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The Ashley Smith inquest was an
Ontario Ontario ( ; ) is one of the thirteen provinces and territories of Canada.Ontario is located in the geographic eastern half of Canada, but it has historically and politically been considered to be part of Central Canada. Located in Central Ca ...
coroner A coroner is a government or judicial official who is empowered to conduct or order an inquest into Manner of death, the manner or cause of death, and to investigate or confirm the identity of an unknown person who has been found dead within th ...
's
inquest An inquest is a judicial inquiry in common law jurisdictions, particularly one held to determine the cause of a person's death. Conducted by a judge, jury, or government official, an inquest may or may not require an autopsy carried out by a coro ...
into the death of Ashley Smith, a teenager who died by self-inflicted
strangulation Strangling is compression of the neck that may lead to unconsciousness or death by causing an increasingly hypoxic state in the brain. Fatal strangling typically occurs in cases of violence, accidents, and is one of two main ways that hanging ...
on 19 October 2007 while under
suicide watch Suicide watch (sometimes shortened to SW) is an intensive monitoring process used to ensure that any person cannot attempt suicide. Usually the term is used in reference to inmates or patients in a prison, hospital, psychiatric hospital or milit ...
in custody at the
Grand Valley Institution for Women Grand Valley Institution for Women (GVI; french: Établissement pour femmes Grand Valley) is a women's prison in Kitchener, Ontario, operated by the Correctional Service of Canada (CSC). In Canada, all offenders sentenced to prison terms of gre ...
. Despite guards watching her on video monitors, Smith was able to strangle herself with a strip of cloth, and it was 45 minutes before guards or supervisors entered her cell and confirmed her death. The warden and deputy warden were fired after the incident; although the four guards and supervisors in immediate contact with Smith were initially charged with negligent homicide, those charges were withdrawn a year later. Smith's family brought a lawsuit against the
Correctional Service of Canada The Correctional Service of Canada (CSC; french: Service correctionnel du Canada), also known as Correctional Service Canada or Corrections Canada, is the Canadian federal government agency responsible for the incarceration and rehabilitation of ...
(CSC) for negligence; this lawsuit was settled out of court in May 2011. The CBC documentary news program '' The Fifth Estate'' produced two separate episodes on the life and death of Ashley Smith. The documentaries describe the circumstances leading up to her death, as well as some disagreement inside the Correctional Service of Canada. ''The Fifth Estate'' claims "Corrections Canada filed an unprecedented publication ban on all exhibits presented at the coroner's inquest into her death." The inquest was frequently interrupted by multiple legal challenges and a change of coroner, before finally being terminated as a
mistrial In law, a trial is a coming together of parties to a dispute, to present information (in the form of evidence) in a tribunal, a formal setting with the authority to adjudicate claims or disputes. One form of tribunal is a court. The tribunal, w ...
on 30 September 2011; a new inquest into Smith's death began on 19 September 2012. On 2 December 2013, the presiding coroner instructed the jury to begin their deliberations with respect to a verdict on Smith's death. On 19 December 2013, the coroner's jury returned a verdict of homicide in the case of Ashley Smith, and provided dozens of recommendations to the presiding judge.


Early life

Ashley Smith (born 29 January 1988,
New Brunswick New Brunswick (french: Nouveau-Brunswick, , locally ) is one of the thirteen provinces and territories of Canada. It is one of the three Maritime provinces and one of the four Atlantic provinces. It is the only province with both English and ...
, Canada) was adopted when she was five days old. According to her adoptive parents, Coralee Smith and Herbert Gober, she had a normal childhood in
Moncton Moncton (; ) is the most populous city in the Provinces and territories of Canada, Canadian province of New Brunswick. Situated in the Petitcodiac River Valley, Moncton lies at the geographic centre of the The Maritimes, Maritime Provinces. The ...
, New Brunswick. Between the ages of 13 and 14, her parents noted distinct behavioural changes in the child; by age 15 she had been before juvenile court 14 times for various minor offences such as throwing crabapples at a mailman, trespassing, and causing a disturbance. In March 2002, Smith was assessed by a psychologist who found no evidence of mental illness. However, her behavioural problems continued and she was suspended from school multiple times in the fall of 2002. In March 2003, after multiple court appearances, Smith was admitted to the Pierre Caissie Centre for assessment. She was diagnosed with
ADHD Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inapp ...
,
learning disorder Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficult ...
,
borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
and
narcissistic Narcissism is a self-centered personality style characterized as having an excessive interest in one's physical appearance or image and an excessive preoccupation with one's own needs, often at the expense of others. Narcissism exists on a co ...
personality traits. She was discharged several days early from the Centre for unruly and disruptive behaviour and returned to the New Brunswick Youth Centre (NBYC). Smith was remanded to the NBYC multiple times over the next three years; during this time she was involved in more than 800 reported incidents and at least 150 attempts to physically harm herself. On 29 January 2006, Ashley Smith turned 18; on 29 July a motion was made under the ''
Youth Criminal Justice Act The ''Youth Criminal Justice Act'' (YCJA; french: Loi sur le système de justice pénale pour les adolescents) (the ''Act'') is a Canadian statute, which came into effect on April 1, 2003. It covers the prosecution of youths for criminal offen ...
'' to transfer her to an adult facility. Smith hired a lawyer to fight the transfer but was unsuccessful. On 5 October 2006, Smith was transferred to the Saint John Regional Correctional Centre (SJRCC). Due to her behaviour at SJRCC, Smith spent most of her time there in isolation; she was tasered twice and
pepper-sprayed Pepper spray, oleoresin capsicum spray, OC spray, capsaicin spray, or capsicum spray is a lachrymatory agent (a compound that irritates the eyes to cause a burning sensation, pain, and temporary blindness) used in policing, riot control, c ...
once. On 31 October 2006, Smith was transferred to the Nova Institution for Women in Nova Scotia (a federal institution). Through 2007, Smith was transferred a total of 17 times among the following eight institutions during 11 months in federal custody: * Nova Institution for Women,
Truro, Nova Scotia Truro (Mi'kmaq: ''Wagobagitik''; Scottish Gaelic: ''Truru'') is a town in central Nova Scotia, Canada. Truro is the shire town of Colchester County and is located on the south side of the Salmon River floodplain, close to the river's mouth at ...
* Joliette Institution,
Joliette Joliette is a city in southwest Quebec, Canada. It is approximately northeast of Montreal, on the L'Assomption River and is the seat of the Regional County Municipality of Joliette. It is considered to be a part of the North Shore of Greate ...
, Quebec * Regional Psychiatric Centre, Prairies,
Saskatoon Saskatoon () is the largest city in the Provinces and territories of Canada, Canadian province of Saskatchewan. It straddles a bend in the South Saskatchewan River in the central region of the province. It is located along the Trans-Canada Hig ...
, Saskatchewan * L'Institut Philippe-Pinel de Montréal,
Montreal Montreal ( ; officially Montréal, ) is the List of the largest municipalities in Canada by population, second-most populous city in Canada and List of towns in Quebec, most populous city in the Provinces and territories of Canada, Canadian ...
, Quebec *
Grand Valley Institution for Women Grand Valley Institution for Women (GVI; french: Établissement pour femmes Grand Valley) is a women's prison in Kitchener, Ontario, operated by the Correctional Service of Canada (CSC). In Canada, all offenders sentenced to prison terms of gre ...
,
Kitchener, Ontario ) , image_flag = Flag of Kitchener, Ontario.svg , image_seal = Seal of Kitchener, Canada.svg , image_shield=Coat of arms of Kitchener, Canada.svg , image_blank_emblem = Logo of Kitchener, Ontario.svg , blank_emblem_type = ...
*
Grand River Hospital Grand River Hospital is a 665-bed hospital serving Waterloo Region, Ontario, Canada, and surrounding communities, primarily through its KW and Freeport Sites, both located in Kitchener. The two sites were independent hospitals that merged to form ...
,
Kitchener, Ontario ) , image_flag = Flag of Kitchener, Ontario.svg , image_seal = Seal of Kitchener, Canada.svg , image_shield=Coat of arms of Kitchener, Canada.svg , image_blank_emblem = Logo of Kitchener, Ontario.svg , blank_emblem_type = ...
* Regional Mental Health Care St. Thomas, St. Thomas, Ontario * Central Nova Correctional Facility,
Dartmouth, Nova Scotia Dartmouth ( ) is an urban community and former city located in the Halifax Regional Municipality of Nova Scotia, Canada. Dartmouth is located on the eastern shore of Halifax Harbour. Dartmouth has been nicknamed the City of Lakes, after the larg ...


Death

While at
Grand Valley Institution for Women Grand Valley Institution for Women (GVI; french: Établissement pour femmes Grand Valley) is a women's prison in Kitchener, Ontario, operated by the Correctional Service of Canada (CSC). In Canada, all offenders sentenced to prison terms of gre ...
in
Kitchener, Ontario ) , image_flag = Flag of Kitchener, Ontario.svg , image_seal = Seal of Kitchener, Canada.svg , image_shield=Coat of arms of Kitchener, Canada.svg , image_blank_emblem = Logo of Kitchener, Ontario.svg , blank_emblem_type = ...
, on 16 October 2007, Smith requested to be transferred to a psychiatric facility; she was placed on a formal suicide watch on 18 October. In the early hours of 19 October, Smith was videotaped placing a ligature around her neck, an act of
self-harm Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilatio ...
she had committed several times before. Guards did not enter her cell to intervene, and 45 minutes passed before she was examined and pronounced dead. On 25 October 2007, three guards and a supervisor at the Grand Valley Institution for Women were charged with criminal negligence causing death in relation to Smith's suicide; the warden and deputy warden were fired, but warden Cindy Berry after almost a year was quietly rehired. The criminal charges against her subordinates were later dropped. No charges were ever brought against the warden or deputy warden. On 8 October 2009, Smith's family launched a
wrongful death Wrongful death claim is a claim against a person who can be held liable for a death. The claim is brought in a civil action, usually by close relatives, as enumerated by statute. In wrongful death cases, survivors are compensated for the harm, l ...
lawsuit against the
Correctional Service of Canada The Correctional Service of Canada (CSC; french: Service correctionnel du Canada), also known as Correctional Service Canada or Corrections Canada, is the Canadian federal government agency responsible for the incarceration and rehabilitation of ...
, demanding in damages; the suit was eventually settled out of court in May 2011 for an undisclosed amount.


Documentaries by ''The Fifth Estate''


''Out of Control''

On 8 January 2010,
CBC News Network CBC News Network (formerly CBC Newsworld) is a Canadian English-language specialty news channel owned by the Canadian Broadcasting Corporation (CBC). It broadcasts into over 10 million homes in Canada. As Canada's first all-news channel, it is th ...
's '' The Fifth Estate'' broadcast a documentary about the case titled ''Out of Control''. In the documentary, reporter
Hana Gartner Hana Gartner CM is a retired Canadian investigative journalist who is best known as the host and interviewer of several programs for the Canadian Broadcasting Corporation. Early life and education Gartner was born in 1948 in Prague, Czechoslova ...
describes Smith as a fourteen-year-old placed in a youth facility for one month in 2003 after throwing
crabapple ''Malus'' ( or ) is a genus of about 30–55 species of small deciduous trees or shrubs in the family Rosaceae, including the domesticated orchard apple, crab apples, wild apples, and rainberries. The genus is native to the temperate zone o ...
s at a mailman. Smith was placed in
solitary confinement Solitary confinement is a form of imprisonment in which the inmate lives in a single cell with little or no meaningful contact with other people. A prison may enforce stricter measures to control contraband on a solitary prisoner and use additi ...
after disruptive behaviour on her first day. Her initial one-month sentence would last almost four years, entirely in isolation, until her death in 2007. Often violent and unpredictable, her behaviours and the force required to intervene were always filmed and recorded, then listed on daily logs. Behaviour that Smith exhibited included many attempts at choking herself into unconsciousness; guards responding were often attacked by Smith, sometimes with weapons she had manufactured and concealed. The frequent "use of force" reports required to document responses became a source of concern for facility officials. According to an internal document obtained and partially read aloud by Gartner, eventually Corrections Canada administrators instructed guards and supervisors not to respond to self-strangling attempts by Smith, "to ignore her, even if she was choking herself". CSC officials kept transferring her to other facilities, preventing the implementation of a
Canadian law The legal system of Canada is Legal pluralism, pluralist: its foundations lie in the English common law system (inherited from its period as a colony of the British Empire), the Napoleonic Code, French civil law system (inherited from its New Fra ...
requiring mandatory review of prisoners kept in isolation for more than sixty days. After Smith's death, and the firing of both wardens and four directly involved officers, the four officers were charged with negligent homicide. The spokesman for the union for the four guards alleged the guards were " scapegoated" by senior management: "There was daily direction given right from the highest levels of management all the way to the front line staff, and we're not talking once or twice, we're talking everyday, repeatedly, 'you are not to go in the cell; this is your orders' ". The union's spokesman relayed his organization's stance that the guards' prosecution was part of a cover-up by those in CSC management. At the conclusion of the documentary, Smith's mother raised the question of responsibility: "Who gave that order, Hana?... Who gave the order to keep that child, we're talking about a child in the youth centre, segregated that length of time? Who gave the order 'don't intervene' if she's still breathing?" The four guards saw the charges against them dropped and were reinstated to their positions; they declined to talk to ''The Fifth Estate''. The Corrections Service of Canada viewed the case as closed, and while the current minister did talk to Hana Gartner, CSC refused any interviews with the reporter, while a lawsuit was pending.


''Behind the Wall''

A second documentary titled ''Behind the Wall'' was first broadcast on 12 November 2010, and looks at the case of another similar detainee, while probing more closely at a four-month period in Ashley Smith's detention while at the Regional Psychiatric Centre, Prairies,
Saskatoon Saskatoon () is the largest city in the Provinces and territories of Canada, Canadian province of Saskatchewan. It straddles a bend in the South Saskatchewan River in the central region of the province. It is located along the Trans-Canada Hig ...
. The program also depicts the two-year conflict between ''The Fifth Estate'' and CSC to broadcast more footage of the last days of Ashley Smith.


Inquests


2011 inquest

The first coroner's inquest into Smith's death began in May 2011. The inquest, initially led by deputy chief coroner Bonita Porter, was controversial; it was originally scheduled to begin in November 2010, but was delayed by a legal challenge by the Smith family. As a result of this challenge, the scope of the inquest was broadened to cover the entire 11-month period of Smith's incarceration under the federal Correctional Service. Further, a panel of judges with the Ontario Divisional Court ruled in May 2011 that Porter should not have excluded video evidence of Smith's forced sedation at the Joliette Institution in Quebec. On 21 June 2011, the proceedings of the inquest were suspended until 12 September; the reason for the delay was apparently to allow the proceedings to be
webcast A webcast is a media presentation distributed over the Internet using streaming media technology to distribute a single content source to many simultaneous listeners/viewers. A webcast may either be distributed live or on demand. Essentially, web ...
. In late June 2011, Porter was replaced as the presiding coroner, apparently due to her impending retirement in November 2011; the replacement presiding coroner was John R. Carlisle. The sudden and unexpected replacement led Smith's family to formally accuse the chief coroner of interfering in the inquest with no legal basis; Porter had apparently indicated that she would deliver three outstanding rulings in July, days before the announcement of her replacement. The inquest resumed briefly on 12 September, only to be suspended once again until 19 September, when the Smith family lawyer challenged the right of the new coroner to continue the inquest, and called for a mistrial. On 30 September 2011, the Ontario Coroner's Office formally terminated the inquest and dismissed the jury.


2012 inquest

A second inquest began on 20 September 2012, opening with a hearing for those who wished to apply for standing at the proceedings. John Carlisle continued as presiding coroner, and in a lengthy ruling released on 25 September 2012, granted standing at the inquest to Smith's family, prison authorities, inmate advocacy groups, and a group of current and former mental-health patients known as the Empowerment Council. Carlisle further widened the scope of the inquest to include the effects of long-term solitary confinement, repeated transfers between institutions across the country, the role of mental health care and the management of Smith as an inmate by prison authorities, and all youth-custody issues arising from Smith's death. Motion hearings for the inquest took place on 23–24 October 2012. Lawyers for the
Correctional Service of Canada The Correctional Service of Canada (CSC; french: Service correctionnel du Canada), also known as Correctional Service Canada or Corrections Canada, is the Canadian federal government agency responsible for the incarceration and rehabilitation of ...
filed a motion to seal video materials and documents related to Smith's forced restraint and sedation while incarcerated in the Quebec prison facility; when the motion was denied by the presiding coroner, the government lawyers requested a temporary
injunction An injunction is a legal and equitable remedy in the form of a special court order that compels a party to do or refrain from specific acts. ("The court of appeals ... has exclusive jurisdiction to enjoin, set aside, suspend (in whole or in pa ...
to stay the inquest proceedings through Ontario Divisional Court. This motion was also denied and the video and documentary material were made available to the inquest, which subsequently proceeded as planned. Additionally, three doctors involved in Smith's treatment during her incarceration challenged the expansion of the inquest to include events that took place outside the province of Ontario. Presiding Coroner Carlisle dismissed this motion at the same time as that of the Correctional Service of Canada motion, but subsequently granted the out-of-province doctors standing at the inquest when they agreed to testify voluntarily at the inquest proceedings. Formal hearings for the inquest began on 13 January 2013, and were expected to last between six months and a year. The jury of five women were expected to be presented with over 100 witnesses and 8,000 documents in the course of the inquest. On 22 January 2013, the jurors were shown prison guard Valentino Burnett's 45-minute video of Smith tying her neck, asphyxiating, and the guards discovery and response. When questioned about their response, Valentino admitted that "in a perfect world", the guards would have intervened to save Smith. On 2 December 2013, after more than a year of testimony and over 12,000 pages of evidence, the presiding coroner instructed the jury to begin their deliberations, and requested they come back with a verdict in Smith's death and recommendations on means to prevent a recurrence of such an event. On 19 December 2013, the coroner's jury returned a verdict of homicide in the Ashley Smith case, indicating the actions of others contributed to her death but stopping short of a finding of criminal or civil liability. The jury additionally provided 104 recommendations to the presiding coroner, most of which were intended to suggest ways in which the Canadian Correctional System could better serve female inmates and inmates with mental illness. The jury specifically recommended that indefinite solitary confinement should be banned.


Political impact

In November 2012, the Ashley Smith case began to have a visible impact on Canadian federal politics. After the public release of video material depicting Smith's treatment while incarcerated, interim leader of the federal
Liberal Party The Liberal Party is any of many political parties around the world. The meaning of ''liberal'' varies around the world, ranging from liberal conservatism on the right to social liberalism on the left. __TOC__ Active liberal parties This is a li ...
Bob Rae Robert Keith Rae (born August 2, 1948) is a Canadian diplomat and former politician who is the current Canadian Ambassador to the United Nations since 2020. He previously served as the 21st premier of Ontario from 1990 to 1995, leader of the ...
raised the matter in
Parliament In modern politics, and history, a parliament is a legislative body of government. Generally, a modern parliament has three functions: Representation (politics), representing the Election#Suffrage, electorate, making laws, and overseeing ...
during
Question Period Question Period (french: période des questions), known officially as Oral Questions (french: questions orales) occurs each sitting day in the House of Commons of Canada, in which members of the parliament ask questions of government ministers (i ...
, asking why the government was attempting to restrict the scope of the inquiry through the Corrections Canada legal challenge. Prime Minister
Stephen Harper Stephen Joseph Harper (born April 30, 1959) is a Canadian politician who served as the 22nd prime minister of Canada from 2006 to 2015. Harper is the first and only prime minister to come from the modern-day Conservative Party of Canada, ...
responded that the government would not interfere with the inquest, and Public Safety Minister
Vic Toews Victor Toews (; born September 10, 1952) is a Paraguayan-Canadian politician and jurist. Toews is a judge of the Court of King's Bench of Manitoba. He represented Provencher in the House of Commons of Canada from 2000 until his resignation on Ju ...
later indicated that Corrections Canada officials had been directed to cooperate with the inquest. However, Toews later appeared to contradict the official government stance and drew significant criticism from the opposition Liberal and
NDP NDP may stand for: Computing * Neighbor Discovery Protocol, an Internet protocol * Nortel Discovery Protocol, a layer two Internet protocol, also called SONMP * Nondeterministic programming, a type of computer language Government * National ...
Members of Parliament when he suggested that Smith was "not the victim" in the case. On 8 November, Rae called for a formal
public inquiry A tribunal of inquiry is an official review of events or actions ordered by a government body. In many common law countries, such as the United Kingdom, Republic of Ireland, Ireland, Australia and Canada, such a public inquiry differs from a royal ...
into Smith's treatment while incarcerated, and additionally into the treatment of mentally ill offenders by the Canadian prison system, after concluding publicly that the government would not release all the information it held relating to the Smith case. Subsequent to the release of the inquest verdict on 19 December 2013, the current
Minister of Public Safety The minister of public safety (french: ministre de la sécurité publique) is the minister of the Crown in the Canadian Cabinet responsible for overseeing Public Safety Canada, the internal security department of the Government of Canada. The ...
,
Steven Blaney Steven Blaney (born April 8, 1965) is a Canadian businessman and Conservative politician. He served as the Minister of Public Safety Canada (July 15, 2013 – November 4, 2015) and previously as the Minister of Veterans Affairs and Minister o ...
, stated that he had asked his officials to carefully review the jury's recommendations.


References

{{DEFAULTSORT:Smith, Ashley 2007 in Ontario 2007 suicides 2007 deaths 2012 in Ontario 2013 in Ontario Canadian adoptees Filmed suicides Kitchener, Ontario People who died by suicide in prison custody People with attention deficit hyperactivity disorder People with borderline personality disorder Suicides by hanging in Ontario Women in Ontario