As you are undoubtedly aware, Ms Brass was a 28-year-old Aboriginal woman who died by hanging in a segregation cell after nearly 2 months' segregation. She had extensively self-harmed and spoken of suicide in the days leading up to her death. The nursing and other staff were unaware of her diagnosis with a serious psychiatric illness. The mental health nurse who saw her on her daily rounds had been working at the segregated maximum security unit for women at the Saskatchewan Penitentiary for a mere three weeks. The psychologist assigned to Ms Brass' case was unaware she was supposed to be working as a psychologist and thought she had been hired as a "counsellor". There was no formal communication or coordination between any of these mental health professionals or with security personnel in the unit.

In short, as the CSC investigation found, the "multi-disciplinary team" approach set out in the 1997 Mental Health Strategy was not followed. At page 35 of their report, the Board of Investigation into Ms Brass' death stated:

Considering the relevancy of this strategy to the operation of the Women's Unit at Saskatchewan Penitentiary, there does not appear to be any action plan to either adopt or ensure compliance (with the strategy) at the Women's Unit.

The Board points out that the process for tracking the implementation of this strategy was through a series of national meetings and committees which represented the regions and the women's institutions. In this case, the Board believes the primary tracking process appears to have been verbal update reports by those staff representing the Women's Unit at Saskatchewan Penitentiary at these meetings. The National Headquarters staff advised the Board that there was no indication to suggest that there were any difficulties with the process at the Women's Unit at the Saskatchewan Penitentiary.

The Board recommended that:

There is a need to determine the resource levels required at the Women's Unit at Saskatchewan Penitentiary in order to provide mental health services to the women as dictated by the provisions of the Mental Health Strategy for Women Offenders.

In our submission, this incident, as reported by the CSC's own Board of Investigation, provides persuasive evidence both of the necessity for an effective, adequately resourced Mental Health Strategy for federally sentenced women, and the utter futility of publishing another un-resourced Strategy. It is our view that a significant issue is the lack of line authority and clarity with respect to the manner in which the strategy is implemented. Amongst other things, this has resulted in responsibility being batted endlessly between head office, the regions, the institutions and institutional staff. Ultimately, no body is identifiable as being responsible for implementation and every body is able to plead ignorance and/or lack of responsibility or resources.