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The Ashley Smith inquest was an Ontario coroner's inquest into the death of Ashley Smith, a teenager who died by self-inflicted strangulation on 19 October 2007 while under suicide watch in custody at the Grand Valley Institution for Women. Despite guards watching her on video monitors, Smith was able to strangle herself with a strip of cloth, and it was 45 minutes before guards or supervisors entered her cell and confirmed her death. The warden and deputy warden were fired after the incident; although the four guards and supervisors in immediate contact with Smith were initially charged with negligent homicide, those charges were withdrawn a year later. Smith's family brought a lawsuit against the Correctional Service of Canada (CSC) for negligence; this lawsuit was settled out of court in May 2011. The CBC documentary news program The Fifth Estate produced two separate episodes on the life and death of Ashley Smith. The documentaries describe the circumstances leading up to her death, as well as some disagreement inside the Correctional Service of Canada. The Fifth Estate claims "Corrections Canada filed an unprecedented publication ban on all exhibits presented at the coroner's inquest into her death." The inquest was frequently interrupted by multiple legal challenges and a change of coroner, before finally being terminated as a mistrial on 30 September 2011; a new inquest into Smith's death began on 19 September 2012. On 2 December 2013, the presiding coroner instructed the jury to begin their deliberations with respect to a verdict on Smith's death. On 19 December 2013, the coroner's jury returned a verdict of homicide in the case of Ashley Smith, and provided dozens of recommendations to the presiding judge. Early life Ashley Smith (born 29 January 1988, New Brunswick, Canada) was adopted when she was five days old. According to her adoptive parents, Coralee Cusack-Smith and Herbert Gorber, she had a normal happy childhood in Moncton, New Brunswick. Between the ages of 13 and 14, her parents noted distinct behavioural changes in the child; by age 15 she had been before juvenile court 14 times for various minor offences such as throwing crabapples at a mailman, trespassing, and causing a disturbance. In March 2002, Smith was assessed by a psychologist who found no evidence of mental illness. However, her behavioural problems continued and she was suspended from school multiple times in the fall of 2002. In March 2003, after multiple court appearances, Smith was admitted to the Pierre Caissie Centre for assessment. She was diagnosed with ADHD, learning disorder, borderline personality disorder and narcissistic personality traits. She was discharged several days early from the Centre for unruly and disruptive behaviour and returned to the New Brunswick Youth Centre (NBYC). Smith was remanded to the NBYC multiple times over the next three years; during this time she was involved in more than 800 reported incidents and at least 150 attempts to physically harm herself. On 29 January 2006, Ashley Smith turned 18; on 29 July a motion was made under the Youth Criminal Justice Act to transfer her to an adult facility. Smith hired a lawyer to fight the transfer but was unsuccessful. On 5 October 2006, Smith was transferred to the Saint John Regional Correctional Centre (SJRCC). Due to her behaviour at SJRCC, Smith spent most of her time there in isolation; she was tasered twice and pepper-sprayed once. On 31 October 2006, Smith was transferred to the Nova Institution for Women in Nova Scotia (a federal institution). Through 2007, Smith was transferred a total of 17 times among the following eight institutions during 11 months in federal custody: Nova Institution for Women, Truro, Nova Scotia Joliette Institution, Joliette, Quebec Regional Psychiatric Centre, Prairies, Saskatoon, Saskatchewan L'Institut Philippe-Pinel de Montréal, Montreal, Quebec Grand Valley Institution for Women, Kitchener, Ontario Grand River Hospital, Kitchener, Ontario Regional Mental Health Care St. Thomas, St. Thomas, Ontario Central Nova Correctional Facility, Dartmouth, Nova Scotia Death While at Grand Valley Institution for Women in Kitchener, Ontario, on 16 October 2007, Smith requested to be transferred to a psychiatric facility; she was placed on a formal suicide watch on 18 October. In the early hours of 19 October, Smith was videotaped placing a ligature around her neck, an act of self-harm she had committed several times before. Guards did not enter her cell to intervene, and 45 minutes passed before she was examined and pronounced dead. On 25 October 2007, three guards and a supervisor at the Grand Valley Institution for Women were charged with criminal negligence causing death in relation to Smith's suicide; the warden and deputy warden were fired, but warden Cindy Berry after almost a year was quietly rehired. The criminal charges against her subordinates were later dropped. No charges were ever brought against the warden or deputy warden. On 8 October 2009, Smith's family launched a wrongful death lawsuit against the Correctional Service of Canada, demanding CA$11 million in damages; the suit was eventually settled out of court in May 2011 for an undisclosed amount. After Ashley Smith's death, her mother became an advocate for changes to the Canadian prison system to prevent similar tragedies in other families. She collaborated with Canadian senator Kim Pate, also a prisoners' rights advocate. Documentaries by The Fifth Estate Out of Control On 8 January 2010, CBC News Network's The Fifth Estate broadcast a documentary about the case titled Out of Control. In the documentary, reporter Hana Gartner describes Smith as a fourteen-year-old placed in a youth facility for one month in 2003 after throwing crabapples at a mailman. Smith was placed in solitary confinement after disruptive behaviour on her first day. Her initial one-month sentence would last almost four years, entirely in isolation, until her death in 2007. Often violent and unpredictable, her behaviours and the force required to intervene were always filmed and recorded, then listed on daily logs. Behaviour that Smith exhibited included many attempts at choking herself into unconsciousness; guards responding were often attacked by Smith, sometimes with weapons she had manufactured and concealed. The frequent "use of force" reports required to document responses became a source of concern for facility officials. According to an internal document obtained and partially read aloud by Gartner, eventually Corrections Canada administrators instructed guards and supervisors not to respond to self-strangling attempts by Smith, "to ignore her, even if she was choking herself". CSC officials repeatedly transferred her to other facilities, preventing the implementation of a Canadian law requiring mandatory review of prisoners kept in isolation for more than sixty days. After Smith's death, and the firing of both wardens and four .... Discover the Coralee June popular books. Find the top 100 most popular Coralee June books.