Ashley Smith's mother spoke publicly for the first time Wednesday about her daughter's death in a federal prison, demanding to know whose decisions allowed the New Brunswick woman, 19, to strangle herself while guards looked on.

Coralee Smith says "faceless bureaucrats" must be held accountable for her daughter's death. (CBC)

"As a family, we feel that Ashley died because no one in Canada really cared," Coralee Smith told reporters in Ottawa.

"No one cared — not the guards who watched her asphyxiate, not the managers who ordered the guards not to intervene in her case, not those nameless bureaucrats who knew that my daughter needed help but did nothing but transfer her 17 times in 11 months. We are heartbroken"

Ashley Smith killed herself while in segregation in the Grand Valley Institution for Women at Kitchener, Ont., in October 2007.

In a report issued Tuesday, the federal prison ombudsman, Howard Sapers, said guards previously had been disciplined for intervening too quickly when she tied a ligature (a strap or cord) around her neck and seemed to choke herself.

Sapers, who heads the Office of the Correctional Investigator of Canada, described her death as entirely preventable. He said it revealed breakdowns in the correctional system and a lack of co-ordination with mental health authorities.

Ashley Smith died on Oct. 19, 2007, after she was found unconscious in her cell. (Courtesy of Ashley Smith's family)

The family seeks a second investigation to fix blame on individual prison managers.

"These faceless bureaucrats have to be held accountable," Coralee Smith said. "We need to know the names of these officials who are responsible for what happened to my girl."

Toronto lawyer Julian Falconer, representing the family, said prison managers may be able to explain their orders, "but we're entitled to have faces and names to those bureaucrats who give those explanations for those orders," he said. "And once we figure out who they are, they should never again be allowed to take care of any of our children.”

Ashley Smith, now buried in her home town of Moncton, was 13 when she was charged for the first time with minor offences. Over the next six years, she went from problem to problem and institution to institution.

There is no doubt she was a difficult prisoner to handle, but that is not an excuse for letting a tragedy happen, the ombudsman said. Preventing harm and preserving life should have been overriding principles, he said.

"Over time, Ms. Smith's behaviours began to exhaust front-line staff," he wrote in the report. "For example, during an institutional visit in June 2007, my staff was advised that Ms. Smith would often 'play with ligatures' (e.g., tie it in a bow-like fashion) and then taunt staff with it.

"There were also times when she would wrap a ligature around her neck, hide herself from view (e.g., under her security gown or mattress), or lie face down on the floor and 'pretend' to be unconscious, and then she would assault staff once they had entered her cell to cut off the ligature.

A dangerous game

"Some staff had begun to perceive this as a dangerous game that Ms. Smith was playing and they indicated that they were growing more and more uncertain as to when to intervene in these situations."

Video evidence showed that the woman sometimes turned blue and broke blood vessels before the guards stepped in, and prison officials do not appear to have discouraged "these untimely staff interventions," he wrote.

"In fact, documentation indicates that the opposite was true: Senior managers at GVI had disciplined front-line staff for intervening too early when Ms. Smith had tied a ligature around her neck, even though she appeared to be in medical distress.

"There were also times when front-line staff had made the decision that Ms. Smith required immediate assistance, however correctional managers ordered the staff to not intervene. In one incident, a correctional manager physically prevented a staff member from entering Ms. Smith's cell to provide assistance."