The death of a 19-year-old Moncton, N.B., woman in a Kitchener, Ont., jail could have been prevented had she been given proper care, Canada's prison watchdog said on Tuesday.

Howard Sapers, the ombudsman for Canada’s federal prison system, made the comments as he handed over his final report to Public Safety Minister Stockwell Day.

Ashley Smith was found unconscious on Oct. 19, 2007, 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."

She 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.

'Litany of serious failures,' report says

Although Sapers said the report won't be made public because of a continuing criminal investigation into the matter, he said it "discusses a litany of serious failures leading up to the tragic and, I believe, preventable death of Ms. Smith.”

"During her brief period of incarceration in the federal correctional system, this young woman did not receive the care, treatment and support that Canadians expect from the Correctional Service of Canada (CSC).

"This troubling case illustrates what can go wrong in federal corrections, and I urge both the minister and the commissioner to immediately implement my recommendations aimed at preventing similar deaths,” Sapers said.

Several investigations were conducted into Smith's death, by Correctional Service Canada, local police, the federal prison ombudsman and the youth and child advocate in New Brunswick.

From 2003 to 2006, Smith had been incarcerated at provincial correctional facilities, the New Brunswick Youth Centre and the Saint John Regional Correctional Centre.

While at the youth centre, she was the subject of over 800 incident reports, over 500 institutional charges and 168 self-harm incidents. She spent nearly two-thirds of that time in segregation.

A year in segregation at penitentiary

She was transferred to a penitentiary at age 18, where she spent nearly a year in federal custody, in segregation the whole time.

Sapers said she did not receive a comprehensive psychological assessment while in federal custody and was not given adequate mental health services.

He also noted that a correctional officer was charged with assaulting Smith six months prior to her death.

"Ms. Smith’s journey through the courts, correctional and health-care systems started at age 13 and ended tragically at age 19. It is clear that none of these systems adequately responded to her needs.

"A concerted effort involving provincial/federal/territorial partners is required to ensure that cases like Ms. Smith's do not happen again,” said Mr. Sapers.

Among his recommendations, Sapers said there needs to be improvement in responses to medical emergencies, use of force and segregation policies.

In a report released earlier this month, New Brunswick's ombudsman called for significant changes in how the justice system handles young people with mental health problems following his probe into the death of Smith.

Bernard Richard said that his six-month review of the time 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.