Anatomy of an outbreak: How COVID-19 overran this Ontario prison

In April 2020, the Ontario Correctional Institute saw what was then the most significant outbreak at any provincially run prison. What lessons were learned — and who was to blame?
By Ashley Okwuosa - Published on Jul 13, 2021
(Illustration by Mary Kirkpatrick)

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On April 14, 2020, employees at Brampton’s Ontario Correctional Institute received a memo informing them that a co-worker had tested positive for COVID-19. “It is important to note that the individual did not experience symptoms while at work,” wrote Mark Parisotto, director of the central region for the Ministry of the Solicitor General’s Institutional Services Division. “The employee remains in self-isolation and is following protocols recommended by health authorities.”

Employees were advised to wash their hands often, sneeze into their sleeve, avoid touching their face and contact with sick people, and stay home if they were ill. They were told that all work areas the employee had come in contact with had been cleaned and that “common area touch points” were being disinfected twice a day. “We have been advised that no additional precautions are necessary at this time,” Parisotto wrote. “Your health and well being are priorities for my management colleagues and I.”

The ministry, which operates provincial correctional facilities, had been made aware of the positive case three days earlier. On April 15, Peel Public Health declared an outbreak, following two lab-confirmed and one probable case of COVID-19 in correctional officers. On April 20, OCI closed. Inmates were moved first to Toronto South Detention Centre and then, in June, to the Maplehurst Correctional Complex. Both facilities later experienced outbreaks of their own. 

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sign reading "Ontario Correctional Institute"
Peel Public Health declared an outbreak at the Ontario Correctional Institute on April 15. (Nathan Denette)

A ministry spokesperson confirms that, when OCI closed, 91 of its 109 inmates had tested positive. According to Adam Cygler, a social worker at OCI and former president of OPSEU local 229, the union that represents its correctional workers, 32 of the roughly 170 staff and 11 family members of staff were either confirmed or presumed to be positive for COVID-19. The ministry did not respond to TVO.org’s request for verification of these numbers.

It was then the most significant outbreak at any provincially run prison in Ontario. At a time when public experts were adjusting guidelines to match the developing knowledge of the disease, it became a flashpoint for concerns about worker and inmate safety and managerial indifference — and fuelled questions about government policy that have echoed throughout the pandemic.  

Staff had raised concerns about the potential for COVID-19 spread within the facility months before the outbreak was declared. “We foresaw this becoming an issue in the correctional institutions,” says Ryan Graham, co-chair of OPSEU’s Provincial Joint Occupational Health and Safety Committee. He says the committee recommended as early as January 2020 that the ministry implement active screening methods in its facilities — but that the ministry pushed back, stating that it wasn’t the time for such measures. “One of the overarching things we have always heard is ‘we’re not there yet,’” says Graham. “If I have to fault the ministry on anything, it is not being proactive enough. We’ve been very reactive.” 

A ministry spokesperson tells TVO.org via email that “from the beginning of the COVID-19 pandemic, the ministry has been working with its partners to keep provincial correctional facilities and our communities safe.” 

closeup of man with long dark hair
Tee was transferred to OCI in January
2020. (Courtesy of Tee)

Inside OCI — which, according to the ministry, provides “specialized and intensive treatment for … substance abuse, sexual misconduct, impulse control and anger management” — inmates’ beds line the walls of large, communal dormitories. Common areas include a day room, bathrooms, a dining hall, and a gym. “We are, apart from eight cells, 99 per cent a dorm setting,” Cygler says. “And individuals interact in a very community-style way.” 

Tee says that, compared to Toronto South Detention Centre, OCI was a “breath of fresh air.” Tee, who asked that TVO.org use only his first name to protect his anonymity, had been incarcerated at TSDC since May 2019 and was transferred to OCI in January 2020.

“I heard that the place is more of a rehabilitation centre as opposed to other provincial jails, because they don’t really offer much. OCI has a bunch of different programs,” says Tee. But in March, things changed. Tee describes the month leading up to the outbreak as chaotic. Many residents were angry because, as they learned about COVID-19 spreading across the province on the news, they began asking for such protective measures as masks or gloves — according to Tee, they were ignored. “It was like they didn’t care what we had to say because we’re in orange,” he says.

OCI, like many institutions, did have its own influenza-preparedness plan. TVO.org obtained a copy of this plan, dated March 2020, through a freedom-of-information request. The document recommends such precautions as PPE use, social distancing, and restrictions on inmate transfers. But staff members and Tee say that they weren’t implemented properly. 

“We were told that they wouldn’t activate the pandemic plan until there was an outbreak, and our response was, ‘Well, then it’s too late,’” says Cygler. The ministry did not respond to direct and repeated questions about when the facility’s pandemic plan was activated.

The facility didn’t mandate social distancing, considering it “a personal choice,” says Jamie, a correctional officer who, concerned about potential professional ramifiations, requested that their name and personal pronoun be changed to protect their anonymity — and distancing was not observed during a staff-appreciation event held at the facility in late March. A spokesperson for the ministry confirms to TVO.org that a drop-in staff event was held on March 25 but states that distancing measures were in place. Prior to the OCI outbreak, Jamie notes, management had placed posters and floor markers throughout the facility to indicate appropriate distances, as set out in public-health guidelines. 

Tee says that, while such markers were in place, inmates did not observe social distancing during meals: “It was kind of weird, because there’s a lot of contradictions that were happening in that time as far as what we can and can’t do.”

drawing of a black shape coming through green bars
(Illustration by Mary Kirkpatrick)

Jamie, who says they worked with the employee who’d been the first reported case, says management did not inform them of the possible exposure and that they found out only when the infected co-worker told them they had a fever. TVO.org asked the ministry when management learned that a staff member was exhibiting symptoms; the ministry responded that it does not publicly discuss confidential human-resources matters, especially in cases involving personal health information.

Mask-wearing guidelines were then in a state of flux: Peel Public Health confirmed to TVO.org that it recommended universal masking at OCI during the outbreak but noted that, at the time, there was no provincial guidance for the management of COVID-19 in congregate settings. It wasn’t until April 6 that the federal government recommended that people use non-medical masks in situations where physical distancing was difficult or impossible, and it wasn’t until July 10 that Brampton mandated masks in all public indoor spaces.

At OCI, a March 17 memo from deputy superintendent of administration John Hasted indicates that correctional officers conducting COVID-19 screenings must wear surgical masks, gloves, and eye protection while within two metres of an unscreened inmate. He adds, however, “Staff/residents who are not involved in the screening and can be 2 metres away before and during the screening do not need to have a mask and eye protection.” 

Some staff, though, wanted more routine mask-wearing — and say they were both ignored and ridiculed. 

In March, there were “hundreds of N-95 masks” in the facility’s training office, says Brett, a corrections officer who, concerned about potential professional ramifiations, requested that TVO.org change their name and personal pronoun to protect their anonymity. Brett says, though, that when they asked whether they could get one to wear while admitting and discharging inmates, they were told by the business administrator that it was not issuing N-95 masks. OCI’s pandemic plan indicated that PPE, including N-95 masks, were available in inventories on site “in quantities estimated to last approximately eight weeks.”

After Brett threatened to file a complaint, they say, OCI offered a surgical mask, but Brett told their superiors they worried that a surgical mask wouldn’t provide adequate protection. Management told them, Brett says, that the N-95 masks had expired and that the straps might break. In the past, Brett says, N-95 masks had been distributed to those likely to come in contact with someone who had tuberculosis, which can spread through droplets. In March, though, Brett says, “They laughed at me when I asked for the N-95, so what can you do? It was almost like a joke. They took it very lightly.” 

Jamie, who tested positive two days after OCI’s closure on April 20, says staff were not required to wear masks until the outbreak was declared on April 15: “We were not required to wear a mask in the facility prior to anybody getting sick.”

memo about positive case at OCI

Prior to the outbreak, Jamie attempted to wear their own mask, but Jamie says that a supervisor told them that they would be subject to disciplinary action for doing so, because masks would frighten the inmates. Jamie says, however, “Inmates were asking why we weren’t wearing masks.” TVO.org repeatedly asked the ministry whether workers could face disciplinary action in this circumstance but received no response.

“I think at the time, the administration was concerned about the inmate population panicking or becoming fearful,” says Cygler. “And what we were saying is sort of the opposite. I think they would be reassured by seeing us take the appropriate precautions.”

Tee says that inmates repeatedly asked correctional workers why they weren’t wearing masks: “There was a lot of back and forth between the residents and the staff … we knew that, because we were pretty much closed off to society, the only way for anyone to get COVID was through someone from the outside, and nobody there wore any PPE whatsoever.” 

On April 9, 2020, superintendent Felecia Hooper issued a memo stating that staff could wear their own masks in situations where doing so was not required under public-health guidelines. “When a staff member enters a situation where PPE is required, they must remove their personal mask and use ministry-issued PPE only,” Hooper wrote in the memo, which TVO.org also obtained through a freedom-of-information request. 

She stated that staff members would be required to sign a waiver to confirm “they are accepting the risk of wearing a personal mask” and to have the mask visually inspected by a management team member each day to ensure that it had no offensive markings, did not present a known and avoidable elevated security risk to the wearer or others, and looked like an N-95 or surgical mask. 

a room with a circle of chairs
OCI suspended all programming on April 15. Pictured here is the institution's Indigenous Program Room. (Independent Review of Ontario Corrections/Queen's Printer for Ontario/mcscs.jus.gov.on.ca)

Still, until the outbreak was declared at OCI, staff say, management did not provide masks. Work refusals filed by OCI correctional staff to the Ministry of Labour indicate that they were unwilling to transfer sick inmates unless the workers had masks; one officer wrote on April 14 that they were refusing to go to a unit with sick inmates unless masks were provided by their employer. The ministry conducted a field visit that day and determined that OCI was meeting its responsibilities under the Occupational Health and Safety Act.

OCI wasn’t the only institution where staff were refusing to work. According to ministry data obtained by TVO.org, 48 refusals were filed last year between March 11 and April 20 at various correctional facilities across the province. Most involved staff alleging that preventative measures weren’t being taken. One refusal, from the Ottawa-Carleton Detention Centre on March 27, states that the facility had not provided or posted a contingency plan to quell panic. Another refusal, from South West Detention Centre, dated March 30, indicates that a staff member was refusing to work in a unit where they could not practise physical distancing; they stated that they would work in the unit if they were given an N-95 mask but that their request for one had not been granted.

“Staff were truly concerned for their health and safety about entering the workplace,” says Graham. 

The Ministry of Labour, in a statement, says it determined the institutions were following the appropriate health and safety protocols. A ministry representative tells TVO.org via email that “when a work refusal is not upheld, the worker’s concern is investigated as a complaint. In some cases, the health & safety concerns were resolved internally by the workplace parties with assistance from a MLTSD health and safety inspector if required.” 

TVO.org asked the ministry at what point it became a requirement that staff members and inmates wear PPE throughout the facility but did not receive a response. On April 22 — a week after the OCI outbreak was declared — OPSEU and the ministry arrived at a deal that required all staff and visitors at Ontario prisons to wear surgical masks.

In an April 15 memo, Deputy Superintendent John Hasted announced that the institution was going into lockdown; movement would be restricted and four units placed on so-called droplet precautions — which, according to April 2020 ministry guidelines “are required for inmates who have symptoms, are persons under investigation for influenza-like illness, or have identified risk factors such as close contact or travel history.”

“Residents that were showing cold-like/flu-like symptoms have been isolated in the segregation area,” he writes. Meals were no longer to be eaten in the cafeteria, and “all staff working in Droplet precaution areas will be issued PPE.” 

Deputy Superintendent Donna Butler released a memo the same day, indicating that OCI had suspended all programming, including “House Meetings, Peer Reviews, Recreation, Library and treatment specific programs, etc., until further notice.”

Howard Sapers, who served as the Ontario government’s independent adviser on 

man in orange jumpsuit holding a mask in front of green bars
(Illustration by Mary Kirkpatrick)

corrections reform from 2017 to 2018, says corrections, like every other sector, was unprepared for the risk that COVID-19 posed. “What caught the rest of the world off-guard also caught corrections off-guard,” he says. “And Ontario, like every other correctional system, was catching up to the virus as the risk of infection was growing.” 

Monica Hau, Peel Region’s associate medical officer of health notes that, at the time of the outbreak, “everything was pretty new still.” Understanding of the disease and its transmission was “rapidly evolving,” she says, adding, “For example, we were just starting to get a better understanding of the role of pre-symptomatic and asymptomatic transmission. And infection-prevention and -control measures that are now so routine were actually relatively new at that time.”

But the union was clear on who needed to shoulder the blame. In an April 20 statement, OPSEU president Warren Thomas said the outbreak had resulted from “management incompetence.” For weeks, he said, “the people running our jails have ignored the direction of public health officials and know-how of frontline workers who want to keep our jails as safe as possible.”

Graham says that the union and ministry had more frequent discussions about safety measures after the OCI outbreak. And the ministry tells TVO.org via email that it has made important operational changes across all provincial correctional facilities; for example, newly admitted inmates are separated from the general population for 14 days, all staff are required to wear a mask and appropriate eye protection while at work, and staff and visitors receive temperature checks. Asked when these measures were introduced, the ministry did not respond.

Since OCI closed, however, outbreaks have been reported in Maplehurst, TSDC, the Thunder Bay District Jail, the Thunder Bay Correctional Centre, the Stratford Jail, the Central East Correctional Centre, and, most recently, the North Bay Jail. Two other facilities have temporarily closed as a result of outbreaks — the Stratford Jail in February and the North Bay Jail in June. According to a research project led by the University of Winnipeg’s Kevin Walby and the University of Ottawa’s Justin Piché, Ontario has reported the highest number of correctional cases of all the provinces tracked, with 2,240 as of June 29

Sapers says that the very design of jails and correctional facilities makes them more susceptible to spread. “You’ve got a high concentration of people living in very close quarters, often with less than optimal fresh-air circulation, and you also have a tremendous amount of movement in and out of the facility,” he says, adding that, as a result, it can be hard to properly apply such public-health guidelines as social distancing. In his view, the most effective way to limit spread is to reduce the number of inmates: “Depopulation of carceral centres, jails, and prisons has proven to be more successful than trying to just take a public-health approach inside the jail.”

Early on the pandemic, he says, the government did pursue that strategy with “a real sense of urgency.” In March 2020, the government announced that it would issue temporary absences beyond the current 72-hour maximum and allow for early release of those inmates near the end of their sentences.

However, a report from the Canadian Civil Liberties Association, produced in partnership with the Centre for Access to Justice and the Criminalization and Punishment Education Project, found that, by early 2021, provincial jails and federal prisons in Ontario and other provinces were detaining more individuals than they had been at the end of the first wave. Statistics Canada data included in the report shows that Ontario’s correctional population steadily increased from 5,811 in June to more than 7,000 in March 2021. 

memo about the lockdown at OCI

“I think that they took their foot off the gas, diversion- and decarceration-wise right when, arguably, the need to ramp up those efforts increased,” says Piché, an associate professor of criminology. 

Graham recommends an additional measure to limit COVID-19 spread: changing the way updates are shared with correctional facilities. 

Currently, he says, information about those who have come in contact with a positive case goes from the local institution to the ministry, which sends it to public health. The information gathered from contract tracing is then sent back from public health to the ministry and from there to the facilities. Contact tracing, Graham says, can take days or weeks: “There’s a lot missed in the meantime.” (Peel Public Health says it received word of the first positive test from OCI on April 10 — but it wasn’t until April 13 that it received the relevant contact list and began tracing.) 

Graham would like to see more direct communication between local public-health units and facilities: “A simple process would be, a staff member is identified positive, the joint health and safety committee does a health and safety investigation. They gather that information and give it to public health, public health does contact tracing, they contact individuals, and the summary gets sent back to the institutions. And that can be done within, arguably, hours.” 

Vera Etches, Ottawa’s chief medical officer of health, has suggested three ways to help prevent future outbreaks in correctional institutions. In a June 21 letter to Ontario’s solicitor general, she recommends the government ensure that facilities have sufficient capacity to isolate inmates and that isolation periods are adhered to; establish practices to monitor the vaccination coverage rates of staff and inmates on a weekly basis to guide on-site immunization efforts; and fully implement rapid testing prior to transfer to or from other correctional facilities. (Etches congratulated the ministry for introducing a pilot program for rapid testing but called for its full implementation.)

For OCI and other correctional facilities across the province, vaccination remains the most effective measure when it comes to reducing spread, Hau says: “I think it’s been very clear, the success in long-term-care homes … I’m certainly hopeful that correctional facilities can achieve the same rate of vaccination.” At the end of May, the ministry told TVO.org that “the current vaccine uptake among inmates [was] approximately 50 per cent.” However, in June, the Toronto Star reported that institution-level vaccination data obtained from the ministry and local public-health units showed that vaccination rates varied widely between facilities — from 100 per cent at the Algoma Treatment and Remand Centre in Sault Ste. Marie to 13 per cent at the Toronto East Detention Centre.

The Agenda With Steve Paikin, April 6, 2020: COVID-19 and the corrections system

OCI has now been closed for more than a year. There’s no indication of when it will reopen. The ministry says it is “carefully considering options before making any plans to reopen OCI.”

Tee say that, since his release last November, he’s realized how difficult it can be to enforce public-health measures, no matter the setting. But he still believes more should have been done at OCI, especially because of its layout: “The guy that sleeps next to me is less than two feet away from me.” Other former inmates feel the same way he does, he says: “They dropped the ball as far as protecting us.” 

According to Cygler, “The impact the outbreak has had on staff and resident morale and trust — that’s going to take a long time to repair.”

Jamie says: “They completely ignored the fact that we are a unique setting,” Jamie says. “They let us down.”

Correction: An earlier version of this article misspelled Felecia Hooper's name. TVO.org regrets the error. 

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