As Ashley Smith slowly choked herself to death at dawn in her Kitchener, Ont., prison cell, seven guards looked on because they were instructed not to intervene if the troubled federal inmate was still breathing.
Court transcripts about Ms. Smith's 2007 death, obtained by The Globe and Mail, show that prison managers were trying to curtail the reviews and paperwork triggered each time guards entered her cell to stop her frequent attempts at self-asphyxiation.
A manager testified she was pressured to reclassify incident reports so that they wouldn't be filed as “use-of-force” interventions, which require more red tape.
Also, the transcripts reveal that Ms. Smith was to be transferred to a psychiatric hospital, but there were no beds available so she was still in her cell when she died. In addition, the prison ignored a grievance she had filed, seeking to end her segregation. The complaint wasn't opened until after her death.
Her story, a tale of death and red tape run amok, will get more attention on Tuesday with the release of Correctional Investigator Howard Sapers's report on her case.
Ms. Smith was a Moncton teen convicted of minor crimes – public disturbance, throwing apples at a postal worker, stealing a CD – who spent most of her last four years in maximum security segregation because of her unruly jailhouse behaviour.
In her first interview, Ms. Smith's mother, Coralee, said she had been told her daughter would get better care when she was transferred to the federal system in 2006.
However, Ms. Smith never received a comprehensive psychological assessment while in federal custody. In less than a year, she was transferred nine times between six facilities from Nova Scotia to Saskatchewan, ending at Grand Valley Institution for Women (GVI) in Kitchener.
“She was treated like a criminal, not a girl who needed help,” Mrs. Smith said. “You've got a family here who's heartbroken over our loss. Life will never be the same. Ashley can't come back. Her demise was at the hand of the system, a system that just plain didn't tend to her needs.”
Details of the case were confidential until now because four correctional employees were charged with criminal negligence.
However, charges were dropped last December. The Crown said it determined that the guards couldn't have saved Ms. Smith in time. Correctional officials have said they will not comment on the case because a coroner's inquest still has to be held.
Court transcripts show that the guards were hamstrung by unusual rules.
“We weren't to go in as long as she was breathing. That's been drilled in our head at every single briefing,” testified Sherri Fairchild, a guard who was present when Ms. Smith died but wasn't charged.
In her testimony, Ms. Fairchild recalled that she and six other guards stood outside the cell urging Ms. Smith to remove the garrote herself.
“It's not pleasant to see somebody with a ligature around their neck and their face purple and being constantly told at briefings and having a seminar on use-of-force to not pay her attention and to not go in her cell.”
The court heard that during the fall of 2007 Ms. Smith choked herself several times a day. Guards who intervened were kicked, grabbed or spat upon.
Incidents where guards used force had to be videotaped and documented on paper. The written reports and videos had to be reviewed by management and regional administrators before being assessed at national headquarters.
There were repeated complaints from management that the videotaping wasn't done properly. Also, the court heard that GVI had a severe staff shortage.
The situation got so severe that in early October, management brought in Ken Allan, a trainer from regional offices, to help staffers deal with the high number of incidents involving Ms. Smith.
