After almost a year of testimony and more than 12,000 pages of evidence, the case of Ashley Smith went to the jury today.

Almost 11 months after they began hearing evidence, Coroner Dr. John Carlisle sent the five women away to come up with a verdict in and with recommendations on preventing a repeat of the tragedy.

"You must sort out what you believe to be the true picture of what happened — use the same common sense that you use every day," Carlisle told the jury.

"We now ask you to speak for Ashley."

Smith, 19, choked to death in a prison cell at the Grand Valley Institution in Kitchener, Ont., in 2007. She had tied a piece of cloth around her neck while guards stood outside her cell door and watched. They had been ordered by senior staff not to enter her cell as long as she was breathing.

“As we sit here today, it’s not over for us,” said Coralee Smith, Ashley Smith’s mother. “There still has been no stand-up accountability, the transparency is just not there so I don’t know in that area if we’ll ever be satisfied.”

Coraleen Smith fought for years with the Correctional Service of Canada (CSC) to have the details of her daughter’s death exposed. Initially the CSC spent millions of dollars on court battles to try to prevent the inquest from going ahead.

Prime Minister intervened

But after startling videos were released last year that showed the teenager repeatedly tied up, pepper sprayed and restrained, Prime Minister Stephen Harper ordered corrections officials to cooperate fully with the inquest.

Since it formally began last January, Smith has watched the proceedings online from her home in Nova Scotia.

“I watched basically daily,” she said. “At time’s it’s very difficult, at times I just have to leave the room and put on my coat and go away for a couple of hours.”

Ashley Smith had a long history of mental illness and conflict with the law. It began with a short youth sentence for throwing apples at a postal worker and ended with her being transferred to a federal prison where she accumulated more time, mainly for lashing out at staff.

She spent almost all her time in segregation, in an empty cell, where staff were told not to communicate with her if she was acting out.

Smith constantly tied ligatures around her neck and limbs. She said it made her feel good. She also told staff she knew they would come in and remove them.

But each time staff entered her cell to remove the ligatures, it prompted a complicated “use of force” reporting mechanism which irritated officials and triggered enhanced scrutiny from Ottawa. Guards were then told not to enter her cell unless she stopped breathing.

Didn’t belong in prison

During the inquest, guards, prison managers and senior corrections officials admitted Smith was seriously mentally ill and didn’t belong in prison. But their solution was to keep her in an empty segregation cell, and when she became too much of a problem, transfer her to different prisons across the country — 17 times in less than a year.

Nancy Noble, lawyer for the CSC, admitted in her closing arguments that corrections fell short in its treatment of Smith. She called Smith’s death a “perfect storm” of unfortunate events and said CSC had since introduced many changes to prevent similar deaths.

But lawyers for the Smith family, the Canadian Association of Elizabeth Fry Societies (CAEFS) and Ontario’s Child Advocate, said the actions of CSC officials were directly responsible for the girl’s death. They urged the jury to return a verdict of homicide.

“Our position is that but for the actions of management at Grand Valley Institution in ordering staff not to go into her cell, Ashley would not have died,” said Breese Davies, lawyer for CAEFS. “They would have done as in the past, go in and take the ligatures off.”

Need for independent oversight

The three also asked the jury to recommend that seriously mentally ill inmates be transferred from prisons to mental health centres, insist on a form of independent oversight to monitor corrections actions in dealing with such cases and ban the use of segregation for inmates who are mentally ill.

“There is a real difference in how young people experience prison … but there has been no recognition in CSC of this distinction and it had tragic effects in this case,” said Richard Macklin, lawyer for Ontario’s Child Advocate.

He said Smith was a child in an adult prison, and prison officials were more concerned about security than treating her illness.

“Canada is the last democracy in on this issue, we’re way behind Europe and the United States and we really need to catch up.”

Throughout the process, the jury of five women have been actively engaged, asking each witness probing questions as they studied the evidence. They are expected to take at least a few weeks to consider their verdict and offer recommendations. But those recommendations are not binding.

“I have no doubt they will produce a very thoughtful response and verdict and hopefully some recommendations that can be reinforced and mechanisms for accountability,” said Kim Pate, executive director of CAEFS.

“The challenge of course is will these recommendations be implemented,” she said. “The light has clearly shone on what has been happening in corrections and something is clearly wrong with what has been happening in our prisons.”