Edward Snowshoe didn't have much of a life.

Born in 1985 in the small town of Fort McPherson, NWT, he was one of four boys. His father died at an early age, leaving Edward's mother to raise the children. It was a struggle. In a town where there was little to do, kids often gravitated toward booze, drugs and trouble.

In his late teens, Mr. Snowshoe moved to Inuvik, where he shot and injured a cab driver in a bungled robbery attempt. He was sentenced to five-plus years in prison and, in the spring of 2007, transferred to the Stony Mountain Institution in Manitoba. There he became another of the thousands of aboriginal men overrepresented in correctional institutions across the country.

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So why are we writing about Edward Snowshoe today? Because he was the subject of a judicial inquiry into his death, the findings of which were recently released. They are ugly. And anyone who believes that we have an obligation in a civilized society to care for our fellow citizens in a humane fashion, regardless of where that life is being spent, should be outraged by Justice James Wheatley's report.

Cutting to the crux of the story, Mr. Snowshoe was placed in segregation on March 1, 2010, for fashioning a "stabbing weapon" out of a small juice-box container. He spent 134 days isolated from the general prison population in a darkened cell before he was taken out for a day to be transferred to Edmonton Institution. Upon his arrival, he was put back in isolation for 28 more days, the last of which he spent fashioning a way to kill himself – which he ultimately did at the age of 24.

For those who knew anything about his time in prison, this should not have come as a surprise. Mr. Snowshoe had tried to kill himself on at least three occasions at Stony Mountain between 2007 and 2009. After a fourth self-harm incident in 2010, he was placed on suicide watch. He was depressive and clearly had severe suicidal tendencies. Given that history, why was he put in segregation for more than five months and allowed to kill himself?

That is what Justice Wheatley set out to find; what he discovered was disturbing. In his report, you can almost feel the contempt for which he holds a system that could treat human beings this way.

Anything of significance that happens with a person occupying a prison cell in Canada is recorded in the Offender Management System (OMS), effectively an electronic log. Information such as suicide attempts and signs of acute depressive behaviour, for instance, would be documented.

Justice Wheatley heard evidence that correction officers in direct supervision of Mr. Snowshoe didn't realize they had access to the OMS system and consequently were not aware of his disturbing mental health history. Proper psychological follow-up assessments that were supposed to have been conducted after his suicide attempts did not take place.

His transfer to Edmonton was botched. The clock on his time in segregation was reset, instead of continuing from the previous institution. If this sounds familiar, it should; it's exactly what happened to Ashley Smith, who strangled herself in an Ontario prison in 2007 after being segregated for most of four years. She was transferred numerous times, and in each case, her segregation count was reset instead of continued from her previous stay.

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Justice Wheatley wrote that during Mr. Snowshoe's brief time in Edmonton, only cursory attempts were made to establish a mental health profile. Mandate reviews of his situation in segregation didn't occur. The officers who interacted with him on a daily basis had no idea of his suicidal history. No one really knew what was going on inside that cell, in which his movements could only be observed through a small mail slot. Meantime, full observation cells were available.

Edward Snowshoe spent 162 days in solitary confinement for brandishing a juice box knife. It was probably the last place someone with his mental health history should have been. Once there, he was essentially forgotten, left to end his sad life on tragic terms.

Justice Wheatley made a number of recommendations aimed at ensuring this story isn't repeated elsewhere. But somehow, that doesn't seem enough. This isn't the first time this has happened in a Canadian prison – it's like a recurring theme. Yet, no one seems to care. Nothing seems to change.

Edward Snowshoe is dead and he didn't need to be. How that happened should concern us all.