The death of a teenager who fought mental demons for months without help in segregation was as preventable as it was tragic, says Canada's prison watchdog.
Correctional Investigator Howard Sapers made 16 recommendations Tuesday to avoid such misery in future - calls to action that have fallen on deaf federal ears before.
Instead of crucial health support, Ashley Smith received mounting prison time for outbursts that ultimately led to her apparent suicide at the Grand Valley Institution for Women in Kitchener, Ont., he said.
"This troubling case illustrates what can go wrong in federal corrections.
"I've concluded that if different decisions had been taken, and if different routes had been pursued, there's every reason to believe she'd still be alive today."
Ms. Smith died last Oct. 19 after she was moved 17 times - including nine transfers between federal institutions in less than a year. An autopsy showed she died of "self-initiated" asphyxiation, although police have said she did not hang herself.
Mr. Sapers submitted his final report Tuesday to Public Safety Minister Stockwell Day. It's not being fully released while criminal charges proceed.
Three guards and a supervisor were fired and charged with criminal negligence causing death. A fifth corrections worker is set to go on trial for assault relating to a separate incident in Saskatchewan six months before Smith died.
Four more staff at the Kitchener prison were suspended without pay for 60 days, and two senior managers were fired last month.
Still, Mr. Sapers hinted at his findings in a news release and an interview with The Canadian Press.
"My report discusses a litany of serious failures leading up to the tragic and, I believe, preventable death of Ms. Smith," he said.
Her doomed journey through the courts, correctional and health-care systems started at the age of 13 in Moncton, N.B., as an unruly kid who racked up minor offences. They included throwing crab apples at a postal worker who was rumoured to deliver welfare cheques late.
Once behind bars, Ms. Smith's downward mental spiral and aggressive behaviour drew punishment and deprivation instead of treatment, Mr. Sapers says.
"It is clear that none of these systems adequately responded to her needs."
Her legal odyssey ultimately ended in psychological breakdown and death in a cell where she slept on a concrete slab and was often heavily shackled.
Mr. Sapers' recommendations include upholding correctional policy and respect for the law in federal prisons, along with improvements to medical emergency response and more oversight of inmate isolation.
Segregation should be reviewed at regular intervals by independent adjudicators, he says, echoing calls made 12 years ago in the landmark Arbour commission report on women in prison.
Ottawa is not compelled to act on his non-binding advice.
"As ombudsman, what troubles me the most is that many of the failures observed in my investigation into the death of Ms. Smith had been the subject of previous recommendations by my office."
A spokeswoman for Mr. Day said the minister would not comment while matters are before the courts.
Jason Godin, Ontario regional president for the Union of Canadian Correctional Officers, says front-line workers submitted a formal report in 2005 on dealing with high-risk offenders like Smith.
"What she needed was intensive support and programming, and she needed to be in a special handling unit," he said. Those recommendations were "virtually ignored."
Mr. Godin blames managers in the federally sentenced women's sector for allowing "too much politics" to get in the way of badly needed services. Seven dedicated staff who did their best in untenable conditions were used as scapegoats, he says.
"We're also victims in this situation. We're victims of a system that didn't take responsibility in ensuring that the proper policies, procedures and the proper environment was put into place to save Ashley Smith's life.
"Our condolences go to the Smith family."