The head of a group that advocates for female prisoners testified Tuesday that teen prisoner Ashley Smith looked “hopeless and dejected” in the weeks before taking her own life.

Smith, 19, choked to death on Oct. 19, 2007, after tying a piece of cloth around her neck while prison guards stood outside her cell and watched at Grand Valley Institution for Women in Kitchener, Ont. The guards say they had been ordered not to intervene.

Kim Pate, the executive director of the Canadian Association of Elizabeth Fry Societies, took the stand Tuesday at the coroner’s inquest into Smith’s death.

She said the first time she met Smith was May 31, 2007. She said Smith's condition deteriorated when she saw her again on Sept. 24 — describing the teen as “hopeless and dejected.”

Pate testified Smith encountered several problems — from too many transfers to problems with paperwork and too much time in segregation.  

Smith was transferred from institution to institution all across Canada. Through 2007, during her time in federal custody, she was transferred 17 times among eight institutions in four provinces.     

Pate said some inmates with mental health issues often get stuck in the cycle of punishment.    

“We see far too many individuals who are sometimes some of the most marginalized ending up in this situation,” the court heard on Tuesday.

“And once you're in the situation it's very difficult to re-characterize that behaviour other than as bad behaviour deserving of punishment," she said. "That's not because there are evil people working in those systems — that's the way the systems are designed."

Pate said she raised concerns after her final visit with Smith. She testified that Smith had no mattress or blanket and only had a security gown in her cell. She said she wanted to take Smith to the hospital for treatment.

She said she helped Smith file a grievance, since she wasn’t allowed paper or pen in her cell, but it wasn’t read until after her death.

The court heard that, after Smith’s death, Pate received a phone call from a woman in the segregation unit at Grand Valley telling her that Smith had died. Pate was supposed to give human rights training at the institution the week that Smith died.

Early intervention key

Pate said early intervention in cases like Smith's is crucial. She told the court she would also like to see some independent oversight of prisoners kept in segregation.

The inquest into Smith’s death has heard from numerous witnesses over the months that Cindy Berry — the acting warden of Grand Valley Institution for Women at the time of the incident — had issued an order for guards not to intervene unless Smith had stopped breathing.

When Berry took the stand earlier this month, she repeatedly denied ever giving such an order.

The inquest, under Dr. John Carlisle, has heard from more than 50 witnesses since beginning in January. It resumed in September after a 10-week summer recess.

Prior to the beginning of the inquest, Smith's family fought for years to gain access to videos and documents related to her treatment in federal custody.