An inquest into the hanging of an 18-year-old Manitoba woman has ended with no recommendations more than five years after her death because the judge determined too much time had passed for them to be relevant.
On an August night in 2010, a month after being released from two years in custody, the woman walked outside, climbed a tree and hanged herself.
An inquest into her death has finished, but Judge Marvin Garfinkel decided not to recommend any changes to Manitoba's correctional system or child welfare system, citing in his report that the time passed makes "any recommendations that may be made immaterial or irrelevant."
He cited lawyers' busy schedules as a contributor to the lengthy delays.
Officers arrive 42 minutes after call
At age five, the woman the inquest refers to only as M.A. was put into the care of Child and Family Services (CFS).
For the next 11 years, she bounced to and from placements a total of 20 times before she was arrested for manslaughter at age 16. Before that, she had no criminal record.
M.A. was given a special and rarely used sentence called intensive rehabilitative custody and supervision. The year the sentence was handed down, only about six youth in Canada got similar sentences.
She spent two years in a Winnipeg youth correctional centre, over which she tried to kill herself several times. She suffered from anxiety and depression, the inquest report says.
One month after her release, she was dead.
The night M.A. killed herself, police were called to respond to a report of someone climbing a tree, but officers weren't dispatched for 30 minutes.
When they arrived, more than 40 minutes later, the woman was cold.
At the time she died, the court had hoped CFS would provide her with a support worker — a close friend had said she did well with the structure she had in the youth centre and her new freedom could cause problems for her.
CFS was under no obligation to provide any support, though, as she had aged out of the system while in custody. They agreed to provide "shelter and maintenance" for M.A. but didn't appoint a support worker to supervise her.
She was released into the custody of her sister and was under supervision of "correctional officials," the inquiry report said.
'She would have been relaxed'
The day before she killed herself, she spoke to her mom on the phone. Her worried mom asked her to come home, but she didn't. She hung up on calls from her mom and sister that night.
The next day, a woman who had volunteered as a Big Sister for M.A. for eight years stopped in to see her.
'The inquest was not completed until September 2015.... Too many years have passed.' - Judge Marvin Garfinkel in his inquest report
She thought M.A. looked high or drunk, but didn't contact any of her correctional workers, the inquest report said.
After M.A.'s death, an autopsy found alcohol, Tylenol 3s and other medications — two anti-anxiety drugs and an anti-psychotic — in her system.
Garfinkel wrote in his inquiry report that she "would have been relaxed" at the time she killed herself.
Garfinkel declined to recommend any changes to either CFS or the correctional system.
'Lawyers are busy,' inquest report says
After M.A.'s death in 2010, the office of the chief medical examiner initially ruled an inquest wasn't required. The decision was reversed with no reason provided.
The hearing of witnesses began in July 2015, and the inquest was complete three months later.
'I would not be surprised if a lawyer told me she or he was booking dates into 2017.' - Judge Marvin Garfinkel in his inquest report
"Some may wonder why hearings were set so far in advance," Garfinkel wrote. "The answer is because co-ordination of several lawyers' diaries was needed. Lawyers are busy. I would not be surprised if a lawyer told me she or he was booking dates into 2017."
The delays ultimately meant no changes as a result of the woman's death, but the judge did say a "deadline should be imposed upon [CFS] to provide a support worker" in similar cases in the future, and "clarifying the role of the child caring agency in these circumstances is very important."
He also acknowledged the woman didn't get the care her mom expected she would.
Ultimately, Garfinkel said, there was a treatment plan for M.A. in place, but "not sufficient resources to keep someone with her 24 hours a day."