ARCHIVED - Backgrounder:
 "A Preventable Death"

Archived Content

Information identified as archived is provided for reference, research or recordkeeping purposes. It is not subject to the Government of Canada Web Standards and has not been altered or updated since it was archived. Please contact us to request a format other than those available.

Summary of events while Ashley Smith was in the care and custody of the Correctional Service of Canada:

  • Ashley Smith, who had a history of self harm, spent some five years in the youth justice system in New Brunswick before being transferred to the care and custody of the Correctional Service of Canada (CSC) in October 2006, at age 18. 

  • The CSC's treatment of Ashley Smith over the eleven and a half months she was in the care and custody of the federal system set the stage for the tragic circumstances that resulted in her death on October 19, 2007, at the Grand Valley Institution for Women, in Kitchener, Ontario.

  • Despite Ms. Smith's well documented troubled history in the provincial juvenile corrections and mental health systems, Ashley Smith was never provided with a comprehensive mental health assessment or treatment plan while under federal jurisdiction. The attempts that were made to obtain a full psychological assessment were thwarted in part by the Correctional Service's decisions to constantly transfer Ms. Smith from one institution to another.

  • Immediately upon entry to the federal system, Ashley Smith was placed on segregation status and maintained on that status for her entire time under federal jurisdiction.  She did not always receive the benefit of the legislative safeguards requiring thorough, timely independent reviews of her segregation status.

  • The conditions of confinement in the various segregation areas were at times oppressive and inhumane. She was often given no clothing other than a smock – no shoes, no mattress and no blanket. During the last weeks of her life she slept on the floor of her segregation cell. 

  • Her grievances concerning these conditions were inadequately addressed by senior management and the few responses received were non compliant with existing policy and regulations governing administrative segregation.

  • Ashley Smith was the subject of over 150 security incidents, many involving the deployment of gas. A number of these interventions resulted in the application of four-point restraints and forced injection of medication, contrary to existing CSC policy.

  • In less than a year, Ashley Smith was moved 17 times between three federal penitentiaries, two treatment facilities, two external hospitals and one provincial correctional facility. Nine of the 17 transfers of Ms. Smith, across four of the five CSC regions, had nothing to do with addressing her needs. Rather, these institutional transfers were implemented as a result of administrative issues such as cell availability and staff fatigue.

  • Most of these institutional transfers were done contrary to existing law and policy with little or no regard for Ms. Smith's mental health needs. On one occasion, while in restraints, Ms. Smith was duct-taped to the seat of an airplane.

  • Ashley Smith was assaulted by a staff member at a federal psychiatric institution resulting in her transfer out of that facility for her own safety. A staff member has been charged.

  • Senior management at the highest levels of the Correctional Service were aware of the on-going challenges presented by Ms. Smith, however no one person of authority took direct ownership or responsibility to ensure that she was treated in a humane and lawful manner.

  • Ms. Smith had been identified by a psychologist at the Grand Valley Institution for Women as highly suicidal; however staff monitoring Ms. Smith in the 48 hours preceding her death were not formally provided with this information. 

  • In the hours just prior to her death, Ms. Smith spoke to a Primary Worker of her strong desire to end her life. Ms. Smith died while under direct 24 hr observation by correctional staff.


  1. All recommendations emanating from the National Board of Investigation and the Independent Psychological Report be implemented and applied as widely as possible including within men's facilities.

  2. The Correctional Service provide a full public accounting of its response to the OCI Deaths in Custody Study, including a detailed Action Plan with expected outcomes and time frames.

  3. The Correctional Service group its women's facilities under a reporting structure independent of the Regions, with the wardens reporting directly to the Deputy Commissioner for Women.

  4. The Correctional Service issue an immediate direction to all staff regarding the Correctional Service's legislated requirement to take into consideration each offender's state of health and health care needs (including mental health) in all decisions affecting offenders, including decisions relating to institutional placements, transfers, administrative segregation, and disciplinary matters. CSC decision-related documentation must provide evidence that the particular offender's physical and mental health care needs were considered by the decision-maker. 

  5. The Correctional Service immediately review all cases of long-term segregation where mental health issues were a contributing factor to the segregation placement.  Particular attention should be paid to inmates with histories of suicide attempts or self-injurious behaviour. The results of this review should be provided to the institutional heads and Regional Deputy Commissioners and, in the case of female offenders, to the Deputy Commissioner for Women.

  6. The Correctional Service seek independent expertise – with a strong women-centered component – to review its policies on managing self-injuring inmates, and inmates displaying challenging behavioural issues. This review should focus on the appropriateness of placing those inmates on administrative segregation status.

  7. All Correctional Service National Boards of Investigation into incidents of suicide and self-injury be chaired by an independent mental health professional.

  8. The Correctional Service review and revise its administrative segregation practices to ensure that all long-term segregation placements are reviewed by regional managers, inclusive of health care, after 60 days of segregation. In those cases where segregation status is maintained, the decision and supporting documentation be referred to the Senior Deputy Commissioner and, in the case of female offenders, to the Deputy Commissioner for Women.

  9. The Correctional Service amend its segregation policy to require that a psychological review of the inmate's current mental health status, with a special emphasis on the evaluation of the risk for self-harm, be completed within 24 hours of the inmate's placement in segregation.

  10. The Correctional Service immediately implement independent adjudication of segregation placements of inmates with mental health concerns. This review should be completed within 30 days of the placement and the Ajudicator's decision should be forwarded to the Regional Deputy Commissioner. In the case of a female inmate, the Ajudicator's decision should be forwarded to the Deputy Commissioner for Women.

  11. The Situation Management Model be modified to require staff to give consideration to an offender's history of self-harm and his/her potential for future or cumulative self-harm when determining whether immediate intervention is required.

  12. The Senior Deputy Commissioner review all of the complaints, and the Correctional Service's response to those complaints, that were submitted by Ms. Smith during her period of federal incarceration, inclusive of the complaint submitted by Ms. Smith in September 2007 at GVI. A written response to these complaints should be issued, and appropriate corrective action and policy clarification should be undertaken.

  13. All grievances related to the conditions of confinement or treatment in segregation be referred as a priority to the institutional head and be immediately addressed.

  14. The Correctional Service immediately commission an external review of its operations and policies in the area of inmate grievances to ensure fair and expeditious resolution of offenders' complaints and grievances at all levels of the process.

  15. The Minister of Public Safety, together with the Minister of Health, initiate discussions with their provincial/territorial counterparts and non-governmental stakeholders regarding how to best engage the Mental Health Commission of Canada on the development of a National Strategy for Corrections that would ensure a better coordination among federal/provincial/territorial correctional and mental health systems. The development of the National Strategy should focus on information sharing between jurisdictions, and promote a seamless delivery of mental health services to offenders.

  16. The Correctional Service undertake a broad consultation with federal/provincial/territorial and non-governmental partners to review the provision of health care to federal offenders and to propose alternative models for the provision of these services.  The development of alternative models should include public consultations.

Status of CSC response to OCI concerns regarding deaths in custody:

The death of Ashley Smith adds to a disturbing and well documented pattern of deaths in federal custody, and is the latest in a series of investigations undertaken by the Office of the Correctional Investigator.  

  • In February 2007, the OCI released its Deaths in Custody Study, which examined the deaths of 82 inmates while in federal custody between 2001 – 2005.  Significantly, the Study found that some deaths in custody could have been averted through improved risk assessments, more vigorous preventive measures, and more competent and timely responses by institutional staff.  

  • In May 2008, the OCI publicly released A Failure to Respond, a report on the death of another federal offender. This report concluded that "the concerns related to the failures by staff to respond to a medical emergency in this case are strikingly consistent with the concerns that have been raised in the past with the Correctional Service by its own National Board of Investigations, Provincial Coroners and the OCI, including the Deaths in Custody Study.

In February 2009, the Correctional Investigator received a response from the CSC to the Deaths in Custody Study.  The Service has committed to a number of important measures to assist in minimizing and preventing deaths in custody. 

Significantly, the CSC has undertaken to publicly report on its obligations in this regard by formally including a section on deaths in custody in its 'Report on Plans and Priorities' for the coming years. 

While encouraged by this and other measures, the Correctional Investigator is still concerned by the overall lack of timelines, rate of progress and clear accountabilities in fully implementing recommendations made by his Office and those of other bodies, including Provincial Coroners, to improving the Service's overall record, response and capacity to prevent deaths in custody.

It is the position of the OCI that the system-wide failures that contributed to the death of Ms. Smith require a thorough examination to ensure better coordination among correctional and mental health systems nation-wide. All levels of government need to take immediate actions to ensure essential mental health care is available to all persons suffering from mental illness inside the criminal justice system.  Their lives depend on it.