The first blow to the Ashley Smith inquest came with the debilitating illness of a police investigator assigned to the proceeding.
With a total of 13 parties and twice as many lawyers participating in the high-profile probe, legal motions and appeals then consumed months of time and generated mountains of new evidence.
Then, in a shattering blow last summer, Coroner Bonita Porter abruptly announced her retirement. Her chief counsel, Eric Siebenmorgen, saw the end of his secondment fast approaching and commenced imparting a vast storehouse of knowledge to his replacement, Crown counsel Fred Duprey.
In January, out of the blue, Mr. Duprey died. For some of those caught up in the inquest, it began to seem cursed.
"At a human level, you sometimes are driven to wonder," Mr. Siebenmorgen said in an interview. "The recent death of my co-counsel was a game-changing event. It hit everybody hard. We have had a series of very unfortunate and unplanned-for events."
The constant delays have exacted a steep price. The inquest will not get going again until late fall or early in 2013. Witnesses' memories will undoubtedly erode, and the prison system will have to continue operating without recommendations that could prevent a similar tragedy.
"We are now asking people to comment on things that happened five, six years ago and even longer," said Howard Rubel, a lawyer for the Union of Canadian Correctional Officers. "Fortunately, much of the evidence is well documented on video and in many volumes of reports."
For the family of Ms. Smith – a 19-year-old, mentally disturbed teenager who died with a ligature around her neck – any sense of closure remains far in the future.
"There are other inmates in a similar situation out there and my clients are very concerned about them," Mr. Rubel said. "This is a difficult inquest partly because we are looking into a problem other authorities should have looked into – but neglected to – for many, many years."
Ms. Smith was found dead on Oct. 17, 2007, in a segregated prison cell at the Grand Valley Institution in Kitchener, Ont. Her mental state had deteriorated as she was shunted through 17 different institutions in her final two years of life.
Once the inquest finally gets under way in earnest, the jury will watch hundreds of hours of prison surveillance tapes. It will also hear from more than 100 witnesses who can shed light on a teenager who had been constantly disciplined for breaking prison rules.
However, before that can happen, the lawyers who take over for Mr. Siebenmorgen and Mr. Duprey will have to embark on a months-long mission to acclimatize themselves to 50,000 pages of evidence and the intricate dynamics of a complex inquest.
"Every time there is a change of personnel, there has to be a knowledge transfer," Mr. Siebenmorgen said. "There are a huge number of documents that have to be organized and kept in the filing cabinet of your mind."
Mr. Siebenmorgen said that the new coroner, John Carlisle, is redesigning the fundamental blueprint of the inquest, rather than simply attempting to build onto the edifice erected by his predecessor.
Dr. Carlisle is working closely with the parties to forge agreements over evidence and tactics, potentially compressing the length of the inquest. However, there may also be replays of earlier legal battles involving prohibitions on media coverage, the pros and cons of expanding the scope of the proceeding, and particular items of contentious evidence.
Dr. Carlisle may also have to revisit whether the faces of correctional officers should be obscured in videotaped evidence and the admissibility of video evidence that depicts Ms. Smith strapped to a metal gurney while medical staff forcibly injected her with tranquilizers.
"It's a mandatory inquest, so it must take place," Mr. Siebenmorgen said. "And it will take place. But we have certainly had to deal with some significant unforeseen bumps in the road. In the meantime, you wonder whether public safety is being adequately addressed by the requisite agencies. You are left to hope that it is."
Editor's note: an earlier version of this story published online and in Thursday's newspaper stated incorrectly that an officer attached to the Ashley Smith inquest had died. The officer was forced to leave the inquest team due to a debilitating illness.