An independent investigator calls the jailing of sex assault victim Angela Cardinal "a complete breakdown of legal protections" in a case that "should be seen as a call to action, to get back to the fundamentals of criminal law."

Cardinal was taken into custody at the Edmonton Remand Centre for five nights in June, 2015 while she testified at her attacker's preliminary hearing.

She was forced to testify in shackles and was transported in the same prisoner van with Lance Blanchard, the man who was ultimately convicted of sexually assaulting her.

The identity of the 28-year old homeless Indigenous woman is protected by a publication ban.

CBC News gave her the pseudonym Angela Cardinal.

The same name is used by Winnipeg criminal defence lawyer Roberta Campbell in her comprehensive and blunt 32-page report on the case, to be released Friday.

After CBC revealed Cardinal's story last year, Alberta Justice Minister Kathleen Ganley asked Campbell to investigate and "make recommendations to ensure that no victim of crime is treated in a similar fashion."

18 recommendations

Campbell makes 18 recommendations for change or review, including a complete overhaul of the current victim services system in Alberta.

"It is difficult to summarize all that went wrong in a case such as this," Campbell writes in the report.

She calls on everyone in the criminal justice system "to learn from the mistakes that led to Ms. Cardinal's incarceration, and to address the systemic problems that it has revealed."

Campbell describes Cardinal as a "vulnerable witness" who was let down by the system at almost every turn.

Convicted sexual predator Lance Blanchard hours after he attacked Angela Cardinal in June, 2014. (Edmonton Police Service) She is harshly critical that there was little or no contact with Cardinal between the time she was sexually assaulted and when she had to testify nearly a year later at Blanchard's preliminary hearing.

"Serious consideration should have been given to her vulnerabilities, and someone should have canvassed what supports were available to ameliorate her situation," Campbell wrote. "Instead, Ms. Cardinal was incarcerated."

Victims need better protection, Ganley says

Alberta Justice Minister Kathleen Ganley said the system needs to offer better protection for crime victims. (Trevor Wilson/CBC) In a statement provided to CBC News, Ganley said the case illustrates that the justice system needs to offer better protection for all victims of crime.

"Angela's story is a crucial reminder that we must do better, not only in her memory, but for all victims who come into contact with the justice system," Ganley said.

"When victims come forward to tell their story, we need to ensure they are not only heard, but that they are treated with courtesy, compassion and respect throughout every step towards justice."

Wrong to detain witness

In her report, Campbell says Crown prosecutor Patricia Innes "should not have sought an order to incarcerate Ms. Cardinal, as such an order was not available under the Criminal Code of Canada." Innes has since announced her retirement.

Campbell says incarceration of a witness should be treated as a last resort, "not the default option of a Crown prosecutor when faced with a difficult or absent witness."

Many of the mistakes that were made could have been avoided if the Crown had followed existing policy, she writes.

Campbell did not comment on the decision ultimately made by provincial court Judge Ray Bodnarek to take Cardinal into custody for five nights.

Overhaul victim services, Campbell says

The current victim services unit in Edmonton, part of the Edmonton Police Service, is made up of 10 staff members and 112 volunteer victim advocates. Similar operations throughout the province are run by the RCMP and other police forces.

Campbell calls the current model "wholly inadequate to address the needs of victims", and describes the information provided by the current unit in Edmonton as "rudimentary and incomplete."

She recommends Alberta Justice create and pay for an entirely new victim services system with paid professionals in every jurisdiction that would be separate from police and RCMP. Similar models are used in Manitoba and Nova Scotia.

Ganley said her department will give that recommendation further research and consultation.

But she said she is willing to hire dedicated court workers to help victims, and Indigenous victim services and court workers to assist Indigenous victims and witnesses.

'Systemic bias' played role

Ganley and others have questioned if Cardinal would have been jailed if she was not Indigenous. Campbell acknowledged the disproportionate number of Indigenous victims and accused in the justice system.

In her recommendations, Campbell says she doesn't believe "that anyone deliberately engaged in racist or discriminatory action towards Ms. Cardinal … but instead believe that systemic bias played a role in the unfolding of the narrative."

Campbell absolves the Edmonton Police Service of any blame or wrongdoing in the Cardinal case, but says it should be mandatory for EPS to provide information about victim services to all victims of crime.

She also recommends the Edmonton Remand Centre develop a policy to treat incarcerated witnesses differently from other inmates. That could include placing them in different units, providing access to mental health or other services and develop a different policy regarding the use of restraints, she says.

Campbell expresses concern that one sheriff's representative told her that it's "common in the jurisdiction of Edmonton" for witnesses to be shackled.

She recommends an independent review on physical restraint practices used by the Alberta Sheriffs Branch. A government spokesperson said the review will be complete by the end of February.

The legacy of Angela Cardinal

Months after she testified at Blanchard's preliminary hearing, Cardinal was killed in an unrelated incident. Campbell writes that Cardinal is owed an apology that can no longer be given.

But she hopes the victim's legacy will be long-lasting change to the justice system in Alberta.

"Ms. Cardinal was a bright, articulate and inspiring woman who showed incredible resilience and character in the face of injustice," Campbell writes. "We offer this report in her memory."