smith ontario death teenager died self inflicted october suicide watch custody despite guards watching video monitors smith able strip cloth minutes guards entered cell confirmed death warden deputy warden fired incident guards immediate contact smith initially charged homicide charges withdrawn year later smith family brought lawsuit lawsuit settled court documentary news program produced separate episodes life death documentaries describe circumstances leading death disagreement inside claims filed unprecedented publication ban exhibits presented death frequently interrupted multiple legal challenges change finally terminated september new smith death began september december presiding instructed jury begin respect verdict smith death december jury returned verdict homicide case provided dozens recommendations presiding judge early life born january new_brunswick canada adopted days old according adoptive parents normal childhood new_brunswick ages parents noted distinct changes child age juvenile court times minor offences throwing causing disturbance march smith assessed psychologist found evidence mental illness problems continued suspended school multiple times fall march multiple court appearances smith admitted assessment diagnosed learning disorder borderline personality disorder personality traits discharged days early centre behaviour returned smith multiple times years time involved reported incidents attempts physically harm january turned july motion transfer adult facility smith hired lawyer fight transfer unsuccessful october smith transferred saint john regional centre behaviour smith spent time segregation twice pepper sprayed october smith transferred federal institution smith transferred total times following institutions months federal custody nova scotia institution quebec regional psychiatric centre montreal ontario grand river hospital ontario central nova facility nova scotia death ontario october smith requested transferred psychiatric facility placed formal suicide watch october early hours october smith placing neck act self harm committed times guards enter cell intervene minutes passed examined pronounced dead october guards supervisor charged criminal causing death relation smith suicide warden deputy warden fired criminal charges later dropped october smith family launched death lawsuit demanding million damages suit eventually settled court undisclosed documentaries control january broadcast documentary case titled control documentary reporter describes smith fourteen year old placed youth facility month throwing smith placed solitary confinement behaviour day initial month sentence years entirely isolation death violent unpredictable force required intervene filmed recorded listed daily logs behaviour smith exhibited included attempts guards responding attacked smith weapons manufactured concealed frequent use force reports required document responses source concern facility officials according internal document obtained partially read aloud eventually administrators instructed guards respond self attempts smith ignore officials kept transferring facilities preventing implementation canadian law requiring mandatory review prisoners kept isolation days smith death firing directly involved officers officers charged homicide spokesman union guards alleged guards senior management daily direction given right highest levels management way line staff talking twice talking everyday repeatedly cell orders sic union spokesman relayed organization stance guards prosecution cover management conclusion documentary smith mother raised question responsibility gave order gave order child talking child youth centre segregated length time gave order don intervene breathing guards saw charges dropped reinstated positions declined talk viewed case closed current minister talk refused interviews reporter lawsuit pending wall second documentary titled wall broadcast november looks case similar closely month period detention regional psychiatric centre program depicts year conflict broadcast footage days smith suicide began initially led deputy chief controversial originally scheduled begin november delayed legal challenge smith family result challenge scope cover entire month period smith federal panel judges ruled porter excluded video evidence smith forced quebec june proceedings suspended september reason delay apparently allow proceedings late june porter replaced presiding apparently impending retirement november replacement presiding sudden unexpected replacement led smith family formally accuse chief interfering legal basis porter apparently indicated deliver outstanding july days announcement replacement resumed briefly september suspended september smith family lawyer challenged right new continue called september formally terminated dismissed jury second began september opening hearing wished apply standing proceedings continued presiding lengthy ruling released september granted standing smith family prison authorities advocacy groups group current mental health patients known widened scope include effects long term solitary confinement repeated transfers institutions country role mental health care management smith prison authorities youth custody issues arising smith death motion hearings took place october lawyers filed motion seal video materials documents related smith forced restraint incarcerated quebec prison facility motion denied presiding government lawyers requested temporary injunction stay proceedings motion denied video documentary material available subsequently proceeded planned additionally doctors involved smith treatment challenged expansion include events took place outside province ontario presiding dismissed motion time motion subsequently granted province doctors standing agreed testify voluntarily proceedings formal hearings began january expected months year jury women expected presented witnesses documents course january shown prison guard minute video smith tying neck guards discovery response questioned response admitted perfect world guards intervened save smith december year testimony pages evidence presiding instructed jury begin requested come verdict smith death recommendations means prevent event december jury returned verdict homicide case indicating actions contributed death stopping short finding criminal civil liability jury additionally provided recommendations presiding intended suggest ways better serve female inmates inmates suffering mental illness jury specifically recommended indefinite solitary confinement banned political impact november case began visible impact canadian federal politics public release video material depicting smith treatment incarcerated interim leader federal raised matter parliament asking government attempting restrict scope inquiry legal challenge prime minister responded government interfere public safety minister later indicated officials directed cooperate later appeared official government stance drew significant criticism opposition liberal members parliament suggested smith victim case november called formal public inquiry smith treatment incarcerated additionally treatment mentally ill offenders canadian prison system concluding publicly government release information held relating smith case subsequent release verdict december current minister public safety stated asked officials carefully review jury recommendations
Ashley Smith inquest