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Ashley Smith, the troubled teenager whose 2007 jailhouse death by self-strangulation underscored how poorly the correctional system handles mentally ill inmates, died by homicide – not suicide – jurors at an inquest have ruled.

The decision and recommendations are the culmination of a probe into how, exactly, it came to be that a 19-year-old on high suicide watch died with a ligature around her neck while guards – who were ordered not to enter her cell if she was breathing – watched and videotaped. Publicly released surveillance footage gave Canadians a rare window into the way prison staff, at times in full riot gear, wrestled with how to manage a young woman first imprisoned in 2003 after breaching probation for throwing crab apples at a postal worker.

"There aren't even words to describe," Ms. Smith's mother, 66-year-old Coralee Smith, told The Globe and Mail Thursday in an interview from her Dartmouth, N.S., home after watching the verdict streamed live on the Internet. "We are quite pleased … We're more than pleased. There's got to be bigger words than that – we're elated, we're delighted, we're out of our mind. What a Christmas gift."

A coroner's inquest is not an adversarial trial determining blame, but rather a mandatory fact-finding inquiry following a death in custody. Still, the homicide verdict delivered Thursday in Toronto is a finding that the actions of others contributed to Ms. Smith's death. The five female jurors chose homicide over four other verdict options – natural, accidental, suicide and undetermined – and made 104 recommendations aimed at improving how the federal system deals with the mentally ill.

In light of the finding, the Smith family's lawyer is calling on authorities to criminally investigate senior prison management who ordered guards against intervening in Ms. Smith's frequent self-harm so long as she was breathing. Four front-line prison staff were originally charged with criminal negligence causing Ms. Smith's death, but those charges were ultimately dropped.

"The real question has to be asked: How could such a flagrant abuse, such a flagrant disregard for human life go unaccounted for?" Julian Falconer, the family's lawyer, said after the verdict was read. "Those who made the order not to go into her cell – the deputy warden, the warden, those above – have yet to be truly investigated or yet to truly answer for their actions."

Mr. Falconer said the Smith family is not calling for the Waterloo Regional Police case against the four guards to be reopened, but rather that the RCMP launch an investigation into the senior management who issued the order.

Ms. Smith's is the story of one, but advocates say her experience stands in as evidence of a legal and correctional landscape that sometimes ensnares those who would be better served by facilities dedicated to mental-health care. Critics have contended Ms. Smith's treatment effectively cut her off from her family and stacked the odds against her receiving adequate and sustained psychiatric care.

The inquest, deemed at the outset by presiding coroner Dr. John Carlisle as a "memorial" to the teen who died at Ontario's Grand Valley Institution, outlined Ms. Smith's journey through the prison system. She bounced between 17 institutions in her final 11 months, spending long stretches in segregation.

The jury was permitted to scrutinize not just Ms. Smith's time at the Ontario institution, but the entire history of her incarceration. That decision opened the door to the sweeping recommendations issued Thursday, including: seriously mentally ill women should serve time in a federally operated treatment facility rather than a prison; decisions around inmates' treatment should be made by clinicians rather than by security management and prison staff; and indefinite solitary confinement should be abolished.

"Ashley Smith's death is a human tragedy that has deeply affected the family of the deceased as well as the Correctional Service of Canada and its employees," Jessica Slack, a spokeswoman for Public Safety Canada, which is responsible for corrections, said in an e-mail. "We will carefully review the recommendations to determine what further actions should be taken to meet the mental health needs of offenders so that tragedies such as this one does not happen again."

The jurors heard from 83 witnesses over the course of 107 days since January, and watched videos showing Ms. Smith being duct-taped to an airplane seat during a correctional transfer, forcibly restrained and injected with powerful drugs and, finally, lying on the concrete floor of a segregation cell breathing her last two breaths. CSC initially fought the release of the footage, prompting charges of "coverup" and "bullying" from the family and others at the inquest.

Some of the 83 witnesses testified the teen spoke positively about her future and going home to her mom; others said she had become inconsolably desolate at the prospects of never leaving prison.

The search for answers in Ms. Smith's death has been a tumultuous one. Proceedings first began in 2011 but were fraught with acrimony and delays, eventually canned after the original presiding coroner announced her retirement. Lawyers fought over what evidence should be allowed. Ms. Smith's family settled a wrongful death lawsuit against the federal government. Even the second set of proceedings seemed destined to follow a path down a legal rabbit hole.

In 2012, the case's profile reached into the House of Commons, where Prime Minister Stephen Harper labelled CSC's behaviour "completely unacceptable" and Vic Toews, then the minister responsible for corrections, raised ire for deflecting questions about Ms. Smith's death by accusing the NDP of caring more about prisoners than victims. NDP Leader Tom Mulcair sprang to his feet, demanding to know whether Mr. Toews was "capable of understanding that she was the victim here."

Although leading criminologists have cautioned otherwise, the Conservative government has implemented a range of mandatory minimum prison sentences and increased the amount of time offenders must spend in custody. Ms. Smith, for her part, was a teen convicted of minor crimes (public disturbance, throwing apples at a postal worker, stealing a CD) but over time she was drawn deeper into the prison system due to more than 800 documented incidents – roughly 150 of them times when she hurt herself.

"Through the inquest we now have a better understanding of how the system failed her and what we need to do to prevent future deaths," Irwin Elman, Ontario's advocate for Children and Youth, said in a statement. "We have come too far to let her down again."

Ms. Smith, jurors heard, acted out: she smeared feces around, grabbed and spit at guards, abused herself, covered her segregation cell camera and window with magazine pages, and tied ligatures around her neck from fabric she had secreted in her body cavities. One psychiatrist, Dr. Jeffrey Penn, described her as "one of the most severe personality pathologies" he had encountered. Dr. Penn testified that Ms. Smith, who had been teased mercilessly growing up in Moncton, N.B., was emotionally immature, giggly, took pleasure in inflicting pain on others and had only a limited capacity for remorse.

Long before the inquest even began, the country's federal correctional investigator said Ms. Smith didn't have to end up dead. In a 2009 report, Howard Sapers concluded her death was "entirely preventable," citing lack of adequate mental health services as a contributing factor. To the frustration of prisoners advocates, Mr. Sapers came out with another report this year that said the federal prison system remains "ill-equipped" to manage female offenders who chronically injure themselves.

The report, entitled Risky Business, said the number of self-injury incidents in federal prisons has more than tripled since Ms. Smith's death in late 2007. About 900 incidents of self-harming were documented in 2012-2013, the report said. It also noted the CSC spent about $90-million strengthening mental-health care in prisons since 2005, for example implementing computerized mental-health screening when offenders are admitted to an institution and improving training for front-line staff.

"Since Ashley's death, several actions have already been taken to improve the way offenders with mental health needs are managed, including improved inmate intake screening, mental health care and treatment, staff training and preparation for reintegration and release," Ms. Slack said in the e-mail.

In Ms. Smith's instance, the Grand Valley warden testified that, in retrospect, she didn't believe the institution was prepared to deal with the teen's behaviour. The inquest also heard that while at the Nova Institution for Women in Truro, N.S., Ms. Smith agreed to a therapy plan to get out of segregation, but "there wasn't much time to do anything beyond trying to set some groundwork that we might be able to build on, and then she was gone," Allister Webster, a psychologist who worked at Nova while Ms. Smith was there, testified. She eventually withdrew her consent for treatment, but Mr. Webster said he still believed she could be helped.

The jury also suggested Ms. Smith's case be used as a case study for training all correctional staff and managers, and that all female inmates be assessed by a psychologist within 72 hours of being admitted to facilities.

With reports from Jane Taber in Nova Scotia, and the Canadian Press

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