An Ottawa inmate spent a year in segregation at the Ottawa-Carleton Detention Centre, including in an "extremely dirty and dark" cell, but Ontario investigators struggled to nail down exactly how long the man spent alone because the jail had recorded five different start dates.
Ombudsman Paul Dubé used that Ottawa example on Thursday as he slammed the Ontario government and its jails for how they track and review the use of segregation.
His four-month investigation found that inmates are falling through the cracks because of outdated processes and human error.
"Inputting incorrect start and end dates, using incorrect date formats or restarting the clock when an inmate is transferred to another facility makes it impossible to know who's in segregation and for how long," Dubé told reporters at Queen's Park.
The United Nations says holding a person in segregation for longer than 15 days is a form of torture, noted Dubé.
But one corrections ministry official told his office, "We probably tracked livestock better than we do human beings."
The story of 'Keith'
Investigators from the ombudsman's office visited the Ottawa-Carleton Detention Centre last November to look into the case of a man named "Keith" who had arrived in October 2015.
The man had asked to be put in solitary confinement because he had an injured shoulder, but had "gang affiliations" and was afraid for his life, according to the ombudsman's report.
Keith didn't have a mental illness, but OCDC staff recorded that he "presented as having diminished cognitive ability and found it difficult to answer any questions or carry on a conversation," the ombudsman's report said.
Keith changed units and cells dozens of times, before finally leaving a dark, dirty segregation cell in January for a new "step-down" unit at the OCDC, intended to be a place where inmates can get mental health support to transition back among the general jail population.
But, the ombudsman's office found contradictory and confusing records for when Keith was actually placed in segregation.
The detention centre had five different dates on file, spanning from October 2015 to June 2016.
Human rights lawyer calls for culture change
Keith's case does not surprise Ottawa human rights lawyer Paul Champ, who won a landmark case for a mentally ill woman from Smiths Falls a few years ago that was supposed to lead to changes.
"As the ombudsman points out, the U.N. has held that more than 15 days in segregation amounts to torture. And I can tell you that message is not getting through to Ontario jails," said Champ.
Champ argues for a change in culture among corrections staff at Ontario jails.
"It's just become normalized. A guy's become a problem, just toss him in segregation and leave him there for weeks or months or, in some tragic cases, even years at a time. It's just wrong. It's a human rights disaster," said Champ.
Even the ombudsman found correctional staff often don't comply with regulations and policy about segregation.
"This is the real problem about jails. People are out of sight out and out of mind," said Champ.
Keeping proper data is critical, said Champ, otherwise cases arise like that of Adam Capay, who spent four years in solitary confinement in Thunder Bay.
Champ hopes the spotlight the ombudsman is putting on the issue will lead the government to make real changes.
He's also looking forward to an upcoming report from former federal corrections watchdog Howard Sapers, who is supposed to recommend jail reforms to the Ontario government this spring.