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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.

“He was going to deal with the policies and procedures that had arisen from her use of forces,” testified Launa Gratton, the prison's security intelligence officer.

It was her job to review each incident report and determine whether force had been used. She said there were instances where higher-ranking managers wanted her to reclassify incidents.

“There was pressure to re-characterize that?” prosecutor Michael Murdoch asked.

“Yes,” Ms. Gratton confirmed.

More details about the pressure Ms. Gratton felt could become public later this week when more court transcripts are released.

Ms. Gratton's testimony also revealed that, just four days before Ms. Smith died, the inmate had been referred to St. Thomas Regional Mental Health Care facility near London, Ont., but there were no beds for her.

“There was attempts in the works to get her to St. Thomas,” Ms. Gratton told the court.

“But by the bad fates – no bed available – Ashley remained locked up in a segregated cell,” Mr. Murdoch said.

“Yes,” Ms. Gratton said.

Ms. Fairchild testified that guards would be disciplined if they didn't heed orders and stay away from Ms. Smith if she was still breathing.

“The direction at GVI was absolutely disgusting,” she said. “What was going on there was disgusting. I didn't agree with any of it from the very beginning and nobody did.”

Kim Pate, executive director of the Canadian Association of Elizabeth Fry Societies, saw Ms. Smith on Sept. 24, 2007, and filed a grievance at her request, asking that she be let out of segregation and taken to a hospital.

The form remained untouched because the inmates' grievance box wasn't emptied. It was processed only after Ms. Smith died because Ms. Pate raised the matter.

Back in Moncton, Mrs. Smith recalled that her daughter had phoned on Oct. 18, 2007, and left a message saying she would call back in the morning.

The next day, Mrs. Smith was out in her backyard with her cordless phone.

“I expected a phone call from her that day,” she said. “I was in the yard waiting for a phone call from her. Instead, two strangers came to tell us that she'd passed away.”

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TIMELINE

Ashley Smith was born Jan. 29, 1988, and grew up in east-end Moncton. Her family remembers a girl who liked camping and animals, and who taught herself to swim. When she was 10, she started being disruptive in school. Relations with her parents became more strained.

March, 2002 At 14, she is sentenced to one year probation for harassing phone calls, assaulting strangers on the streets, insulting bus passengers and drivers.

March 4, 2003 Ordered to a youth centre for breach of probation. She undergoes a psychiatric assessment that mentions a possible learning disorder, ADHD and borderline personality disorder.

Oct. 21, 2003 While home on probation, she throws apples at a postal worker. She is returned to the youth centre, beginning a near-continuous detention until her death.

February, 2004-February, 2005 Released but quickly rearrested, twice for pulling a fire alarm and once for stealing a CD.

Oct. 24, 2006 Gets an adult sentence for charges while at the youth centre. Sent to a federal prison in Nova Scotia, then Saskatchewan.

May-June, 2007 Does her first stint at Grand Valley Institution in Kitchener, Ont.

June-July, 2007 Spends time shuffling between two Quebec facilities, then two more in Nova Scotia.

Aug. 30, 2007 Returned to Grand Valley. During her time there, 50 ligatures are confiscated from her. It is believed she used glass shards to cut strips of cloth into garrotes.

September, 2007 According to court testimony, guards at Grand Valley get new instructions not to enter her cell while she is still breathing.

Sept. 24, 2007 Kim Pate files a grievance on her behalf.

Oct. 15, 2007 Gets a referral to a hospital, but no bed is available.

Oct. 19, 2007 Dies at 19 after tying a garrote around her neck.

Source: New Brunswick Ombudsman, court evidence.

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Unanswered grievance

One month before Ashley Smith's death, a visitor to Grand Valley Institution for Women filed a formal grievance on her behalf asking that the 19-year-old inmate be moved out of segregation. The paperwork was ignored by authorities, unread in a box.

Most of the period Ms. Smith was a federal inmate was spent in segregated detention, kept constantly alone in a bare cell, under the permanent observation of a guard. Kim Pate, executive director of the Canadian Association of Elizabeth Fry Societies, visited her there on Sept. 24, 2007.

She said the cell was about the size of an average family bathroom. It was empty but for a metal toilet and sink unit. Ms. Smith's body was barely covered by a padded gown and she had no other clothes or belongings.

She spoke to Ms. Pate through the slot in her cell door. She wanted her visitor to file a grievance on her behalf since she couldn't have pen or paper for security reasons.

She said in her complaint that she wanted to be let out of segregation and be taken to a hospital.

Ms. Pate filled out the form, showed it to Ms. Smith through the door slot for approval. Then Ms. Pate got a guard to confirm in writing that Ms. Smith couldn't sign it herself since she couldn't have a pen.

She placed it in the inmates' grievance box. It wasn't opened until several weeks after Ms. Smith's death, when Ms. Pate brought up the matter with officials.

Ms. Pate said Ms. Smith's case is exceptional but not unique, reflecting the inability of the correctional system in dealing with mentally troubled inmates. "It's treated as an isolated incident," she said, "but these tragedies aren't unpredictable or isolated."

Tu Thanh Ha