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Why is coroner’s office ignoring crucial evidence in teen’s suicide?

The video recordings made at the Joliette Institution in Quebec reportedly show Ashley Smith being forcibly injected with massive doses of anti-psychotic drugs, sometimes under threat by a nurse, and left strapped to a narrow metal gurney for almost 12 hours, her pleas for a fresh tampon ignored.

Two people who saw these videos, Kim Pate, executive director of the Canadian Association of Elizabeth Fry Societies, and Paul Beaudry, a psychiatrist, respectively said they are "shocking and disturbing" and raise "ethical, clinical and equipment-related" questions about Ms. Smith's treatment at Joliette.

Eighty-five days after the last video, Ms. Smith, by then transferred first to a Nova Scotia prison and then to the Grand Valley Institution in Kitchener – being moved from pillar to post, rarely for her benefit but rather for the system's, was the story of her life as Her Majesty's guest – the teenager, wearing only a suicide smock and lying on the floor of her segregation cell with a ligature tied tightly around her neck, asphyxiated herself while correctional staff watched.

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Now, it may seem self-evident that what happened to Ms. Smith in the months prior to her death is directly relevant to her state of mind, not to mention to the Correctional Service of Canada view of her, at the last stop on her tour of the Canadian prison circuit.

It may seem, particularly, that any body worth its salt charged with investigating her death, as the office of Ontario's chief coroner is mandated to do by law with any in-custody death, would want to get its hands on those videos, which are there for the getting.

Inquests, after all, have two distinct functions.

One is to examine the circumstances of a death, and answer the five (who died; where; when; how, and what was the manner of death) mandatory questions.

But the critical function of an inquest is to serve the broader public interest by holding a thorough, open inquiry, with the notion to prevent other similar deaths.

But Bonnie Porter doesn't see it that way.

The deputy coroner, and the woman set to preside over the inquest which at this writing is still scheduled to start next Monday, this week ruled that for the life of her, she can't find "a nexus" – a link – between Ms. Smith's escalating use of ligatures and the details of her horrific death on Oct. 19, 2007.

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(Lawyers for Ms. Smith's family are challenging Dr. Porter's latest decision, which could see the inquest yet delayed.)

Dr. Porter declined to obtain the Joliette videos from three key dates in late July, 2007, and another which showed Ms. Smith being transferred from a psychiatric centre in Saskatchewan and another institution in Quebec that spring, during which, according to Ms. Pate of the Elizabeth Fry Societies, the young woman was restrained in her seat with a hood over her entire face.

Dr. Porter, having found no link between how this treatment may have affected Ms. Smith or her handlers, declined to issue a summons for the videos.

She was a mentally ill teenager, for God's sakes, whose greatest crime was her self-injurious behaviour, not some hard-line terrorist; she was in Canadian prisons and facilities, not in those run by a Third World despot. Why on Earth would the deputy coroner not want to see the videos which better than anything else offer neutral evidence of what this girl endured?

Ms. Smith's story is nuanced and complex.

Admitted to her first facility at the age of 13, she was always a handful. Her early institutional life appears to have been mostly a tale of missed opportunities to help her.

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But once she turned 18, all her institutional charges as a young person were converted to an adult sentence of more than two years, and it was then she entered the federal system, and that journey of 17 prisons and hospitals in less than a year was ever more fraught, outrageous and cruel.

According to those who have examined it, such as the federal correctional investigator Howard Sapers, Ms. Smith's time in the federal system was so marred by violations of her rights and the rules (the multiple transfers; the use of administrative segregation which left her so craving human contact that, as a psychologist reported after her death, her self-harming behaviour likely escalated "as a means of drawing staff into her cell in order to alleviate the boredom, loneliness and desperation"; the consistent use of force, etc., etc.) that her treatment was "at times, inhumane."

Mr. Sapers concluded in his June, 2008, report, which he called A Preventable Death, that this combination of arbitrary transfers, the enormous amount of time she spent utterly alone, and the regular harsh use of force combined to escalate her bad behaviours, erode her trust in her handlers, and make her ever more difficult to handle.

That report is almost three years old. Mr. Sapers had no trouble seeing the nexus between Ashley Smith's final hours and all that went before. How can Dr. Porter be so blind?

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