A health review board examining the case of Ashley Smith has been left with a lingering question: How was an obviously troubled 19-year-old inmate left so long without proper treatment?
The Health Professions Appeal and Review Board was only mandated to examine one specific aspect of the case — reviewing an investigation about the conduct of two doctors.
But it was still compelled to raise a critical question of Canada's prison service.
"From our perspective, it is difficult to understand how the resources of Correctional Services Canada and the numerous health professionals who were involved with (Smith), particularly in the last year of her life, could not have, somehow, appropriately treated her admittedly severe behavioural problems," the board said.
Ms. Smith, a 19-year-old from Moncton, N.B., choked herself to death in Grand Valley Institution in Kitchener, Ont., in 2007. She had been engaging in repeated and escalating self-harming behaviours such as tying ligatures around her neck.
She wasn't suicidal, one of the doctors treating her told the province's medical college, but her tendencies were so high risk it was like she was playing Russian roulette.
Ms. Smith's case, the board said, "lies somewhere in the spectrum between a travesty and a tragedy."
Her family and the Canadian Association of Elizabeth Fry Societies had asked the board to review a decision of the province's medical college not to discipline two doctors involved with Smith at Grand Valley Institution.
The board found that the investigation of the College of Physicians and Surgeons of Ontario was adequate.
But some aspects of the case clearly raised some eyebrows at the board.
One of the two doctors — who are only identified in the health review decision by initials — suggested a decision not to send Ms. Smith for a psychiatric assessment just days before her death may have been different if she had been told of a vital shift in Corrections policy.
On Oct. 15, 2007, just four days before Ms. Smith died, staff were discussing whether to send her to Grand River Hospital for an assessment after a ligature incident, the doctor wrote in a letter to the college.
Several previous trips to the hospital had accomplished little, as Ms. Smith was sent back to the prison after no assessment and no treatment, so it was decided Ms. Smith would stay at the prison, where staff were more accustomed to her behaviour, the doctor said.
Only after Ms. Smith's death did the doctors learn that the guards had received new instructions from senior security staff not to enter Ms. Smith's cell unless she had stopped breathing.
"Had we been made aware of this policy, it may have influenced our feeling of security in having (Smith) managed within the institution," the doctor wrote.
The review board said that with the benefit of hindsight, "it may well have been preferable" for Corrections to have shared this information with health staff.
The coroner's inquest into Ms. Smith's death — currently on hiatus — has heard that Ms. Smith had told a psychiatrist she knew staff would come in to rescue her when she choked herself. But no one told Ms. Smith either that the protocol had changed.
A forensic psychiatry expert asked to provide opinions for the college's investigation said Ms. Smith, identified in the board's decision as A.S., was not an average patient with a mental illness.
"Rather, she had severe maladaptive personality traits with unremitting aggression, impulsivity, chronic suicidality, sadistic and masochistic needs, emotional lability and manipulative behaviour," Dr. Lisa Ramshaw wrote.
Ms. Smith was in federal custody for the last 11 months of her life and was transferred 17 times between prisons, treatment facilities and hospitals. She was in near-constant segregation, the inquest has heard.
The delay-plagued inquest has been put off until September, and will resume under a different coroner.