More than 10 months of testimony into the videotaped choking death of a teenager in her segregation cell have done little to shake her mom's view that Canada's prison system abused her daughter terribly.
Speaking after final submissions wrapped up at the Ashley Smith inquest, Coralee Smith said it would be unfair to lay responsibility for the tragedy at her daughter's feet.
"I still think it was a horrific situation," Smith said outside the coroner's court.
"I think Ashley was tortured. Things haven't changed a whole bunch for me, and that's coming as a mother."
Following presiding coroner Dr. John Carlisle's charge on Monday, the five women jurors will have to grapple with a verdict as to "by what means" Smith, 19, of Moncton, N.B., met her death at the Grand Valley Institution in Kitchener, Ont.
Lawyer Jocelyn Speyer, acting as coroner's counsel, urged the jury to come back with a verdict of "undetermined," which she called appropriate.
The evidence as to whether the deeply disturbed Smith meant to kill herself by tying a ligature around her neck – as she had done countless times – simply wasn't clear-cut, Speyer said.
Some of the 83 witnesses, who testified over 107 days starting last Jan. 14, said 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, noting her sentence began with a few weeks for throwing crab apples at a postal worker but ballooned to a cumulative 2,239 days by the time she died on Oct. 19, 2007, mostly for acting out in prison.
Similarly, Speyer said, there was no clarity the death was accidental.
Speyer was adamant, however, in recommending the jury not return a verdict of homicide – a neutral, non-criminal finding that someone contributed significantly to Smith's death.
Several parties, including Smith's family, have urged the homicide finding on the basis that the prison warden, Cindy Berry, had ordered guards to stay out of her cell as long as she was still breathing.
They argue the order – along with the threat of discipline and even criminal sanction – prompted guards to delay going in to save her life.
Speyer called it impossible to untangle the "intertwined" complexities that bound both Smith and Correctional Service Canada.
"Can you confidently say that but for the order, Ashley would not have died?" Speyer asked.
"Terrible things often happen for not a single reason."
Berry has denied giving the guards any no-entry order as many witnesses claimed.
Speaking for her, lawyer James Cameron also urged against a homicide verdict.
"Suicides and homicides are rare; accidents happen all the time," Cameron said.
Berry, he noted, had no experience with women offenders when she arrived in August, 2007, at Grand Valley, an already "fragile" institution.
The coroner took the extraordinary step of dressing down two lawyers who warned jurors the public might misinterpret a homicide verdict as suggesting criminal blame, or that frontline guards and others could be hurt by such a finding.
Carlisle ordered the jurors to ignore those submissions.
Nancy Noble, speaking for Correctional Service Canada, called the tragedy the result of a "perfect storm" but insisted improvements have been made since Smith's death.
Prison authorities had never come across anyone like the teen, but said everyone cared for her.
"No one wanted her to die," Noble said.
"Perhaps Ashley Smith didn't mean to kill herself. Perhaps it was an accident."
But Coralee Smith said a verdict of undetermined would be an "easy way out."
While Smith's case shows the "clear and urgent" need for changes, Speyer urged jurors to make concrete, specific recommendations that would have measurable results and not unintentionally make matters worse.
"Ashley's voice has been heard," Speyer said, tearing up.
"I hope that your voice will be loud. I hope you will be heard."