” or shortly after such supervision had stopped. Furthermore suicide is the leading cause of death in prisons both in the United States and Canada, Global estimates for the year 2000 indicated that death by suicide exceed homicide and war related deaths. But Research fails to explain the process by which inmates make the decision to commit suicide. Process variables may include both situational variables and personal variables that can reflect changes in the risk for self harm. Personal process variables include well-known constructs such as hopelessness. Depression and hopelessness are two well-documented personal variables associated with suicide. Depression in inmates is a prevalent concern within correctional systems. A study of over 1,900 inmates in Canada showed that lifetime depressive disorders ranged from 21.5% (stringent criteria) to 29.8% (wide criteria ignoring severity and exclusions) of the sample. Other studies have found depressive symptoms reported by inmates to be higher on average than the general population. These high suicide rate numbers are even with the 1992 Ontario court ruling that provided that “the required standard of proof is proof to a high degree of probability in order to judge a death a suicide” therefore a systematic suicide prevention programme is viewed as essential to reduce suicide within correctional facilities.

Caring in Corrections
The initial premise of clinical problems among prisoners and a legacy of official neglect have been well established. Examination of other grounds nevertheless illustrates serious gaps between the ideal of humanist, effective treatment intervention and its application to all inmates. Over the years Canadian penitentiaries have broadly failed to support clinical approaches to imprisonment, “the senate subcommittee on Canadian penitentiaries repeatedly confirmed the dominate ideology of prison security and the low priority accorded to clinical services”; this is illustrated through two indices. First index is provided by intake procedures which classify inmates either on the basis of believed escape-proneness or requirements of prison industry rather than therapeutic considerations. In Canadian penitentiary system the three-fold classification of low, medium, high risk escape is used in the organization and classification of newly arrived inmates. The second index is the limited support for clinical treatments and the failure to attract professional treatment staff. According to Burtch and Ericson the ratio of professional staff to inmates does not meet minimal standards for adequate treatment, a truism which has been advanced by the solicitor general of Canada’s advisory Board of Psychiatric Consultants. The lack of highly skilled forensic workers reflects the unprestigious nature of institutional work and relatively lower salaries of prison clinicians vs. Clinicians in the civilian sector. Furthermore it is believed that existing treatment staffs in penitentiaries are in-adequately trained. This could be due to the ideology that the penal institutions are mainly designed to contain and control its prisoners rather than to correct any inappropriate behaviour. Nonetheless, the onus has rightfully fallen on the prison authorities to provide adequate clinical care for prisoners. In Canadian prisons nurses play the largest role in providing care to inmates, more than 700 nurse’s work in the federal system (167 of them in Ontario), serving more than 12,000 inmates. A further 400 work in Ontario’s correctional system caring for almost 9,000 people. McGraw, a nurse in one of Ontario’s prisons states that she sees upwards of 50 inmates a day, “We’re a hospital within the walls of the prison,” she says. “We have a physician twice a week, a dentist once a week, a physiotherapist once a month and an optometrist every six weeks.” McGraw also must treat the wounds of inmates who intentionally injury themselves in ways such as breaking the razor blades out of disposable razors and slashing, “our inmates engage in risky behaviour that’s why they are here” To be a nurse in a prison you are taking on more than your average role, you also act as a teacher, discharge manager and role model. You have to be able to provide emergency palliative care, and help with addiction withdrawal. Correctional nurses also need to have faith in their own ability to improve the health of people who may never have had someone to look after them. For some offenders, incarceration has led to their first contact with health care in a very long time, if ever.

Conclusion
Institutions have moral and ethical guidelines and all prisoners are entitled to the right of healthcare, but the needs just are not being met. The history shows that there have been major changes to the prison healthcare systems since the 20th century. Yet there is still much work to be done to bring the system up to standards. Prisons are reliant on nurses, and the nurses are expected to act as a mother, friend, teacher, role model, mentor and more and all for an average wage. The hospitals within prisons are often still inadequate and the treatments and rehabilitation courses are often not mandatory and therefore not taken. The reliance on nurses and lack of additional health care professional’s implies that the health care systems for Correctional Institutions within Canada, specifically Ontario, are still underdeveloped in modern society.