The judge wrote that Edward Snowshoe fell through the cracks of the system and no one was aware of how long he had been in segregation even though the information was readily available.
The 24-year-old from the Northwest Territories committed suicide on August 2010.
He had been locked away because he had turned a juice box inside out and used it as a weapon.
The judge recommends a review of segregation policies and for prison staff to recognize the cultural issues involved with aboriginal inmates.
Snowshoe was held in segregation for 134 days at the Stony Mountain prison in Manitoba before his transfer to the Edmonton Institution, where he was put in segregation for 28 days. (CHED)
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