The prison guardsâ decision not to intervene as Ashley Smith strangled herself in her cell was a âtragic mistake,â Canadaâs correctional investigator said Tuesday.
Howard Sapers said the troubled teenager had harmed herself in custody âwell over 100 times before,â and someone was always there to stop her.
âIn every one of those incidents correctional staff had intervened and often saved her life by removing ligatures or stopping her behaviour,â Sapers told CTVâs Power Play.
But on Oct. 19, 2007, âthe decision had been made to try a different approach and it was a tragic mistake,â he said.
Smith, 19, died after tying a ligature around her neck at the Grand Valley Institution for Women in Kitchener, Ont., as guards watched her lying on the floor in her segregation cell and gasping.
The jury at a coronerâs inquest into Smithâs death watched a disturbing video Monday of the teenâs last moments and efforts to revive her once the prison guards finally entered the cell.
Sapers, who titled his 2008 report on Smithâs case âA Preventable Death,â said Tuesday that correctional officers always have the responsibility to âpreserve life.â
Staff who have dealt with Smith in various institutions were âconcerned about her well-being, but not always feeling equal to the task of managing her,â he said.
âQuite sadly, there are many offenders in the system, men and women, who self-harm,â Sapers said.
Many of them have a history of mental illness and are held in segregation cells for lengthy periods of time, he said.
âAshley was an extreme case, but unfortunately not unique in terms of repeated incidents of self-injury.â
The guard who videotaped Smithâs final attempt to strangle herself told the coronerâs inquest Tuesday he was just doing his job and following orders.
Rudy Burnett, a fill-in guard, had just finished his shift at Grand Valley and was about to go home when an emergency call sounded.
When he arrived at Smithâs cell, Burnett said he was given a video camera and told to start recording.
"If an order is given to me and I don't agree with it, there's a grievance procedure," he told the inquest.
Burnett said he believed he had done nothing wrong, even after he was arrested and charged with criminal negligence and failing to provide the necessities of life. The charges against him and three other prison employees were later dropped.
Smith, originally from Moncton, N.B., was first jailed at 15 for throwing crab apples at a mail carrier. She was supposed to serve a short prison sentence but racked up numerous offences against correctional staff and remained in jail for more than four years.
Smith was transferred in and out of various institutions in five provinces before ending up at Grand Valley.
Sapers said there are still âmany circumstancesâ of self-injury in prisons.
âWe certainly havenât seen the last death in custody as a result of self-harm or suicide,â he said. âThese things will happen.â
But he hopes that the inquest into Smithâs death will lead to improvements in Canadaâs correctional system and a âmore robust responseâ to emergencies involving inmates.
With files from The Canadian Press