Ashley Smith repeatedly harmed herself as a sign of distress, not defiance, and her treatment in the federal prison system was “unacceptable and inconsistent with Canadian values,” a lawyer representing the Canadian Association of Elizabeth Fry Societies told the teen’s inquest Tuesday.

Toronto lawyer Breese Davies slammed the Correctional Service of Canada (CSC) for operating under a security-first model that was detrimental to Smith and continues to fail about 20 other federally sentenced women who self-harm like Ashley did and have serious mental health problems.

“CSC can’t be trusted to fix the problems that lead to Ashley Smith’s death, without ongoing, independent oversight,” the lawyer said in her closing remarks to the five-member panel of jurors in Toronto.

The solution also lies in having a “culture shift” at CSC, where the “cloud of secrecy” around the treatment of prisoners — especially women like Ashley — is lifted, Davies added.

The jury is hearing recommendations from lawyers at the inquest, which is probing the events leading up to Ashley’s self-strangulation death Oct. 19, 2007 at Grand Valley prison for women in Kitchener. It is tasked with coming up with recommendations on how to prevent a similar tragedy from happening in the future.

Davies echoed the position taken Monday by Smith’s family’s lawyer, Julian Roy, who argued that Ashley’s death was a homicide.

Davies said an illegal order from Grand Valley’s acting warden and deputy — that guards not enter Ashley’s segregation cell whenever she tied ligatures around her neck, as long as she was still breathing — caused a fatal delay before guards came to her assistance the morning she died.

Rather than treating her ligature tying with a security response, CSC and their institutions should have looked at Ashley’s behaviour through a therapeutic lens, Davies told the jury.

“Her self-harming was a coping mechanism,” Davies said.

The inquest has heard about numerous instances during Smith’s time in the federal system — from late 2006 until Ashley’s death in October 2007 at age 19 — when the teen was subjected to body cavity searches against her will, forced injections, restraints, pepper spray and physical struggles with prison emergency response teams — all used to address Ashley’s repeated ligature tying and self-harming.

What Ashley needed instead was warmth, human contact, and health-care providers who had the patience and persistence to deal with her complex needs, Davies told the jury Tuesday.

Davies said Ashley’s repeated moves during her stay in the federal system — she was shipped around 17 times between prisons, secure forensic treatment facilities and hospitals — was “justified to meet their needs (Corrections’ and its institutions) not necessarily Ashley’s,” Davies told the jurors.

And her prolonged stay in segregation — she spent most of her 11 months in the federal system in segregation — resulted in a “loss of humanity for Ashley,” Davies said.

Davies and the Elizabeth Fry Society made nearly 30 recommendations Tuesday, including:

Calls for CSC to work out arrangements with provincial health-care facilities to provide long-term treatment and care for female inmates who self harm and display other complex health needs; and

That CSC immediately transfer women in the prison system to these external health-care centres.

Corrections Canada should fund the beds or facilities, but not run them, Davies said. A number of parties with standing at the inquest support this call, but lawyer John McNair, who represents the St. Thomas forensic psychiatric hospital where Ashley stayed briefly in 2007 during her time in federal custody, told the jurors to reject this recommendation.

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“The notion of relieving CSC of the legal responsibility for women with complex mental health problems has an air of irresponsibility to it, and doesn’t arise from reasoned, considered opinion,’’ McNair told the jurors.

Lawyer Richard Macklin, who is acting at the inquest on behalf of Ontario’s advocate for children and youth called for a host of changes at CSC, including the creation of policies, programs and services geared toward the “cultural and developmental needs’’ of 18-21-year-olds in adult institutions.