Ashley Smith died on Oct. 19, 2007, after she was found unconscious in her segregation cell at the Grand Valley Institution for Women in Kitchener, Ont. (Courtesy of Ashley Smith's family)

The 2007 death of a troubled 19-year-old Moncton, N.B., woman in an Ontario prison was the "entirely preventable" result of a series of systemic failures, says a report released Tuesday by Canada's correctional investigator.

Authored by Howard Sapers, the report says Ashley Smith's death followed "the inability of federal and provincial health-care and correctional systems to provide her with the care, treatment and support she desperately needed."

"None of the systems, programs and professionals that Canadians would reasonably expect to have been made available to help this young woman were there to adequately respond," says the report, which was released during a news conference in Ottawa.

"Her death, we believe, if not for a series of significant failures, was entirely preventable."

Smith died on Oct. 19, 2007, after being found unconscious in her segregation cell at the Grand Valley Institution for Women in Kitchener. She was taken to hospital, where she died of what police have described as "self-initiated asphyxiation."

Despite spending years in the youth correctional system and having an established history of violence and self-harm, Smith never received a comprehensive psychological assessment while in federal custody, said the report.

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 2007.

Kept in segregation

The Union of Canadian Correctional Officers claims guards were told not to intervene whenever Smith appeared to be harming herself by tying items around her neck, unless she stopped breathing.

The report says Smith was kept in "highly restrictive and at times, inhumane" segregation during her 11½ months in federal custody even though her mental health issues had been "aggravated by years of isolation in provincial youth facilities."

"There is reason to believe that Ms. Smith would be alive today if she had not remained on segregation status and if she had received appropriate care," says the report.

While in federal custody, she was involved in roughly 150 "security incidents" including choking herself, banging her head against the wall and cutting her arms, says the report. Smith was "generally non-compliant" when staff intervened.

She made seven complaints to try to get out of segregation, but the report says there is no evidence management appropriately reviewed her confinement status. Her final complaint, submitted in a sealed envelope, was opened two months after her death.

While at the Kitchener prison, video evidence shows times when Smith turned blue, had trouble breathing and broke blood vessels while trying to harm herself before staff physically intervened, says the report. Staff who immediately responded were sometimes reprimanded by senior management.

"The message that was given was that waiting would … stop reinforcing that behaviour," said Sapers. "It is my position that whenever there is a instrument of self-harm present and whenever life is at risk, that should trigger an immediate intervention."

Need national mental health strategy: report

Sapers said there were violations of law and policy within the Correctional Service, including inappropriate use of institutional transfers and interventions involving force.

The care and treatment Smith did receive was "inadequate and disjointed," he said, culminating in a failure to respond appropriately to her medical emergencies.

Sapers recommended more thorough assessments, more vigorous preventative measures, and more training for federal prison staff.

He said federal, provincial and territorial governments also need to develop a national strategy to better co-ordinate correctional and mental-health systems across the country.

"Governments must take immediate action to fill the void and ensure essential mental health care is available to Canadians at risk of incarceration," he said.

"A start would be to ask the Canadian Mental Health Commission to address this on an urgent basis."

The system "must and can do better."

With files from the Canadian Press