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A framed photo of her late son Eddie Snowshoe hangs on a wall of Effie Bella Snowshoe's Fort McPherson, NWT home on July 23 2014. Eddie Snowshoe committed suicide while serving time in segregation in an Edmonton area correctional institution on August 13 2010.The Globe and Mail

Four and a half years after a 24-year-old federal inmate with a clear history of attempted suicide took his life in prison – following a 162-day spell in solitary confinement – a government lawyer told an inquiry that the man was partly to blame because he was not "fully cooperative" with efforts to help him.

The statement, contained within a 374-page inquiry transcript provided to The Globe and Mail after a five-month delay, amounts to the sole direct comment the federal government has made concerning the death of Edward Christopher Snowshoe, who died at the maximum-security Edmonton Institution in 2010.

"…[Mr. Snowshoe] was not being fully cooperative with the institutional authorities and framework," said lawyer David Stam during his final statement to a provincial death inquiry headed up by Justice James Wheatley. "…maybe had he been with them more co-operative perhaps some of his mental health needs could have been much clearer and much earlier addressed. And we can only do so much as an institution.… Surely, if Mr. Snowshoe had wanted to avail himself of some services of some of the intervention that was being offered on his behalf, that could have occurred."

It is just one of the revealing statements contained within the transcript, which offers a rare airing of views from inside the Correctional Service of Canada. Among the issues covered: the long-term effects of solitary confinement, the grinding realities of the prison as a workplace, and the sometimes contradictory demands of government's prison regulations. The Globe examined these issues in a special report on Mr. Snowshoe's death that appeared last December.

Howard Sapers, the federal correctional ombudsman, called the lawyer's final statement "at worst meaningless and at best inflammatory."

"It does smack of blaming the victim," Mr. Sapers said. "Here's an individual who, I think it's fair to say, did not receive the help the Correctional Service of Canada is mandated to provide."

The Correctional Service refused an interview request for this story. In a statement, a spokeswoman said the agency "takes every incident of inmate suicide very seriously and is continuing to improve prevention and intervention strategies for all offenders." She could not answer questions specifically about the Snowshoe inquiry because the Correctional Service is still reviewing Justice Wheatley's five-page final report, released nine months ago.

In 2007, Mr. Snowshoe was sentenced to five years in prison for shooting a cab driver in Inuvik, NWT, during a botched robbery attempt. (The cabbie has declined to comment to The Globe.) In prison Mr. Snowshoe had attempted suicide three times and been diagnosed with multiple mental-health issues. He had already spent 134 days in solitary confinement at the medium-security Stony Mountain Institution in Manitoba by the time he was transferred to the harsher confines of the Edmonton Institution on July 16, 2010.

The transfer came about because he'd brandished "a homemade stabbing weapon that he attempted to use towards a officer," according to a deputy warden at the inquiry. Justice Wheatley scoffed at the menacing characterization, noting the weapon was made out of cardboard and later asking in his report, "how does a juice box knife end up with 162 days in segregation?"

But the dubious rationale for his transfer was only the beginning of a string of miscues. Shortly after his arrival, front-line staff were never made aware of his troubling mental-health history and decided he was fit to remain in solitary confinement indefinitely. Restricted to a 2.5-metre-by-3.6-metre cell for 23 hours a day, he lapsed into lethargy, declining his alotted daily recreation time and refusing to speak to a psychologist who tried interviewing him through a food slot.

The transcript shows how Correctional Service staff reciprocated Mr. Snowshoe's apathy. A nurse who conducted his initial health assessment didn't consult his recent medical history. His parole officer withheld his suicide history from prison staff before leaving on vacation. His psychologist gave Mr. Snowshoe's prison file a cursory glance before conducting the aborted food-slot interview and filing what a lawyer for the Snowshoe family called a misleadingly rosy assessment of the young inmate.

With each of these oversights, employees testified that their actions always complied with the Commissioner's Directives – the confusing, ever-changing code of over 100 rules that govern federal prison operation.

The psychologist, for instance, testified that the workplace directives regularly clash with his professional code of ethics. In conducting his one-minute food-slot interview, Dev Sawh explained he was obeying a Commissioner's Directive to evaluate every inmate's psychological fitness for segregation. But because Mr. Snowshoe refused to co-operate, the psychologist risked breaching the Canadian Psychological Association Code of Ethics.

"He did not give informed consent," stated Mr. Sawh, who was working at the prison on a fill-in basis due to chronic understaffing. "There's – really, I should not have been even continuing speaking with him…. I would say [the Commissioner's Directives] quite often conflict with the Code of Ethics…"

Based on that ethically compromised exchange – as well as a cursory look at Mr. Snowshoe's prison records – Mr. Sawh said he was left with little choice but to check the "no" option on a psychological assessment form asking whether the inmate was suicidal.

"I want to know why you could say 'no' that day?" Justice Wheatley demanded during the inquiry.

"Because the gentleman gave no information," Mr. Sawh replied.

With Mr. Sawh's assessment in hand, a review board decided on Aug. 13, 2010, that Mr. Snowshoe should remain in segregation. He would hang himself that evening.

The psychologist went on to describe the demands of his workplace as "not 100 per cent fully reasonable," a sentiment echoed by several other Edmonton Institution workers who testified.

Toward the beginning of Mr. Snowshoe's incarceration at Edmonton, his primary parole officer, Kevin Kindrachuk, left on vacation without transferring his caseload to another staff member. He explained the practice was widespread because the Correctional Service does not back-fill parole officers.

The head of the union representing parole officers confirmed that the no-backfill practice remains the norm. "If a parole officer is gone for a couple of weeks, their regular work is simply not done," said Stan Stapleton, president of the Union of Solicitor General Employees.

Justice Wheatley, along with lawyers representing Mr. Snowshoe's family and the Alberta government, had other troubling issues to raise with Mr. Kindrachuk, such as why he didn't meet one-on-one Mr. Snowshoe before going on vacation, and why he ignored multiple phone calls from Mr. Snowshoe's mother.

"[U]pon arrival," he told the inquiry, "there were no immediate precursors or signs or symptoms or reports from anybody saying that [Mr. Snowshoe] was exhibiting any type of suicidal behaviour, thought, ideation, anything of that nature. And secondly, he wasn't – he wasn't sent to us for self-harm reasons. It was for security concerns."

Another parole officer offered a candid assessment of general dysfunction within the prison.

"To be honest, our training sucks," testified parole officer Ansar Bacchus. "…I went to two weeks of parole training prior to getting the job. It was probably the worst two weeks of training I ever had in my life."

He added that parole officers face unwieldy caseloads of 30 inmates – up from 25 in 2010 – and unique cultural hurdles as they try to manage the lives of offenders while trying to uphold the guards' demands for security. "You don't want to be perceived as a con lover," he said.

As a whole, the testimony also touched on the growing argument against solitary confinement in prisons. Three front-line correctional workers said they had witnessed solitary confinement wreak adverse impacts on inmates – observations in line with two recent lawsuits against the Correctional Service calling for the end of solitary confinement in Canadian penitentiaries.

"Long-term solitary is a form of torture," said Catherine Latimer, executive director of the John Howard Society of Canada, one of the plaintiffs, upon reading a portion of the transcript. "Let's not blame the victim of torture for its consequences."

Two guards told the inquiry how they spotted Mr. Snowshoe slumped in cell 115 just after 9 p.m. on Aug. 10, 2010. "We tried to get his attention by yelling at him and stuff through the door or through the food slot, and he was unresponsive," stated one guard. "So, at that point we opened the door and then we entered."

Mr. Snowshoe was declared dead at 9:59 p.m.