Ashley Smith, 19, died six years ago after guards hesitated in rushing to remove a ligature the troubled young inmate had tied around her neck because of orders from senior management not to intervene as long as she was still breathing.
Smith's family and others had urged jurors to return a homicide verdict because of that order, which they believed significantly contributed to her death.
They are calling on authorities to criminally investigate those who issued that order.
``The real question has to be asked: How could such a flagrant abuse, such a flagrant disregard for human life go unaccounted for?'' Julian Falconer, the family's lawyer, said after the verdict was read.
``Those who made the order not to go into her cell – the deputy warden, the warden, those above – have yet to be truly investigated or yet to truly answer for their actions.''
Four front-line prison staff were originally charged with criminal negligence causing Smith's death, but those charges were ultimately dropped. Falconer said the family is not calling for their case to be reopened.
The inquest's five female jurors heard extensive evidence from 83 witnesses, who testified over 107 days since January about how poorly equipped the prison system was to deal with the mentally ill young woman.
The jury made 104 recommendations Thursday, most of them dealing with ways the correctional system can provide better supports to female inmates.
But, the jury recommended, women with serious mental health issues or self-harming behaviours should serve time not in prisons, but in a treatment facility.
``It is urged that more than one federally operated treatment facility is available for high-risk, high-needs women in the event that a major conflict occurs between the inmate and staff,'' the jury recommended.
``Furthermore, and specifically, that existing male federally operated treatment facilities be adapted to accommodate a wing for female inmates.''
Indefinite solitary confinement should be abolished, the coroner's jury recommended.
The young woman from Moncton, N.B., spent most of the last three years of her life in segregation, shunted from one institution to another in isolation.
In the last year of her life she was transferred between institutions 17 times – restarting the clock each time to avoid reviewing her segregation status.
Smith's sentence originally began with a few weeks for throwing crab apples at a postal worker but ballooned to a cumulative 2,239 days by the time she died on Oct. 19, 2007, mostly for acting out in prison.
Some of the witnesses said Smith spoke positively about her future and going home to her mom. Others said she had become inconsolably desolate at the prospects of never leavingprison.
The inquest heard that psychiatrists prescribed medication without seeing the teen and psychologists made fitful attempts to offer some form of therapy – through the food slot of her cell door.
The diagnosis, somewhere along the line, was that Smith suffered from severe borderline personality disorder.
Through it all, Smith was drugged against her will, pepper-sprayed for biting or scratching guards or being obdurate. She spent countless hours in a barren segregation cell, often with nothing more than a security gown designed to protect what was left of her dignity.
Smith at times covered her segregation cell camera and window with magazine pages. She dismantled the sprinkler head. She tied ligatures around her neck from fabric she had secreted in her body cavities, forcing staff to constantly to go into her cell to remove them.
She was at times deprived of all cell effects – which meant no blanket, mattress or hygiene products – for refusing to hand over her self-harming tools.
Decisions for such inmates' treatment should be made by clinicians rather than by security management and prison staff, the jury recommended.
The jury also suggested Smith's case be used as a case study for training all Correctional Services staff and managers and that all female inmates be assessed by a psychologist within 72 hours of being admitted to facilities.
© 2013 The Canadian Press