Thursday, August 4, 2011

Ashley Smith's Inquest: It's Our Call

As reported in The Vancouver Sun July 19, 2011

"Two doctors were cleared of wrongdoing in relation to the care they provided Ashley Smith while she was incarcerated, the Ontario Health Professions Appeal and Review Board concluded in a recent decision.

"However, the review is critical of the treatment Smith received before her eventual death in an Ontario prison.

"From our perspective, it is difficult to understand how the resources of Correctional Services Canada and the numerous health professionals who were involved with (Smith), particularly within the last year of her life, could not have somehow appropriately treated her admittedly severe behavioural problems," the review, dated July 15, states.

"The review was brought to the board by the Elizabeth Fry Societies, on behalf of Smith's family, to appeal an earlier decision by the College of Physicians and Surgeons of Ontario that had previously cleared two physicians of any wrongdoing in their assessment of Smith while she was in prison.

"One of the physicians was a family doctor conducting weekly consultations at the Grand Valley Institute for Women, while the other was a psychiatrist who made similar weekly visits to the prison.

"The Smith family's original complaint wanted to ascertain why Smith was not referred to a psychiatric facility in the days leading up to her death and whether it was a result of inadequate care from one, or both, of the physicians.

"The College of Physicians decided to take no action against the two doctors. The Smith family requested the Appeal and Review Board go over that decision because they were "not satisfied" with the ruling.

"We have concluded that the (College of Physicians) did conduct an adequate investigation and its decision was reasonable," the review board concluded.

"Smith died at age 19 in 2007 after tying a ligature around her neck in a Kitchener, Ont., cell as prison guards watched. In the final 11 months of her life she was transferred to various prisons 17 times because of bad behaviour, overcrowding and staff fatigue.

Reported by

Results from assorted inquiries and inquests gather dust on desks across the country. Don't expect government agencies to improve their treatment of youth, indeed anyone, sent to jail but urgently in need of medical and spiritual attention. What can you and I do?

The following can be found at

BACKGROUND: Ashley Smith, 19, died in her prison cell at Grand Valley Institution near Kitchener, Ont., in October 2007 from self-strangulation. She had been transferred between federal institutions 17 times during her final 11 months, most of that time kept in segregation and often on suicide watch dressed in a highly restrictive gown. Jailed at age 13 for a crab apple-throwing incident in New Brunswick, Smith was eventually transferred to an adult facility after she kept getting into trouble behind bars by constantly kicking, grabbing and spitting at guards. Lawyer's for her family and the media have been fighting Coroner Dr. Bonita Porter's efforts to limit the scope and evidence to be called at the inquest which had been placed on hold. The inquest is of interest to this Blog because it relates to the openness of public death investigations - and the necessity to ensure that deaths warranting inquests get full scrutiny.

"The Ashley Smith inquest has a new coroner at the helm," the National Post story by Christie Blatchford published June 30, 2011, under the heading, "Coroner replaced in prison death inquest: Oral arguments presented to coroner Bonita Porter will now have to be repeated, Smith's lawyer says," see

"Dr. Bonita Porter, who had presided over the oft-delayed and troubled inquest into the strangulation prison death of the mentally ill teenager, has been replaced by Dr. John Carlisle," the story continues.

"The Ontario government made the announcement in a brief press release Wednesday.

The announcement pointed to Dr. Porter's pending retirement this fall as the reason for the abrupt move.

Due to the expected length of the inquest, "Dr. Porter, who is scheduled to retire in November, would have been unable to complete the inquest when it resumes in the fall," the release said.

But a line in the announcement hints at another significant reason for the mid-race switch to a new horse -Dr. Carlisle is not only a medical doctor, but also a lawyer and veteran law professor.

If ever an inquest illustrated the need to have a lawyer or judge in the driver's seat, as some other provinces do, it was this one.

Dr. Porter had formally granted "standing" to about a dozen groups and individuals -meaning these parties are entitled to cross-examine witnesses -some of them represented by some of the fiercest advocates in the Ontario bar.

Almost daily, she faced procedural and evidentiary challenges from these lawyers, and from those representing the press, and was often clearly out of her depth.

Several times, lawyers appealed one or another of her decisions to the Ontario Divisional Court, most famously when Dr. Porter ruled that prison videos, showing Ms. Smith being forcibly injected with anti-psychotics and subjected to other harsh treatment at Quebec's Joliette Institution, weren't relevant to her state of mind.

Ms. Smith, then 19, strangled herself with a ligature in her cell at Kitchener's Grand Valley Institute for Women on Oct. 19, 2007, about three months after she had been repeatedly strapped to a stretcher and drugged at Joliette.

Last month, the court called Dr. Porter's decision not to seize the videos confusing, overturned her and told her to re-think the matter.

Neither did it appear Dr. Porter was getting particularly good advice from her own legal team, made up of three lawyers from the provincial attorney-general and a fourth who appeared occasionally to argue particular issues.

If originally coroner's inquests were medical investigations into a death, the high profile ones, particularly those involving matters that have captured the public's attention, have long since morphed into contests that are much more legal in nature than medical.

Dr. Porter adjourned the inquest late last month, and about a week ago, with her key decision about the Joliette videos and two others still pending, announced the proceeding would resume in September.

She promised at that time to deliver her rulings -critical to the scope and openness of the inquest -this week.

Instead, Dr. Carlisle will now "review and decide" on these issues.

Before joining the coroner's office in 2004, Dr. Carlisle served as a medical officer with the College of Physicians and Surgeons of Ontario and as a professor at York University, where he taught a course in law and medicine for more than 25 years. These credentials appear to make him almost uniquely well-qualified to steer the inquest back on the right course.

When the proceeding adjourned last month, the five member jury had heard only part of the evidence from only one witness.

Julian Falconer, lawyer for Ms. Smith's family, was furious at the announcement, calling the inquest "a colossal waste, a mess."

He said he and other lawyers have "wasted weeks and weeks" of oral argument on the three motions that were before Dr. Porter, and pointed out that now these will have to be reargued because Dr. Carlisle has heard none of what they have to say.

"It begs the question of what's going on at that office," Mr. Falconer snapped. "And remember what this delay does to the family."

Ms. Smith, originally sent to a youth facility in her home province of New Brunswick for throwing crabapples at a mailman, ended up spending most of the last three years of her life in isolation, or segregation, units of youth and adult facilities, provincial and federal prisons, and several hospitals.

She was transferred among these various facilities no fewer than 17 times in less than a year, once being strapped to her airplane seat in the process."

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1 comment:

  1. Again what more can you and I do? Any suggestions?