CORRECTIONAL SERVICES CANADA TECHNICAL SERVICES …

CORRECTIONAL SERVICES CANADA TECHNICAL SERVICES BRANCH

ELECTRONIC SECURITY SYSTEMS

LSMS Trial Report Revision 0

2014 Nov27

LIFE SIGN MONITORING SYSTEM (LSMS)

TRIAL PROJECT REPORT

USED AT JOYCEVILLE CORRECTIONAL INSTITUTION

AUTHORITY

Recommended corrections, additions or deletions should be addressed to the Design Authority at the following address: Director, Electronic Security Systems Correctional Service of Canada 340 Laurier Avenue West, Ottawa, Ontario K1A 0P9 Prepared by: Approved by: Sylvio Bisson Marc St-Amand Electronic Systems Engineer, Director, Electronics Security Systems Electronic Security Systems

Electronic Security Systems LSMS Trial report Statement of Technical Requirement Revision 0 2014 Nov 27

Correctional Service Canada Technical Services Branch 2

TABLE OF REVISIONS

Revision Paragraph Comment 0 N/A Original



TABLE OF CONTENTS

TABLE OF REVISIONS .................................................................................................. 2 TABLE OF CONTENTS .................................................................................................. 3 TABLE OF ABBREVIATIONS ........................................................................................ 5 TABLE OF DEFINITIONS ............................................................................................... 6 1 INTRODUCTION .................................................................................................. 7

1.1 General ................................................................................................................ 7 1.2 Scope ................................................................................................................... 7 1.3 Contract details ................................................................................................... 7 1.4 Description .......................................................................................................... 7 1.5 Central PC ........................................................................................................... 8 1.6 LSMS Software .................................................................................................... 9 1.7 Sensor Dome with Integral CDCIU .................................................................... 9 1.8 Door/Food Pass Hatch Contacts ..................................................................... 10 1.9 Network Time Server ........................................................................................ 10 1.10 Uninterruptible Power Supply ......................................................................... 10 1.11 FAAS Integration .............................................................................................. 11 1.12 BILL OF MATERIALS ........................................................................................ 11 1.13 Recommended spare equipment .................................................................... 11

2 APPLICABLE DOCUMENTS ............................................................................. 12

2.1 Applicable Standards, Specifications, and Statements of Work .................. 12

3 LSMS SYSTEM OVERVIEW .............................................................................. 13

3.1 Why LSMS ......................................................................................................... 13 3.2 Simplified block diagram ................................................................................. 13 3.3 User Screen Info ............................................................................................... 13 3.4 Legend: Icon & Colours Interpretation ........................................................... 15 3.5 Description of UI Elements .............................................................................. 16 3.6 LSMS states descriptions ................................................................................ 16 3.7 What had to be done after a Red Alert ............................................................ 17

4 RESULT FROM THE TRIAL .............................................................................. 18

4.1 Test result summary table ............................................................................... 18 4.2 Root cause of the Nov 19th False alerts found ............................................... 18 4.3 Attempt at fixing the water movement with air vent March 12th 2014 .......... 19 4.4 Feb 20th 2014 New software load installed to filter water movement. .......... 20 4.5 In adversely delaying of the cell Occupancy assessment ............................ 21 4.6 Inmate breathing rate movement observation ............................................... 23 4.7 Case of apnea observed and confirmed by officer ........................................ 24 4.8 Trying toilet with pinch valve to solve water movement issue ..................... 25 4.9 May11 2014 false alert. It took 6 minutes by officer to clear the Red Alert .. 27 4.10 False alert May 24 2014. ................................................................................... 28 4.11 Sept 10 2014 false alert when door closed with toilet flushing .................... 30 4.12 Sept 23 2014 false alert when door closed with toilet flushing .................... 31



4.13 New software load version 15.06 installed Oct 6th 2014 ................................ 32 4.14 Suspecting pinch valve issue in Cell 117 Oct 10th 2014 ................................ 34 4.15 New software load version 15.08 installed Dec 11th 2014 ............................. 34

5 OBSERVATIONS, RECOMMENDATIONS, AND CONCLUSION ..................... 35

5.1 No false alert has been observed since September 23rd 2014. ..................... 35 5.2 Hanging is the principal method of suicide in prisons ................................. 35 5.3 Suicide by strangulation observation from Dr. Sauvageau .......................... 35 5.4 Extract from a NY Times article ....................................................................... 36 5.5 Study Finds Defibrillators at the Airport save lives ....................................... 36 5.6 Recommendations: .......................................................................................... 37 5.7 Conclusion ........................................................................................................ 37



TABLE OF ABBREVIATIONS

Abbreviation Expansion AC Alternative Current ATP Acceptance Test Plan CB Citizen’s Band CCTV Close Circuit Television CER Common Equipment Room CSC Correctional Service Canada DA Design Authority DES Director Engineering Services ES/SOW Electronics Systems/Statement of Work ES/SPEC Electronics Systems/Specifications ES/STD Electronics Systems/Standard FDS Fence Disturbance Detection System FAAS Facility Annunciation Alarm System ID Identification IEC International Electrotechnical Commission IEEE Institute of Electrical and Electronics Engineers IP Internet Protocol LSMS Life Sign Monitoring System MCCP Main Communications and Control Post MHz Megahertz mW Milli-watt MDS Motion Detection System MJPEG Motion Joint Photographic Experts Group MTBF Mean Time Between Failures NVR Network Video Recorder NVUS Network Video User Station ONVIF Open Network Video Interface Forum PA Public Address PIU PIDS Intrusion Unit PIDS Perimeter Intrusion Detection System PoE Power over Ethernet PTT Push-to-Talk RFP Request for Proposal RTEO Regional Telecommunications and Electronics Officer SDK Software Development Kit STR Statement of Technical Requirements SIDS Supplementary Intrusion detection System TCP/IP Transmission Control Protocol/Internet Protocol TER Telecom Equipment Room UPS Uninterruptible Power Supply UHF Ultra High Frequency VHF Very High Frequency



TABLE OF DEFINITIONS

Term Definition Design Authority Director, Electronic Security Systems Contract Authority Public Works & Government Services Canada Contractor The Company selected as the successful bidder on the contract Project Officer A CSC employee or a contracted person designated by DES to be

responsible for the implementation of the project.



1 INTRODUCTION

1.1 General

.1 Correctional Service of Canada (CSC) by doing this trial want to test technology that could help with reduction of the number of deaths of inmate in custody. CSC acquired a Life Sign Monitoring System (LSMS) to assist in the identification and notification of the cessation of an inmate's breathing movement within a cell. Detection of cessation of breathing and prompt notification can hopefully reduce the time for staff to become aware of a problem and thus allow them to act more adequately; thereby potentially saving lives.

.2 CSC did a trial of this technology called LSMS at Joyceville Institution which is located 20 kilometers north east of Kingston and document covers the result of this trial.

1.2 Scope

.1 This report will cover the rationale that prompted the Life Sign Monitoring Technology Trial, it’s failures and what was done to overcome them etc., and then the final results and conclusions on the suitability of the product.

1.3 Contract details

.1 RFP was issued and contract awarded 2012-12-06 to:

.1 Delco Automation Inc 858039449PG0001 3735 Thatcher Avenue Saskatoon Saskatchewan S7R1B8 Canada Contact: Tom Coxford 613-795-8552 [email protected]

.2 Contract No. - N° du contrat 21120-124209/001/HN

.3 Total Estimated Cost - Coût total estimatif $71,990.04

.4 After DCR3 : Clause 5.5 Emergency service/repairs in its entirety Revised estimated cost: $76,950.07

.2 On April 8 2014 a PO was issued to Franke for buying two toilets with pinch valves

.1 Key contact: Cory Macey (705) 526-5427 ext.303 [email protected]

.2 Quotation from Franke Kindred Canada Limited: K1404-402R1

.3 Total cost with taxes: $9,900

.4 Order No: 15503280

.5 Financial Codes - Codes financiers 15503. 280. 12118.240. 07711. 1. 1

.3 On October 2 2014 a PO was issued to LSMS to add features to system software.

.1 Key contact: Alan Holford – Walker Tel: 07831 778 444 [email protected]

.2 Quotation from LIFE SIGNS MONITORING SOLUTIONS LIMITED: Q1402

.3 Requisition 1817168:

.4 Total: $6,824.21 CAD

.5 ORDER NO 21156-15-2105543-0

.6 Doc. No. 211 56-15-2105543-0

1.4 Description

.1 The function of the LSMS is to notify through audible and visual alerts when no breathing movement has been detected for a predetermined period of time in an enclosed occupied observation cell environment. The objective of the LSMS is to reduce the time to the awareness of a problem and potentially saving lives.

.2 The LSMS will consist of the following elements:



.1 Sensor Dome with integral CDCIU Interface Unit

.2 Door Magnetic contacts: ANSI Triple‐Bias Detention Grade Door Contacts (1 per cell door – Sentrol 2707A)

.3 Food Pass Hatch Contacts: 1 per cell door – Sentrol 2707A

.4 Central LSMS Computer (COSATT CCUR‐5055‐2U) running COMS24 Software

.5 17” LSMS Operator Touchscreen (Elographics ELO1715L)

.6 17” Rackmount Admin/Maint. Monitor with Keyboard (Startech RACKCONS1701)

.7 Uninterruptible Power Supply (APC SMX1500RM2U)

.8 Network Time Server (Galleon NTS‐4000)

.9 Network Switch (Netgear GS108E)

.10 12VDC Power Supply (Omron S8VM‐03012CD)

.11 PC Amplified Speaker (Cyber CA‐2012RB).

.3 The following figure shows the block diagram of the LSMS .

1.5 Central PC

.1 One rackmount LSMS Central PC was installed in the existing Segregation TER equipment cabinet.

.2 The LSMS PC is equipped with ports to interface the CDCIU, two monitors, a Network Time Server, a UPS unit, and a future FAAS interface.

.3 A Startech RACKCONS1701 pullout KVM was installed in the existing Segregation Unit equipment cabinet. This monitor allows ADGA and designated CSC staff to complete LSMS maintenance and administrative functions.

.4 An Elographics ELO1715L touchscreen monitor was desk mounted on the existing Segregation Unit Control Post desk and was used to control and monitor the LSMS. In the event of an alarm condition, an amplified PC speaker (Genius SPi250G) located



immediately beside the touchscreen monitor was used to present the operator with an audible alarmindication.

.5 The LSMS computer was equipped with COMS24 software running on MS Windows 7.

.1

1.6 LSMS Software

.1 COMS24 is Cell Occupant Monitoring System software that provides the operator with the means to monitor movement within an inmate cell.

.2 If ALL movement ceases, the operator is presented with an alarm condition on the operator touchscreen monitor.

.3 In addition to monitoring movement within the cell, the COMS24 software monitors door position switches installed on the inmate cell door and food pass hatch.

.4 If the software detects that either the door or food pass hatch is open, the alarm to the operator is disabled to prevent a nuisance alarm.

1.7 Sensor Dome with Integral CDCIU

.1 One polycarbonate sensor dome unit equipped with 4‐6 low power microwave transceivers (sensors) will be strategically mounted on the ceiling of each monitored cell.

.2 The low power microwave sensors detect movement using the principles of Doppler shift radar.

.3 The sensors are completely safe and have been evaluated by NRPB on behalf of the Home Office Scientific Development Branch (HOSDB) in the UK.



.4 Each sensor dome communicates with an integral Cell Data Collection and Interface Unit (CDCIU). Each CDCIU is powered from a dedicated 12VDC power supply (Omron p/n S8VM‐03012CD) located in the Segregation TER.

.5 The CDCIU provides RS485 communications to the central LSMS PC and is also used to gather contact closures from the associated cell door and cell food pass hatch.

.6 The sensor dome was installed directly on the cable tray with the rear mounted CDCIU protruding upwards into the cable tray to ensure the assembly is of the lowest possible profile.

.7 Radar sensor heads

.

1.8 Door/Food Pass Hatch Contacts

.1 Each cell door and food pass hatch are continuously monitored to eliminate nuisance alarms.

.2 The door and hatch contacts are physically connected to the CDCIU which in turn communicates contact status to the central LSMS PC.

.3 The door and food hatch is equipped with Sentrol 2707A triple biased contacts that is surface mounted on the doorframes of the cell and the cell door.

.4 The mating magnets is surface mounted on the food hatches and cell doors.

1.9 Network Time Server

.1 A Galleon NTS‐4000 Network Time Server was installed to provide GPS‐based time synchronization.

.2 The NTS‐4000 is a 1U device that will be rackmounted in the existing Segregation TER equipment cabinet.

.3 The NTS‐4000 is supplied with a lightning arrestor and a MSF antenna (10m cable).

.4 Delco mounted the antenna on the exterior wall of the Segregation Unit and interconnected it to the NTS.

.5 The NTS‐4000 is equipped with a network interface which is connected to a new Netgear GS108E Network Switch along with the LSMS PC and a UPS.

1.10 Uninterruptible Power Supply

.1 The LSMS was installed with a dedicated UPS.

.2 The UPS consist of one American Power Corporation (APC) model SMX1500RM2U rack mounted UPS in the existing Segregation TER equipment cabinet.



.3 The UPS is equipped with a network interface for connection to the new Netgear network switch.

.4 The UPS is provided with software to allow a controlled shutdown of the LSMS computer. This feature prevents the LSMS computer from being hard crashed when the UPS is active and the battery becomes fully discharged.

.5 The provided UPS is connected to an essential power circuit available in the Segregation Unit TER.

1.11 FAAS Integration

.1 The LSMS is capable of being integrated to the FAAS using a built‐in remote interface.

.2 The remote interface will allow cell state information to be transmitted to the FAAS.

.3 In order to integrate to the current Senstar 100 FAAS, a custom COSATT to Starcom software translator would need to be developed.

.4 FAAS integration was not part of the scope of work for this trial.

1.12 BILL OF MATERIALS

DESCRIPTION QTY MANUFACTURER PART NUMBER LSMS Microwave sensor (w/ 3 mW heads) 2 COSATT LSMS‐SENSOR‐JVI‐13 Cell Data Collection and Interface Unit (CDCIU) 2 COSATT LSMS‐CDCIU‐JVI‐13 Control Station PC with COMS24 Software 1 COSATT LSMS‐CONTROLPC‐JVI‐13 Triple Bias Door/Latch Contact 4 Sentrol 2707A Omron 12VDC Power Supply 2 Omron S8VM‐03012CD 17” Touchscreen Monitor 1 Elographics ELO1715L 1500VA UPS 1 APC SMX 1500RM2U Rackmount Pullout KVM 1 Startech RACKCONS1701 Amplified Speaker 1 Cyber Acoustics CA‐2012RB Network Time Server 1 Galleon NTS‐4000‐GPS‐R Network Switch 1 Netgear GS108E Custom Cowling for Cell Ceiling 2 LSMS‐COW‐JVI‐13

1.13 Recommended spare equipment

DESCRIPTION QTY MANUFACTURER PART NUMBER LSMS Microwave sensor (w/ 3 mW heads) 2 COSATT LSMS‐SENSOR‐JVI‐13 Cell Data Collection and Interface Unit (CDCIU) 2 COSATT LSMS‐CDCIU‐JVI‐13 Triple Bias Door/Latch Contact 4 Sentrol 2707A Omron 12VDC Power Supply 2 Omron S8VM‐03012CD 17” Touchscreen Monitor 1 Elographics ELO1715L



2 APPLICABLE DOCUMENTS

2.1 Applicable Standards, Specifications, and Statements of Work

.1 Access to non-government specifications is the responsibility of the contractor.

Number Title ES/SPEC-0507 Electronics Engineering Specification, Life Sign Monitoring System LSMS FDR-R2.zip Final Design Report – R2 June 24, 2013 (CONTRACT NO. 21120‐124209/B) STR LSMS R5 Statement of Technical Requirement Rev5 August 18 2012 .PPT LSMS USER Training presentation August2 2013



3 LSMS SYSTEM OVERVIEW

3.1 Why LSMS

.1 Correctional Service of Canada (CSC) wants to reduce the number of inmate deaths in custody.

.2 This technology is to assist in the identification and notification of the cessation of an inmate's breathing movement within an observation cell.

.3 Detection of cessation of breathing and prompt notification can: reduce the time for staff to become aware of a problem and allow officers to act more adequately and thereby potentially saving lives.

3.2 Simplified block diagram

.1 LSMS consists of: 1) Sensor Dome inside Observation cells 117 & 118 2) LSMS common equipments installed in Telecommunication Equip Room 3) Touch screen terminal & Speaker installed in Control Post

3.3 User Screen Info





3.4 Legend: Icon & Colours Interpretation



3.5 Description of UI Elements

3.6 LSMS states descriptions

.1 When Door and Hatch are opened, the cell is not occupied and therefore LSMS is not monitoring cell for movement

Cell unused Stated (door and hatch opened)

.2 When Door is opened and Hatch is closed. The cell is still not occupied and therefore LSMS

is not monitoring cell for movement

Cell unused Stated (Door opened and hatch closed)

.3 Right after Door and Hatch are closed, LSMS is assessing for presence. While assessing

for presence the window color will be flashing between white and light blue. Cell being Assess for occupancy

.1 If LSMS doesn’t detect a presence in cell then window color turns light blue and LSMS stop monitoring for movement. Cell Unoccupied state

117

117

117



.2 If LSMS detects a presence in cell then window color turns green and the LSMS start

monitoring for lack of movement. Cell Occupied state.

.3 While cell is Occupied if LSMS stop detecting movement for 72sec in cell then window

will start flashing red and sound Red Alert State

.4 In case of Red Alert when door is opened, the Red Alert is automatically cleared.

Cell unused Stated (Door opened and hatch closed)

RED little square dot appears to indicate alert history.

3.7 What had to be done after a Red Alert

.1 Officer needed to immediately investigate state of the inmate within the cell.

.2 In case of emergency, officers were to follow the normal recommended procedure on how to response to medical emergency.

.3 Officers were asked to complete a post incident report to:

.1 Record inmate condition,

.2 Record inmate position within the cell, and

.3 Capture any useful notes about conditions leading to false alert

.4 Manager had to log in as the Supervisor to clear history and to send sensor analog recording to Sylvio Bisson At NHQ.

117

117

117

117



4 RESULT FROM THE TRIAL

4.1 Test result summary table

.1 Nov 18th 2013: System training completed and system officially turned on

.2 Nov 19th 2013 Two false alerts linked to toilet water movement

.3 Feb 20th 2014 New software load installed to prevent LSMS to assess a cell as Occupied. This while we were still looking for a solution to water movement.

.4 April 2nd 2014 Inmate with symptom of apnea being observed

.5 July 29th 2014 New toilets with pinch valve arrived and one of the toilet installed in cell 118.

.6 Sept 10 2014 false alert when door closed with toilet flushing

.7 Sept 23 2014 false alert when door closed with toilet flushing

.8 New software load version 15.06 installed Oct 6th 2014 Ignore time was increased to 60 sec to prevent LSMS to assess cell as occupied after the was closed door with toilet being flushed.

.9 Oct 10th 2014 issue identified with pinch valve issue in Cell 117

.10 Dec 2nd 2014 More tests have been recommended by toilet manufacture to determine the cause of non functioning pinch valve in cell 117.

.11 Dec 2nd 2014 No false alert since September 23rd 2014 Trial ending. No more false alert and no additional incident occurred.

4.2 Root cause of the Nov 19th False alerts found

.1 LSMS detects water movement from toilet when a toilet from floor above or below is being flushed, or from air pressure variation due to wind.

.2 These waveforms have been captured while both Cell 117 & 118 were unoccupied and when toilet being flushed directly above cell 117 and cell118.



.3 These waveforms have been captured while both Cell 117 & 118 were unoccupied and with strong wind outside.

.4 We could see here that most of the time the movement noise in cell 117 would delay the red alert by masking the inmate lack of movement. So we have to fix the water movement issue.

4.3 Attempt at fixing the water movement with air vent March 12th 2014

.1 The movements that we could see here are not linked to toilet being flushed but to wind causing air pressure variation in air vent plumbing system.

.2 The effect of wind appears to be higher on cell 117 than 118.

.3 Note that plumping air vent changes has been done to cell 118 as an attempt to diminished the effect of air-pressure variation to toilet water movement.

.4 As we could see those changes were not sufficient to eliminate this issue of toilet water movements being such that they could mask or prevent alarm being raise do to lack of movement due to inmate try to kill himself.



4.4 Feb 20th 2014 New software load installed to filter water movement.

.1 Typically when an inmate has just been assigned to a cell the movement detected are a lot stronger and the one caused by the water. So a new software load has been introduced with an option to be able to push out the detection thresholds and this to allow LSMS to filter out water movement during the cell occupancy assessment period.

.2 This waveform shows cell 118 while LSMS is assessing for occupancy right after the door closure. This prevented the cell from assessing as occupied while cell empty and presence of water movement. This had the negative effect of potentially delaying a real alert.

.3 With this figure we could see wind noise being filtered out during cell 118 being assessed

as unoccupied.



.4 Cell 118 while cell being assessed as occupied; Note thresholds pushed out and this shows how strong the signal is from inmate movement.

4.5 In adversely delaying of the cell Occupancy assessment

.1 From this figure you could see Cell 117 Hatch being opened and system waiting for door to close to complete the cell occupancy check. (via the Alarm threshold being pushed out and the warning window) Cell118 Hatch is closed, then door is opened and then closed. Cell 118 is then being assessed as empty



.2 Log cell 118. Shows door being closed and hatch open at same time.

.3 Another one of the case where door is closed with hatch opened and left opened for a long

time. So cell not being assessed and therefore system is not monitoring for life sign



.4 We noted that this was occurring during lunch time while officers would assign a cell to an inmate for serving lunch. Assigning inmate to a cell and opening the hatch too quickly (not waiting for the LSMS to assess cell before opening the hatch). A window would then pop up warning officer that the hatch is opened.

.5 The issue here is the fact that the system didn’t have time to assess the cell for occupancy and the system is not checking for life sign while the hatch is opened. The system is effectively by-passed and waiting for hatch to be closed to complete it assessment cycle.

.1 Manager was informed by phone and email to prevent this by waiting before opening hatch.

.2 And a software feature was request to be able to ignore hatch status during cell occupancy sequence.

4.6 Inmate breathing rate movement observation

.1 Cell 117 occupied with inmate not moving much. We could see breathing rate.



.2 On cell 118 we could clearly see inmate breathing pattern

4.7 Case of apnea observed and confirmed by officer

.1 April 2nd 2014 with remote access to the LSMS we were able to observe a case of apnea in cell 117.



4.8 Trying toilet with pinch valve to solve water movement issue

.1 April 8th 2014 order placed for new toilet with pinch valve



.2 June 16th 2014 New Toilet using pinch valve being delivered to Joyceville

.3 June 24th 2014 New toilets are 3inches too long, so had to stop and think of a way to install.

.4 July 24th 2014 Security has granted access to plumber at cell 118.

.5 July 29th new toilet with pinch valve was installed in cell 118.

.6 As you could see by flushing toilet on floor above caused water movement in cell 117 but no movement in cell 118.



.7 Since using the new toilet the Coarse Multiplier was set to 1

4.9 May11 2014 false alert. It took 6 minutes by officer to clear the Red Alert

.1 By looking at the following log we could see that it took 6 minutes to clear the Red Alert (by opening the hatch. Note that we have 80% chance of save a person after 4 min of stop of heart.

.1 DF9E, 2," 118", 3608773979,Sun May 11 01:12:59 2014,ALARM D18F, 2," 118", 3608796306,Sun May 11 07:25:06 2014,HATCH OPEN AL



.2 Result from running the log file with simulator.

.3 By changing to the assessment parameters, I was able to rerun sim and show that we could avoid red alert. So following changes were made to assessment parameters.

4.10 False alert May 24 2014.

.1 One main concern here it is that It took a day by officer to clear the alert!

.2 Root cause: I am suspecting that by flushing the toilet caused the system to arm while cell was empty. (Cell 118 Assessed as occupied)

.3 By running the log via the simulator we got the following:



Cell arming; being assessed as Occupied

Cell going into the Red Alert, Started counting down.

.4 With no one in cell 118 the system armed and took 5 min to raise the red alert. So to shorten this time the system parameter was change to the following:

.1 head 0, 2056, 2074 was 2058 2071 head 1, 2070, 2089` was 2073 2085 head 2, 2061, 2084` was 2063 2082

.2 I rerun the simulator log and it was taking 1.3min to alert (with no one in cell with water movement to cause the alert)

.3 So after applying the following changes, I rerun via the simulator and was able to avoid the false arming and therefore the red-alert:



.5 Also by looking at the following log we could see that it took almost a day for guard to open the door of cell 118 to clear the Red Alert.

.6 The question was ask to supervisor by email May 26 2014 and received no respond

.1 1886, 2," 118", 3609924018,Sat May 24 08:40:18 2014,ALARM BD2A, 2," 118", 3610006464,Sun May 25 07:34:24 2014,DOOR OPENED 35A1, 2," 118", 3610006464,Sun May 25 07:34:24 2014,DOOR OPEN 6AD5, 2," 118", 3610006469,Sun May 25 07:34:29 2014,ASSESSING BA24, 2," 118", 3610006470,Sun May 25 07:34:30 2014,DOOR OPENED

4.11 Sept 10 2014 false alert when door closed with toilet flushing

.1 False alert due to toilet being flushed then closing the door. So causing the system to think that someone was present after door was close on cell 118.



4.12 Sept 23 2014 false alert when door closed with toilet flushing

.1 False alert due to toilet being flushed then closing the door. So causing the system to think that someone was present after door was close on cell 117 and cell 118.

.2 Oct3 2014 changed the configuration to prevent toilet noise from arming system. Coarse

Multiplier change to 3 and increasing ignore time to 60sec. Using simulator shows no alarm using old log files.



4.13 New software load version 15.06 installed Oct 6th 2014

.1 The intent of the new load is as follow:

.1 To allow cell occupancy assessment after door closure while ignoring the hatch status, but still raising a warning when hatch stays open for too long

.2 To monitor movement while cell status is empty and raising a warning if detecting movement in empty cell.

.3 Fixing “ the COMS running twice issue”

.4 Fixing the RS485 comms port reverting to 0.

.2 Release notes since last software load version 14.03:

.3 COMS V15.06 20141014

.1 Corrected alarm log information on saving.

.2 Reinstated head disable funtion.

.4 COMS V15.05 20141013

.1 Fixed non-operating LED displays.

.2 Fixed supervisor controls.

.5 COMS V15.04 20141010

.1 Added threshold info to empty log.

.2 Prevented enormous empty log files.

.3 Added recovery mechanism for temporary loss of com port (USB hiccup).



.6 COMS V15.03 20140928

.1 Added time stamp to log option for comms faults.

.2 Added facility to change alarm dump delay length.

.3 Added disabling of heads on assessment.

.4 Added option for auto enablement in empty condition.

.7 COMS V15.02 20140922

.1 Fixed non retention of comms port in ini file.

.2 Added log option for comms faults.

.8 COMS V15.01 20140919

.1 Fixed failure to update site name on main screen.

.2 Hid various controls when not in debug mode.

.9 COMS V15.00 20140919

.1 Fixed empty monitoring bug.

.2 Simplified parameter storage and retrieval.

.3 Modified storage to use .ini files.

.4 Corrected alarm dump data (wrong for 14.12 - 14.14).

.5 Fixed stuck in EMPTY when empty activity monitoring disabled.

.10 COMS V14.13 20140815

.1 Allowed disable of empty monitoring by setting to zero.

.11 COMS V14.12 20140813

.1 Prevented multiple instances of COMS.

.2 Allowed disabling of empty monitoring.

.3 Set default coms channel to 2.

.4 Forced blip on door and hatch graph at start of calibrating.

.12 COMS V14.11 20140717

.1 Prevented display of LEDs when LEDs disabled.

.2 Prevented "service interval" warning after "service time" warning.

.3 Tidied up "LED" and "Count" help messages.

.13 COMS V14.10 (pre-release) 20140610

.1 Changed thresholds display so these always show the calibration values.

.2 Added Threshold Multiplier to engineers cell panel for ASSESSING and EMPTY conditions.

.14 COMS V14.09 20140602

.1 Added "Arming Hatch Ignore" faclilty.

.2 Fixed "Last Alarm Log".

.3 Was being opened for append, not write.

.4 (Error occured at V14.05.)

.15 COMS V14.08 20140409

.1 Hid DOOR_OPENED state.

.2 Expanded some help messages.



.16 COMS V14.07 20140319

.1 Fixed display of max and min signal values.

.17 COMS V14.06 20140316

.1 Added time to graph when replaying alarm files.

.2 Improved help on Test button.

.18 COMS V14.05 20140305

.1 Added fast forward and fast rewind facilities for replay.

.2 (Coms dem only)

.3 Added save activity dump when cell determined to be empty.

.19 COMS V14.04BETA 20140226

.1 Experimental fast forward and fast requind.

.2 Augmented error message on alarm logs interpretation.

4.14 Suspecting pinch valve issue in Cell 117 Oct 10th 2014

.1 Oct 28th 2014 Water pressure was increase to 50lb as an attempt at fixing the issue but water movement still there

.2 Dec 1st 2014 Joyceville’s plumber tried a few test and confirmed pinch valve issue

.3 Dec 2nd 2014 More test have been recommended by toilet manufacture to determine the cause and a fix to last issue of non functioning pinch valve in cell 117.

4.15 New software load version 15.08 installed Dec 11th 2014

.1 Release notes since last software load version 15.06:

.2 COMS V15.08 20141118: 4.15.1.2.1. Corrected UIRs. 4.15.1.2.2. Fixed calibration with no hatch. 4.15.1.2.3. Fixed intermittent no led indication. 4.15.1.2.4. Made engineers led activity controllable.

.3 COMS V15.07 20141111: 4.15.1.3.1. Corrected operation of VA enable. 4.15.1.3.2. Added escape to wait loop in Send()



5 OBSERVATIONS, RECOMMENDATIONS, AND CONCLUSION

5.1 No false alert has been observed since September 23rd 2014.

.1 The LSMS is stable and will alert only when cell is occupied and no movement is detected.

5.2 Hanging is the principal method of suicide in prisons

.1 Suicide rates have been observed as high as 47 per 100,000 inmates in local jails and 15 per 100,000 inmates in prisons.

.2 Reference: Unobtrusive Suicide Warning System, Final Technical Report, Phase III Document No.: 243922 This report has not been published by the U.S. Department of Justice. To provide better customer service, NCJRS has made this Federally-funded grant report available electronically.

5.3 Suicide by strangulation observation from Dr. Sauvageau

.1 Dr. Sauvageau did a study based on video from law enforcement evidence of suicide by strangulation.

.2 These two figures summaries his observations:

.3 Note that cessation of movement could happen up to 8 min after breathing has stopped.

.4 COSATT has reported that in two cases, the LSMS has been has been able to save life and this based cases that they have been made aware of.



.5 Reference:

https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CB8QFjAA&url=https%3A%2F%2Fwww.ncjrs.gov%2Fpdffiles1%2Fnij%2Fgrants%2F240230.pdf&ei=2ZKIVKyrJoieyATLpYD4DA&usg=AFQjCNGWkgiWzjsfePOiMBelNmORKGwKWw&bvm=bv.81456516,d.aWw

.1 Document Title: Unobtrusive Suicide Warning System, Final Technical Report

.2 Author: Jeffrey M. Ashe, Meena Ganesh, Lijie Yu, Catherine Graichen, Ken Welles, Bill Platt, Joy Chen

.3 Document No.: 240230

.4 Date Received: November 2012

.5 Award Number: 2007-DE-BX-K176

5.4 Extract from a NY Times article

.1 Survival rates for out-of-hospital cardiac arrest are only 1 percent to 5 percent and usually are predicted by how quickly emergency workers arrive at the scene.

.2 But in studies in which defibrillation was applied almost immediately, survival rates have reached as high as 80 percent.

.3 With each minute of delay in defibrillation, survival chances drop by about 10 percent.

.4 In June 1999, A.E.D.’s were installed throughout Chicago’s O’Hare and Midway Airports so that response time would be about one minute at any location.

.5 In the first 10 months, 14 cardiac arrests occurred, and 9 of the 14 victims, or 64 percent, survived.

.6 Reference: http://well.blogs.nytimes.com/2008/06/19/could-a-defibrillator-have-saved-tim-russert/?_r=0

5.5 Study Finds Defibrillators at the Airport save lives

.1 Another important finding was that patients who were defibrillated with an AED within 5 minutes of going into cardiac arrest had a 67% survival rate.

.2 Research has shown that survival rates drop drastically when defibrillation is delayed beyond 5 minutes, and plummet further after 10 minutes.



.3 Often, emergency medical response teams are not able to get to a patient within 5 to 10 minutes.

.4 Reference: http://www.empowher.com/media/reference/study-finds-defibrillators-airport-save-lives

.1 Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. NEJM. 2002;347:1242-1247.

.2 Weaver WD, Peberdy MA. Defibrillators in public places—one step closer to home. NEJM. 2002;347:1223-1224.

5.6 Recommendations:

.1 Based from observations from the trial, it will be important to communicate to the officers the importance of:

.1 Never turning off the LSMS’ speaker and the LSMS’ terminal located in the control post so that they don’t delay time required in attending inmate in case of a real alert.

.2 Attending inmate as quickly as possible once Red Alert occurs, will maximize chance of being able to resuscitate an inmate. (Keeping in mind that 75 sec is being used by LSMS to detect lack of movement)

.3 Insure the Control Post is equipped with a defibrillator.

.2 In order to lower cost of the system, we should find a way to deal directly with Cosatt for installation and support of a LSMS.

.1 Cost of an equivalent 2 cell system in the UK is under $30,000 compared to $76,000 that we paid Delco.

5.7 Conclusion

.1 Could the LSMS save life?

.1 Based from COSATT’s experience, they have been made aware of 2 cases of people having been saved by LSMS.

.2 Water noise movement issue with toilet has been resolved and the LSMS has been proven to be stable since Sept 2014.

.3 I don’t see any evidence to show that this LSMS system can’t save life.

Documents

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