The family of a young woman who choked herself to death in prison is "heartened" that an Ontario coroner heeded their call to expand the scope of an inquest to examine what led to Ashley Smith's troubled mental state.
The decision released Friday significantly broadens the coroner's inquest, as it was originally limited to looking at the past 13 weeks of Ms. Smith's life - the time she was in Ontario prisons.
Her family had urged the presiding coroner to expand it to all 11 months Ms. Smith, 19, spent in federal custody, saying that would provide an accurate picture of the mental trauma that led to her death.
"The family is certainly heartened that Dr. [Bonita]Porter listened ... and is prepared to abandon the old scope of the inquest," their lawyer Julian Falconer said in an interview from Moncton, N.B., where he was meeting with the Smiths.
Those 11 months included 17 transfers among prisons and other facilities across the country, and the constant movement meant the mentally ill woman never got the chance to be properly treated, the family alleges.
In the ruling, Dr. Porter agreed the inquest could reach even further back through Ms. Smith's life.
"One of the very important roles of an Ontario inquest is to fully inform the public," Dr. Porter writes in her decision.
"Therefore the scope of this inquest will include an examination of factors that may have impacted Ms. Smith's state of mind on Oct. 19, 2007. The information that is presented to the jury will not necessarily be restricted by her age, geography, date or nature of the institution that was tasked with her care."
Ms. Smith choked herself with a strip of cloth at the Grand Valley Institution for Women in Kitchener, Ont. Video evidence shows staff failed to respond immediately to the emergency.
A pre-inquest hearing this month heard that Ms. Smith had been choking herself and engaging in other self-harming behaviour frequently during her time in federal custody, though the coroner's own counsel cited evidence suggesting it started as early as Ms. Smith's time in youth custody.
What was originally a 90-day sentence for throwing crabapples at a postal worker became a life sentence for Ms. Smith as in-custody incidents kept prolonging her jail time, a lawyer for a female prisoner advocacy group told the hearing.
Ms. Smith's self-harming behaviour escalated throughout her time in custody, said Susan Chapman, who is representing the Canadian Association of Elizabeth Fry Societies. At Grand Valley there were 49 incidents in seven weeks.
Ms. Smith had told a psychiatrist she knew staff would come in to rescue her when she choked herself, Ms. Chapman said, citing an internal 2007 report commissioned by Correctional Services that concluded Ms. Smith's death was likely an accident and not a suicide.
"I'm not going to die, because it's your job to save me," Ms. Smith had said.
But tragically no one told Ms. Smith the rules had changed and guards had been instructed not to enter the cell, Ms. Chapman said.
Mr. Falconer earlier told the coroner that when guards did enter the cell the day Ms. Smith died they removed the cloth from her neck and thought they heard a breath, so they left her lying on the floor.
Ms. Smith's saga "is probably one of the most outrageous and barbaric examples of mistreatment of a mentally ill person that this country has ever witnessed," Mr. Falconer has said.
Ms. Smith was in isolation during her whole time in federal custody and was subject to "atrocious" conditions, including more than 150 interventions involving use of force, not enough toilet paper, not enough sanitary products when she was menstruating and not enough soap or deodorant, Mr. Falconer told the hearing.
Mr. Falconer and the family have been calling for the RCMP to investigate the Correctional Service of Canada, including for an incident in which Ms. Smith was forcibly injected with anti-psychotics. They have also called for a royal commission of inquiry into the correctional system.
When asked Friday whether the RCMP had yet responded to the family's requests they made in mid-October for an investigation, Mr. Falconer said he had "no comments to make about the criminal investigation."
Dr. Porter's decision on Friday made it clear that despite the inquest's expanded scope, it would not reach beyond the mandate of a coroner's inquest.
"I will be vigilant to ensure the inquest is not encroaching into areas that are not relevant to the purpose of the investigation of Ms. Smith's death or the formation of recommendations that might have prevented it," Dr. Porter writes.
"A broad inquiry into the management, operations and administration of Corrections Canada is not within the jurisdiction of an Ontario coroner's inquest."