Proper accountability is desperately needed to prevent a recurrence of the Ashley Smith tragedy, a lawyer for a women's prisoner advocacy group told jurors.
In closing submissions, Breese Davies said it would be useless to simply recommend a culture shift at Correctional Service Canada.
"This inquest has taught us the risks of allowing CSC to continue to operate under a cloud of secrecy," Davies said.
"They have lost their moral compass. The cloud of secrecy has to be lifted."
Speaking for the Canadian Association of Elizabeth Fry Societies, Davies said prison authorities need to focus less on security and more on therapy when it comes to mentally ill and chronically self-harming women.
Davies, who joined with Smith's family in urging jurors to return a verdict of homicide in the teen's choking death, said CSC has done little to deal with the issues that led to the tragedy.
"CSC cannot be trusted to fix the problems," she said.
The deeply troubled Smith, 19, strangled herself in her segregation cell in Kitchener, Ont., on Oct. 19, 2007, as guards delayed going in to try to save her.
Davies opposed a finding of suicide or accidental death given evidence the warden had ordered underlings to stay out of Smith's cell as long as the inmate was still breathing.
"The order was a well researched, meticulously-crafted policy that we now know was a major factor in Ashley's death," Davies said.
"It was extreme hesitation that caused her death that day."
An inquest homicide verdict is a neutral finding that does not involve liability or blame but indicates only that a person contributed to the death of another.
But John McNair, speaking for a psychiatric hospital in St. Thomas, Ont., where Smith spent some time, rejected a homicide verdict.
Smith brought a "terrible compulsion" to self-harm with her into the federal prison system and repeatedly played a game of "Russian roulette" she knew was potentially lethal, McNair said.
"CSC failed to prevent Ashley's death, but didn't cause it," McNair said. "It was Ashley's acts...that caused her death."
McNair also urged jurors to reject suggestions that regular psychiatric hospitals are the solution for such cases.
Smith needed intensive one-on-one therapy over a long period in a specialized therapeutic facility such as the CSC-run Regional Psychiatric Centre in Saskatoon, McNair suggested.
"You should not let CSC off the hook," he said. "You shouldn't let CSC shift that level of responsibility to another level of government."
In submissions for Ontario's child and youth advocate, lawyer Richard Macklin urged a more therapeutic approach to "emerging adults" who find themselves in adult prisons.
That means offering specialized treatment by correctional staff experienced and knowledgeable in dealing with prisoners 18 to 21 years old, said Macklin, who backed a homicide verdict.
Immaturity leads to an inability to cope, leads to acting out, which in turn prompts a heavy-handed security response, creating a vicious cycle, jurors heard.
"Ashley Smith was a child," Macklin said. "It was the security focus that led to her undoing."
As her mother Coralee Smith smiled broadly, Macklin replayed a video clip of a chatty, smiley Smith on a transport plane bantering happily with guards about going shopping.
"That was the best thing yet," Smith said afterward.
The inquest has heard that about 20 high-needs women with issues similar to Smith, who repeatedly tied cloth strips around her neck, are in Canadian prisons poorly equipped to deal with them.
Self-harm has to be seen as a medical issue, not a security issue, Davies said.
Smith, whose index offence was throwing crab apples at a postal worker, was kept in segregation, restrained or injected with drugs against her will, and repeatedly shunted from prison to prison because she was too difficult to handle.
"Forced compliance was exactly the opposite of what Ashley needed," Davies said.
Davies called for independent oversight of the use of restraints and a ban on segregation for the mentally ill.
"If it's not an option, then other forms of intervention will be found," she said.
To ensure jury suggestions aren't ignored, Davies urged jurors to include public, ongoing oversight of their recommendations along with an independent five- and 10-year audit.
"This way, the cloud of secrecy can't persist, or return."
Submissions continue Wednesday. Corrections is expected to make its submissions on Thursday.