Investigators say Canadian teen died due to failure of mental health services

From MSNBC:

OTTAWA, ONTARIO - A report released by Mr. Howard Sapers, Correctional Investigator of Canada, into the death of Ashley Smith finds the teenager died following the inability of federal and provincial health care and correctional systems to provide her with the care, treatment and support she desperately needed.

Addressing Ms. Smith's specific time in the care and custody of the Correctional Service of Canada (CSC), the corrections Ombudsman said a culmination of failures contributed to the 19 year old's death at the Grand Valley Institution for Women, Kitchener Ontario, on October 19, 2007.

Finding Ashley Smith's death "preventable," the report states the tragic incident continues a disturbing pattern of deaths in custody which are the result of ill-functioning and under-resourced correctional and mental health systems. It recommends federal, provincial and territorial governments engage the Mental Health Commission of Canada to develop a National Strategy to ensure better coordination among correctional and mental health systems nationwide, and ultimately, enhance public safety.

"Governments must take immediate actions to improve the assessment, care and treatment of persons with mental illness, inside and outside the justice system," said Mr. Sapers. "Failure to act will continue the unacceptable outcome of individuals with mental illness being incarcerated. Once in the correctional system, it is too often the case that their conditions deteriorate even further. The troubling death of young Ashley Smith not only speaks to system-wide breakdowns within federal corrections, but also to a lack of coordination and cohesiveness among federal/provincial/territorial mental health and correctional systems."

Examining Ms. Smith's short 11 1/2 months in federal custody, the Office of the Correctional Investigator (OCI) found many of the actions and decisions taken by the CSC - at the individual, institutional, regional and national levels - were non-compliant with the law and the Service's own policies. The violations included inappropriate use of institutional transfers, administrative segregation, and interventions involving force. The care and treatment Ms. Smith did receive was inadequate and disjointed and culminated in a failure to respond appropriately to her medical emergencies.

Other key recommendations in this latest report on deaths in custody by the OCI include the Correctional Service:

- Issue an immediate directive that all decisions affecting offenders take into account their health care, including mental health, needs;

- Ensure all Correctional Service National Boards of Investigation into incidents of suicide and self-injury be chaired by an independent mental health professional; and

- Amend its segregation policy to require a psychological review of an inmate's mental health status, with an emphasis on the evaluation of the risk for self harm, be completed within 24 hours of an inmate's placement in segregation.

In 2008, the OCI released A Failure to Respond, a report on the death of another federal inmate. In 2007, the OCI released its Deaths in Custody Study which examined 82 deaths of prisoners while in custody of the Correctional Service from 2001 - 2005. This report concluded that, as in the case of Ashley Smith, some of these deaths could likely have been averted through improved risk assessments, more vigorous preventive measures, and more competent and timely responses by institutional staff.

The Correctional Investigator is mandated by an Act of Parliament to be an independent Ombudsman for federal offenders. This work includes ensuring that systemic areas of concern are identified and addressed. The report on the death of Ms. Smith, as well as other deaths in custody reports, is available at www.oci-bec.gc.ca.