New Brunswick's ombudsman is calling for significant changes in how the justice system handles young people with mental health problems following his probe into the death of a 19-year-old woman in an Ontario prison.

Bernard Richard said Monday that his six-month review of the time Ashley Smith spent in the youth criminal justice system "tells a pretty tragic story" and highlights the need to change practices, particularly to divert youth with mental illnesses and behavioural problems away from the justice system by boosting services and foster care.

"We need a really serious wakeup call in terms of mental illness … We need to respond better to youth suffering from mental illness and severe behaviour disorders," he said. "We have to stop criminalizing these youth. The way to do that is to provide mental health services outside, of course, of the New Brunswick youth centre."

That change is one of 25 recommendations in Richard's report released Monday, titled Ashley Smith: A Report of the New Brunswick Ombudsman and Child and Youth Advocate on the Services Provided to a Youth Involved in the Youth Criminal Justice System.

He said the province must establish specialized foster homes, provide more resources to families and instruct clinicians within the justice system on how to handle young people. He also called for a national health strategy to co-ordinate mental health and corrections services for youth.

Additionally, Richard recommended changing practices at youth jails, including the use of segregation cells, and that using stun guns on minors should "absolutely stop." He said he was surprised to learn that a Taser had been used on Smith twice in the span of a month.

Richard said officials "need to respond more appropriately and much sooner, otherwise we're making kids worse, and that's what I think we did in this case."

He launched the probe, which looked at more than 6,000 pages and 40 hours of video interviews, after Smith, from Moncton, was found unconscious on Oct. 19 in her segregation cell at the Grand Valley Institution for Women in Kitchener, Ont., and later died in hospital of what police have described as "self-initiated asphyxiation."

Smith had been serving a six-year, one-month sentence for offences committed as a young offender, including assault with a weapon and assaulting a peace officer, and would have been eligible for release in November.

'Pretty shocking stuff': Richard

Richard looked at Smith's incarceration from 2003 to 2006 in provincial correctional facilities, the New Brunswick Youth Centre and the Saint John Regional Correctional Centre.

He said he was disturbed by some of his findings, including that there were over 800 incident reports, over 500 institutional charges and 168 self-harm incidents while she was at the youth centre. She spent nearly two-thirds of that time in segregation, he said.

"I was shocked at the number of criminal charges that she faced as a young inmate at the New Brunswick youth centre. To have 70 criminal charges, between the ages of 14, almost 15, to 18, and to have almost half of those, I think 38, about 38, of those criminal charges were a result of incidents within the prison," he said.

"That's pretty shocking stuff."

Ombudsman hopeful of change

Richard said he was "very encouraged" that the government would move forward with the recommendations.

"I'm hopeful it will provide some impetus to really generate some change," he said, adding his recommendations were "very do-able."

He said the draft copies of the report had been well received by government officials.

Richard said federal prison ombudsman Howard Sapers also welcomed the recommendations.

Government promises to act on review

The government will act on Richard's recommendations, a news release issued later Monday said.

"The government takes this report very seriously, and while we cannot comment on a specific case, we are taking solid actions to ensure that the events that led to a tragic death will not be repeated," said Education Minister Kelly Lamrock, chair of the Integrated Services for Youth Team, in the release.

"Government will continue to review and enhance government services to address the needs of youth at risk better."

The Integrated Services for Youth Team, a ministerial committee, will also develop strategies to address Richard's recommendations, the release said.

"This government has acted and will continue to act to ensure youth at risk are protected and well served in New Brunswick," Lamrock said.