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Ashley Smith was not a killer or a hardened criminal; she was a mentally ill 19-year-old with personality disorders. Yet when she took her life in federal prison, she had been confined for 11 ½ months to a solitary cell measuring 6 ft. by 9 ft., without a mattress, a book, or pen and paper. Seven staff looked on as she suffocated after tying a ligature around her neck. They did not go to her aid because, for bureaucratic reasons, they had been instructed to wait until she stopped breathing.

Her suicide in 2007 is a black mark on Canada's mental-health and corrections systems. Canada is simply not equipped to handle extreme behavioural disorders in children and teenagers. The Dickensian response to Ms. Smith, as described in an inquiry report last week by Correctional Investigator Howard Sapers, is indicative of wide failings that even now are probably being felt by an unknown number of inmates and mental patients.

This was not some backwoods jail in which Ms. Smith was kept. This was Canada's federal prison system, governed by laws and policies that reflect Canadians' expectations of humaneness for all prisoners. Yet those laws and policies were routinely violated, even subverted.

The use of solitary confinement is, by law, subject to automatic review by regional correctional authorities after six weeks. Ms. Smith never received a single such review in nearly a year of solitary. Why not? Because every time she was taken out of solitary to attend court, or to be transferred to another federal institution, or to a psychiatric facility, the "solitary clock" was reset at zero, though she was always put immediately back into segregation. This is simple lawbreaking.

Federal policy forbids the transfer of suicidal inmates, except to a treatment facility. Yet the suicidal Ms. Smith was transferred 17 times. And senior managers were made to watch her stop breathing because in interventions requiring force (to take away anything she might harm herself with), too much paperwork was required. This is dishonesty, and is deserving of strong consequences - to be felt by someone other than Ms. Smith.

No wonder former Supreme Court justice Louise Arbour, heading a federal inquiry into the state of women's prisons in 1996, urged independent adjudication of the use of segregation, or solitary confinement. The federal authorities cannot be trusted to use solitary in a humane way, as it now stands.

From the time she was 10, Ms. Smith was desperately in need of help. When mental-health services failed, she wound up in youth prison at 15 in New Brunswick for petty crimes; eventually, she served federal time in adult jails because of offences committed in jail, against guards who had come to her cell to try to stop her from harming herself. Federal corrections managers did not even bother seeking the help of the psychologists on their staff. Only by killing herself could Ms. Smith draw attention to her humanity.

The question now is how many other Ashley Smiths are being treated the same way, and what mental-health and corrections authorities are doing to ensure no one else dies as she did.

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