Only an independent, external watchdog can force improvements on a secretive prison system deeply resistant to change, jurors at the inquest into the death of Ashley Smith heard Tuesday.
Proper accountability is desperately needed to prevent a recurrence of the Smith tragedy, a lawyer for a women's prisoner advocacy group told the jurors.
In closing submissions, Breese Davies said it would be useless to simply recommend a culture shift at Correctional Service Canada.
"This inquest has taught us the risks of allowing CSC to continue to operate under a cloud of secrecy," Davies said.
"They have lost their moral compass. The cloud of secrecy has to be lifted."
Speaking for the Canadian Association of Elizabeth Fry Societies, Davies said prison authorities need to focus less on security and more on therapy when it comes to mentally ill and chronically self-harming women.
Davies, who joined Smith's family in urging jurors to return a verdict of homicide in the teen's choking death six years ago, said CSC has done little to deal with the issues that led to the tragedy.
"CSC cannot be trusted to fix the problems," she said.
The deeply troubled Smith, 19, strangled herself in her segregation cell in Kitchener, Ont., on Oct. 19, 2007, as guards delayed going in to try to save her.
Davies opposed a finding of suicide or accidental death given evidence the warden had ordered underlings to stay out of Smith's cell as long as the inmate was still breathing.
"The order was a well researched, meticulously-crafted policy that we now know was a major factor in Ashley's death," Davies said.
"It was extreme hesitation that caused her death that day."
An inquest homicide verdict is a neutral finding that does not involve liability or blame but indicates only that a person contributed to the death of another.
"The people who made the order foresaw or expected her death," Davies said. "They were told directly."
'Ashley Smith was a child'
In submissions for Ontario's child and youth advocate, lawyer Richard Macklin urged a more therapeutic approach to "emerging adults" who find themselves in adult prisons.
That means offering specialized treatment by correctional staff experienced and knowledgeable in dealing with prisoners 18 to 21 years old, said Macklin, who backed a homicide verdict.
He replayed a video clip of a chatty, smiley Smith, of Moncton, N.B., on a transport plane bantering happily with guards about going shopping.
Immaturity leads to an inability to cope, leads to acting out, which in turn prompts a heavy-handed security response, creating a vicious cycle, jurors heard.
"Ashley Smith was a child," Macklin said. "It was the security focus that led to her undoing."
The inquest has heard about 20 high-needs women with issues similar to Smith, who repeatedly tied cloth strips around her neck, are in Canadian prisons poorly equipped to deal with them.
Self-harm has to be seen as a medical issue, not a security issue, Davies said. As such, jurors heard, the focus should be on getting mentally ill women out of prison and into independent, therapy-centred health facilities.
'Cloud of secrecy'
The inquest has heard how Smith, whose index offence was throwing crab apples at a postal worker, was kept in segregation, restrained or injected with drugs against her will, and repeatedly shunted from prison to prison because she was too difficult to handle.
"Forced compliance was exactly the opposite of what Ashley needed," Davies said.
Davies called for independent oversight of the use of restraints in prisons, and a ban on segregation — where Smith was kept for years — for the mentally ill.
"That's the right thing to do," she said. "If it's not an option, then other forms of intervention will be found."
The lawyer called for a strengthened women's secretariat within CSC — given that prisons are a male-dominated system — to which its institutions for females would report.
To ensure jury suggestions aren't ignored, Davies urged jurors to include public, ongoing oversight of their recommendations along with an independent five- and 10-year audit.
"This way, the cloud of secrecy can't persist, or return."
Corrections Canada is expected to make its submissions on Thursday.