The Ontario coroner's inquest into the death of Moncton teenager Ashley Smith is entering its final phase.
This week, lawyers for all of the parties involved will present their submissions to the jury.
Smith died in her cell at the Grand Valley Women's Institute in Kitchener, Ont., after tying a ligature around her neck. Prison guards watched as Smith choked to death. The inquest heard testimony that they were acting on orders not to intervene unless Smith, 19, stopped breathing.
Lawyer Julian Roy is representing Smith's family.
He said everything that could go wrong, did go wrong for the teen while she was in the custody of the Correctional Service of Canada.
Roy believes the inquest has been thorough.
"We have heard from all of the guards and managers in the institution so we have heard their perspectives about what went wrong and most of the witnesses have been quite candid with the court in my view," he said.
The inquest began in January and ran until early July before taking a summer-long recess. It resumed in September and wrapped up in early November.
Roy believes the inquest has heard from everyone that was necessary.
"We have gone up the chain to regional headquarters and to national headquarters all the way up to the most senior official with Corrections Canada Commissioner Don Head, so there has been no stone left unturned," he said.
The coroner's jury is not to assign blame for Smith's death, but is to make recommendations for change.
"Is there a silver bullet? Is there a magic solution to this problem of how we care for people who suffer from mental illness in custody?" said Roy. "I'm not sure about tha,t but there's certainly a lot of room for improvement in the short term and some potentially bigger solutions in the medium and long term."
Submissions by lawyers will continue until Thursday.
Presiding coroner Dr. John Carlisle is scheduled to give his charge to the jury on Dec. 2.
Smith, who was incarcerated for the first time at age 15, was transferred 17 times among nine institutions in five provinces during the last year of her life, the inquest has heard.