The coroner's inquest into the death of Ashley Smith continued today with Correctional Service Canada (CSC) Commissioner Don Head taking the stand.

Head had secretly tried to have his summons quashed last month, arguing he had never met Smith and had no connection to the death of the 19-year-old from Moncton, N.B. The coroner refused, saying as head of the CSC, his testimony is important.

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.

At the time of Smith’s death, Head was the deputy commissioner for CSC, though he was away on language training for a good portion of her stay.

Under cross examination by the Smith family's lawyer, Julian Roy, Head admitted Smith's name came up in 22 "situation reports" he saw. Head said he did not question this any further.

“You were glancing at the references and 22 times in five months — that’s at least once a week … — there is somebody that keeps popping up over and over and over again. Is that right? And there’s no way that could have escaped your notice, right?” Roy asked Head.

“You never asked a single question about what on earth is happening with 22 incidents of ligature use … You never asked a single question about that?”

He also pressed Head about why he never questioned the number of times Smith was transferred. 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.

Head responded, “No. I did not get involved in the operations of it, no.”

Head said in hindsight, there are better ways to deal with prisoners who suffer from mental illness.

Lessons learned

Roy questioned Head on CSC's position on how to respond to a prisoner in distress, citing Smith's suicide while guards stood by. 

Head acknowledged in the case of medical distress it is, "safer to err on the side of caution and respond.”

He also agreed there are more effective ways of disseminating information to CSC employees than just posting passively to an internal website. 

Head said changes have, and continue to be, implemented to CSC policies in light of the Smith case, including:

  • Taking the time to properly debrief employees just beginning their shift.
  • Changes to training programs when it comes to dealing with prisoners diagnosed with mental illness.
  • More timely, streamlined, reporting on at-risk inmates.
  • Incorporating case studies into the training curriculum for CSC staff.
  • Ensuring qualified and experienced staff review incident reports.
  • Recognizing the need for interdisciplinary co-operation needed among those in the mental health field, parole officers, and other CSC staff.

Head also admitted that although some progress has been made since Smith died, there are still gaps in the system for inmates dealing with mental health issues.

Head said that there still is no training in place to inform CSC employees about mental illness and self harm.

He told the jury at the inquest to make practical recommendations which can be implemented because, in terms of funding for CSC, he said there is “no free pot of money.”  

This Saturday marks six years since Smith took her own life. At the time of her death, she was facing a six-year sentence mainly for charges incurred while in prison.