Coroner’s Inquest Touching the Death of Ashley Smith

Verdict of Coroner’s Jury – The Coroners Act – Province of Ontario

Surname: Smith
Given Names: Ashley
Aged : 19
Held at: Coroner’s Court Toronto, Ontario
From the: September 20, 2012 to the: December 19, 2013
By: Dr. John Carlisle, Coroner for Ontario

Having been duly sworn/affirmed, have inquired into and determined the following:
Name of Deceased: Ashley Smith
Date and Time of Death: October 19, 2007 at 8:10 a.m.
Place of Death: St. Mary’s General Hospital in Kitchener
Cause of Death: Ligature strangulation and positional asphyxia
By what means: Homicide
The verdict was received on the 19th day of December, 2013
Dr. John Carlisle

Jury Recommendations

  1. That Ashley Smith’s experience within the correctional system is taught as a case study to all Correctional Service of Canada management and staff at the institutional, regional and national levels. This case study can demonstrate how the correctional system and federal/provincial health care can collectively fail to provide an identified mentally ill, high risk, high needs inmate with the appropriate care, treatment and support. This case study can also demonstrate the lack of communication, cohesiveness, and accountability of a large organization such as Correctional Service of Canada.
  2. That the Ashley Smith case study be designed for all existing and future CSC management and staff, offering a comprehensive understanding and gaps analysis of the practices that occurred leading to this case. This case study will include documents and evidence presented throughout the Ashley Smith Coroner's Inquest, specifically:
    • The Jury's Recommendations, December 2013;
    • Report to Coroner Investigating the Death of Ashley Smith at Grand Valley Institution for Women (GVI), October 11, 2013, University of Toronto, Professor Kelly Hannah-Moffat (Exhibit 206);
    • A Preventable Death, June 20, 2008, Correctional Investigator of Canada (pages 1-30) (Exhibit 22); and
    • The Ashley Smith Report, June 2008, Ombudsman and Child and Youth Advocate (excerpts) (Exhibit 6).
  3. That, within 72 hours of admission to any penitentiary or treatment facility, all female inmates will be assessed by a psychologist to determine whether any mental health issues and/or self-injurious behaviours exist.
    1. That, should an inmate be identified as having high needs mental health issues and/or self-injurious behaviours, the Chief of Psychology will notify the Institutional Head, Rights Advisor and Inmate Advocate (RA-IA)*, Women Offender Sector, and the Regional Complex Mental Health Committee in writing within 48 hours of assessment.
    2. That this process of assessment will continue to be conducted on an on-going basis and as required by the inmate.
    3. That the Chief of Psychology implements a plan of effective treatment strategy which will be documented and shared as required.
    *The role of the RA-IA is defined in Recommendations #73-75.
  4. That a full range of effective therapeutic interventions are:
    1. individualized to the needs of female inmates considering her self-identified needs, regardless of their security classification, status; or placement;
    2. enhanced to include de-escalation training, and art, music, or pet therapy.
    3. trauma-, age-, and gender-informed, and developmentally appropriate; and
    4. determined and authorized by mental staff.
  5. That Correctional Service of Canada (CSC) create a permanent peer support program, with highly trained and qualified peer support workers in each of the women's penitentiaries that:
    1. is available to all women, including segregated women and regardless of security status, upon their request, 24 hours a day;
    2. provides training and on-going support for the peers by women-centred psychologists and social workers;
    3. ensures confidentiality between the female inmate and the peer to the greatest extent possible;
    4. can be utilized during an incident of self-injurious behaviour, if requested; and
    5. is offered to women actively engaged in self-injurious behaviour or at risk of engaging in self-injurious behaviour as a therapeutic intervention.
  6. That CSC ensure nursing services are present on-site for inmates on a 24 hour per day, 7 day per week basis, as well as available to staff for consultation.
  7. That CSC access community mental health services by developing partnerships with external mental health experts.
  8. That there be adequate staffing of qualified, mental health care providers with expertise and experience in treating a population with mental health issues, self-injurious behaviours, suicidality, and trauma, at every women's institution to provide services and supports to female inmates. These providers will include:
    1. Psychiatrists;
    2. Psychiatric Nurse or Nurses;
    3. The Chief Psychologist*;
    4. Psychologists;
    5. Social Workers;
    6. Behavioural Counsellors** and/or Recreational Counsellors;
    7. General Practitioners; and
    8. Other professional service providers, as required.
    *It is further recommended that, whether working in the position indeterminately or in an acting capacity, the Chief Psychologist must hold a Ph.D. in Clinical Psychology and be a member in good standing of the Ontario College of Psychologists (or provincial equivalent).

    **It is further recommended that behavioural counsellors have qualifications to counsel in behaviour. Otherwise, it is recommended that the title of Behavioural Counsellor is amended to Behavioural Therapy Coordinator.
  9. That CSC expands the scope and terms of psychiatrists' contracts to enable them to fulfill their duties in a meaningful way.
  10. That all staff providing mental health care will report to, and be accountable to, health care, not security, and that the therapeutic relationship should not be compromised by the assignment of security-focused assessments.
  11. That CSC organize and fund secondments for nursing staff to psychiatric wards of local Schedule 1 hospitals, or other specialized mental health institutions. These secondments are to be of sufficient length and completed with regularity. This will ensure the continual improvement of their knowledge and skills in the provision of mental health care, services and supports to female inmates, and their knowledge of community nursing practices and standards generally.
  12. That the decision to disclose information to security by a mental health care provider should be governed by the applicable legislation, and professional and ethical standards, bearing in mind that reporting may affect the therapeutic relationship. The decision to disclose must also take into account the paramount duty of CSC to ensure the safety of the inmate. Service providers should be encouraged to consult with their professional governing bodies or colleagues when determining the necessity of disclosure.
  13. That CSC create an institutional social worker position or positions whose responsibility will include working in consultation with local Canadian Association of Elizabeth Fry Societies (CAEFS), and other community groups, to identify, coordinate and access available community services, including mental health services and supports. The mandate of this position would include the dissemination of information regarding the availability of, and assistance with connecting to, such services and supports to female inmates and to staff (including contract-based clinicians).
  14. That CSC is required to provide all contract physicians with copies of Commissioner’s Directives, including revisions to Commissioner’s Directives, that govern their practice within the penitentiary.
  15. That female inmates with serious mental health issues, and/or self-injurious behaviours serve their federal terms of imprisonment in a federally-operated treatment facility, not a security-focused, prison-like environment.
  16. That female inmates who have been identified as having serious mental health issues and/or self injurious behaviours be promptly transferred to such a facility as soon as reasonably practicable.
  17. That such a facility or facilities be made available at least on a regional basis, and particularly in Ontario. It is urged that more than one federally-operated treatment facility is available for high risk, needs women in the event that a major conflict occurs between the inmate and staff. Furthermore, and specifically, those existing male federally­ operated treatment facilities be adapted to accommodate a wing for female inmates.
  18. That CSC negotiate arrangements with provincial health care facilities to provide long-term treatment to female inmates who chronically engage in self-injurious behaviour or display other serious mental health problems. Further:
    1. that the Government of Canada sufficiently and sustainably funds the CSC to enter into such agreements;
    2. that this will include any and all capital and operating costs associated with the establishment of such facilities, and that the accommodation and treatment of female inmates therein will be the responsibility of CSC;
    3. that the focus of such a facility be on the preparation for treatment of, and treatment of, the inmate; and
    4. that a female inmate with mental health issues and/or self-injurious behaviour who is not consenting, and/or withdraws consent, to treatment remain in a pre-contemplative therapeutic environment for the purpose of allowing health care professionals to seek her consent to treatment.
  19. That decision-making with respect to the clinical management and interventions of inmates with mental health issues are made by clinicians in consultation with the inmate, rather than by security management and staff.
  20. That a treatment facility has the capacity to be designated as the home facility of a female inmate serving her sentence therein.
  21. That such a facility in Ontario, or a part thereof, is designated as a Schedule 1 facility under the Ontario Mental Health Act.
  22. That inmates in such facilities must have access to an independent patient advocate system, equivalent to the advocacy system to be provided to inmates in penitentiaries, pursuant to these recommendations, including the newly adopted RA-IA (see Recommendations #73-75).
  23. That a Treatment Team is created at the institutional level to support high needs female inmates with a consistent and dedicated team of qualified health professionals, which will include psychiatrists, psychologists and general practitioners, and that such a team:
    1. meet during the psychiatrist's regular visits at the institution in order to provide on-going, timely, and regular care to inmates;
    2. support the inmate regardless of her security classification, status, or placement within the institution;
    3. seek input from the inmate about the efficacy of her therapeutic relationships and interventions on an on-going basis;
    4. seek input from frontline staff assigned to support the inmate with mental health care needs; and
    5. develop management plans for the purposes of therapeutic intervention and preventative measures. This plan will take into account the inmate's past experiences of trauma, and the potentially traumatic effects of being incarcerated, segregated and/or restrained, and further, that such management plans are developmentally-appropriate, and age- and gender-informed.
  24. That the selection of the frontline staff assigned to a female inmate will consider:
    1. the skill and interest of the frontline staff;
    2. the wishes of the inmate; and
    3. Input from the Treatment Team.
  25. That CSC maintains a roster of external psychologists and psychiatrists to provide a second opinion regarding treatment, services and/or recommendations when challenging behaviours are identified.
  26. That an external and independent review be conducted of the Regional and National Complex Mental Health Committees to determine their efficacy, and identify opportunities for improvements.
  27. That, in accordance with the Recommendations of the United Nations Special Rapporteur’s 2011 Interim Report on Solitary Confinement, indefinite solitary confinement should be abolished.
  28. That there should be an absolute prohibition on the practice of placing female inmates in conditions of long- term segregation, clinical seclusion, isolation, or observation. Long-term should be defined as any period in excess of 15 days.
  29. That until segregation and seclusion is abolished in all CSC-operated penitentiaries and treatment facilities:
    1. CSC restricts the use of segregation and seclusion to fifteen (15) consecutive days, that is, no more than 360 hours, in an uninterrupted period;
    2. That a mandatory period outside of segregation or seclusion of five (5) consecutive days, that is, no less than 120 consecutive hours, be in effect after any period of segregation or seclusion;
    3. That an inmate may not be placed into segregation or seclusion for more than 60 days in a calendar year; and
    4. That in the event an inmate is transferred to an alternative institution or treatment facility, the calculation of consecutive days continues and does not constitute a “break” from segregation or seclusion.
  30. That conditions of segregation be the least restrictive as possible for inmates and determined on a case by case basis-female inmates in segregation should, as much as possible, have access to programs, activities, and facilities and have contact with other inmates, staff, visitors, and non-governmental organizations, such as CAEFS.
  31. That, as a mandatory duty, the Institutional Head will visit all inmates in segregation, seclusion, or medical observation at least once every day, in addition to meeting with individual inmates upon their request. This meeting is not to be accomplished through the food slot under any circumstance, and:
    1. that, on days when the Institutional Head is away, the visit will be conducted by the highest authority; and
    2. that any such authority must report in writing to the Institutional Head the findings and outcomes of such visits.
  32. That, as a mandatory duty, a mental health professional will visit all inmates in segregation, seclusion, or medical observation at least once every day, in addition to meeting with individual inmates upon their request. This visit will pay particular attention to both the mental and physical health of such inmates, with a focus on assessing the inmate's tolerance to segregation. This meeting is not to be accomplished through the food slot under any circumstance.
  33. That a sub-roster team of frontline staff is dedicated to complex high needs female inmates in the segregation unit, with a minimum of one (1) to two (2) consistent staff at all times. Such a team will ensure comprehensive and consistent support for the inmate.
  34. That CSC repeal its existing Review of Offender's Segregated Status Working Day Review policies and replace them with five (5) and ten (10) day reviews that are administered by way of consecutive calendar days. This review will focus on the inmate's needs and behaviours with the goal of returning the inmate to the general population.
  35. That CSC amend its current policies to ensure that female inmates held in “seclusion” or “mental health observation” are recognized as being on ”segregation status” and are therefore entitled to all relevant reviews.
  36. That CSC make every effort to ensure that female inmates, including those in segregation or observation cells, have access to, and the opportunity to meet in private with, the RA-IA, Office of the Correctional Investigator, Citizens Advisory Committee, non-governmental organizations and community agencies.
  37. That, for the purposes of monitoring and tracking, the Institutional Head will notify the following bodies once any inmate has been placed in segregation or seclusion, and that they will also be responsible for conducting a yearly review.
    1. Women Offender Sector;
    2. Mental Health Services Branch;
    3. Office of the Correctional Investigator;
    4. RHQ-Members of the Regional Complex Mental Health Committee; and
    5. NHQ-Members of the National Complex Mental Health Committee.
  38. That, in the development of any new policy on the use of restraints, CSC move toward a restraint-free environment by implementing a least restraint policy, and that this recommendation is reflected in CD 843.
  39. That the application of restraints must be authorized by a psychiatrist or psychologist, and that this recommendation is reflected in CD 843.
  40. That any inmate placed in restraints is given one-on-one therapeutic support for the entire time in restraints, and that this recommendation is reflected in CD 843.
  41. That body cavity searches for female inmates may only occur in the following circumstances:
    1. with the consent of the inmate; or
    2. in the absence of consent, only in exceptional circumstances. For greater clarity, exceptional circumstances will only exist when, in the opinion of a physician, there is a risk of death or serious bodily harm to the inmate or another person and the risk cannot be mitigated through any other reasonably available means.
    All examinations are to be performed by a licensed medical professional at an external medical facility, in a manner most compatible with the inherent dignity of the inmate. Correctional Service of Canada staff escorting the inmate to the external facility is to request that the examination be conducted by a female.
  42. That, for the purposes of continuity of care, the institutional psychologist is notified within 24 hours of any body cavity search conducted on a female inmate, including those in treatment facilities.
  43. That all incidents of self-injurious behaviour must be reported as such.
  44. That all reports regarding incidents of self-injurious behaviour, incident reports and Officer Statement Observation Reports, must contain a detailed description of the nature of the self-injurious behaviour and a detailed description of any physical injury or changes in physical well-being of the inmate.
  45. That all reports regarding incidents of self-injurious behaviour must be forthwith distributed to and read by the following;
    1. The Warden;
    2. The Chief of Healthcare;
    3. The Chief Psychologist;
    4. Women Offender Sector (for female inmates);
    5. Office of the Correctional Investigator;
    6. RHQ - Members of the Regional Complex Mental Health Committee;
    7. NHQ - Members of the National Complex Mental Health Committee; and
    8. For additional clarity, the duty to read such reports is not delegable, except in circumstances when the responsible officer is on leave, and even then, the responsible officer is to read such reports forthwith upon return to the institution.
  46. That following each incident of self-injurious behaviour a Referral for Consultation Form be completed by nursing staff and a copy of the psychology assessment in relation to the incident be appended to this form and this package be forwarded to the institutional psychiatrist. The Chief of Healthcare will be responsible for ensuring this package is also provided to the institutional physician.
  47. That if frontline staff determine that immediate intervention is required to preserve life, there is no requirement that they seek authorization prior to intervening, or prior to calling 911.
  48. That, when an inmate is engaged in self-injurious behaviours, health care staff are on-site, on a 24 hour per day,7 day per week basis, to support the intervention.
  49. That, when an inmate is engaged in self-injurious behaviours, the institutional psychologist are on-call, on a 24 hour per day, 7 day per week basis, for the purposes of supporting the intervention and de-escalating the incident when deemed necessary by frontline staff.
  50. That CSC develop a new, separate and distinct model, from the existing Situation Management Model, to address medical emergencies and incidents of self-injurious behaviour.
  51. That the Situation Management Model not be resorted to in any perceived medical emergency.
  52. That, when reporting a Use of Force intervention to preserve the life of an inmate who has self-harmed an expedited reporting system will apply. Further, all such incidents should be reviewed, within 48 hours, by:
    1. The Warden;
    2. The Chief of Healthcare;
    3. The Chief Psychologist;
    4. Women Offender Sector (for female inmates);
    5. Office of the Correctional Investigator;
    6. RHQ - Members of the Regional Complex Mental Health Committee; and
    7. NHQ - Members of the National Complex Mental Health Committee.
    The review will focus on the mental health needs of the inmate, her behaviour and its lethality, as well as the response of frontline staff, including its appropriateness. It will assist and support the well-being of the inmate, in addition to the efforts of the institution and frontline staff. It will also include strategies to manage the inmate in a safe manner, and encourage staff to exercise good judgment.
  53. That CSC policy state that any item used by an inmate for self-injury be classified as contraband.
  54. That any inmate engaged in self-injurious behaviour must have a Management Plan in place within 24 hours of the first self-injurious incident, and that plan must address how staff is to respond to self injurious behaviours.
  55. That, to reduce institutional or criminal charges laid against an inmate, CSC adopts the methods of the St. Lawrence Valley Correctional and Treatment Centre model of care for disruptive or self-injurious behaviours symptomatic of a mental health disorder.
  56. That, if a complaint is made to police in regard to alleged misconduct by an inmate with mental health issues, (occurring in the context of an incident of self-injurious behaviour), the Security Intelligence Officer will provide police with complete information. This will include the:
    1. behaviour that is alleged to amount to a criminal offence;
    2. context in which that behaviour occurred; and
    3. circumstances of the incident of self-injurious behaviour.
  57. That, if a criminal charge is laid in regard to alleged misconduct by an inmate with mental health issues, (occurring in the context of an incident of self-injurious behaviour), a staff member who was not involved in the incident, and is selected with input from the inmate (preferably a member of her interdisciplinary team), will:
    1. attend any court appearances with the inmate;
    2. advise the prosecutor of his/her presence; and
    3. provide any information that is required by the court to deal appropriately with the charge.
  58. That female inmates be accommodated in the region most proximate to her family and social supports. This principle is a priority for young adults and/or female inmates with mental health issues and/or self-injurious behaviours.
  59. That non-emergency transfers of female inmates with mental health issues and/or self-injurious behaviours will occur only when it is aligned with the clinical needs of the inmate. Non-emergency transfers of female inmates with mental health issues and/or self-injurious behaviours will not occur for reasons related to constraints within the institution, or challenges related to the management of the inmate.
  60. That subject to the above, a female inmate may be transferred to an institution or treatment facility so long as that transfer has the approval of clinicians (psychiatrist and/or psychologist) in the sending and receiving institutions. Prior to her discharge a current written plan must be in place for re-integrating the inmate to her home institution.
  61. That, in the event a female inmate is transferred away from her home institution, the following measures will address the disadvantages that result from being detained in a location away from home. Such measures may include, but are not limited to:
    1. longer visits from family or support persons chosen by the inmate;
    2. increasing the inmate's access to family or support persons via telephone, videoconference, and/or web-cast, e.g. Skype or Facetime; and
    3. providing the inmate's family or support persons with appropriate access to telephone, videoconference and/or web-cast, when they are unable to visit the inmate due to financial restrictions.
  62. That, in the event of a transfer, an inmate's/patient's medical file accompanies her during the transfer to ensure continuity of care.
  63. That the receiving Treatment Team will connect with the sending institution's Treatment Team to share best practices, success stories, triggers, and recommendations.
  64. That CSC create and implement an electronic medical database to facilitate access to medical information between sending and receiving penitentiaries and treatment facilities.
  65. That no transfer occurs on a Friday or holiday given the reduced number of on-site staff at these times.
  66. That CSC establish separate and distinct programs and services for young adults , that is, 18 to 21 year olds within adult institutions which will be geared toward their cultural and developmental needs (e.g. educational, vocational, therapeutic, as appropriate to specific needs and situations).
  67. That CSC develop training to prepare staff to recognize and respond to the particular issues faced by a young adults housed in an adult institution.
  68. That CSC develop a transition protocol that begins before a young adult is placed in, or transferred to, an adult institution, and which has the following features:
    1. provides clear and structured process for transition which is understood by incarcerated young adults and institutional management and staff;
    2. provides guidance on roles and responsibilities for those involved in the transition process;
    3. provides guidance on identifying needs and sharing information during the transition process; and
    4. helps build relationships between young offender and adult institution in order to support continuation of care.
  69. That CSC facilitate, support, and document, at minimum, weekly communications by:
    1. increasing the inmate's access to family or support persons via telephone, videoconference, and/or web-cast, e.g. Skype or Facetime; and
    2. providing the inmate's family or support persons with appropriate access to telephone, videoconference and/or web-cast, when they are unable to visit the inmate due to financial restrictions.
  70. That CSC streamline the approval process for visits and contact with families and support persons of young adults. In particular, it will be conducted at a national level such that their families and support persons are not subjected to a repeated approval process at each institution.
  71. That health care professionals advise young adults of the benefits of providing consent to disclose health information to their families or support persons.
  72. That, at an institutional level, young adults are consulted on an on-going basis to determine if their needs for particular activities and programs are being met.
  73. That CSC implement an independent RA-IA for all inmates, regardless of security classification, status, or placement. The institution will be responsible for advising all inmates of the existence of; and their right to contact, the RA-IA.
  74. That the RA-IA will be responsible for providing advice, advocacy and support to the inmate with respect to various institutional issues, including:
    1. Transition into institutions;
    2. Transfers;
    3. Security classification, status, or placement;
    4. Parole and release eligibility, including escorted and unescorted absences;
    5. Temporary absences;
    6. Use of restraints - physical and chemical;
    7. Seclusion and segregation;
    8. Complaints and grievances;
    9. Consent to treatment and capacity to consent;
    10. Consent to medication, including available alternatives;
    11. Consent to disclosure of information; and
    12. Institutional and criminal charges.
  75. That inmates are protected from reprisals related to contacting the RA-IA and exercising their rights.
  76. That the Citizen Advisory Committee have unrestricted and unannounced access to local CSC-operated institutions at any time and be provided with the opportunity to speak with any female inmate, including those in segregation. These discussions will take place in private, out of hearing of staff.
  77. That Citizen Advisory Committees are required to publish annual reports and that CSC facilitate the publication of these reports on their website.
  78. That non-governmental organizations, including CAEFS advocates, have broad access to local CSC-operated institutions at any time and be provided with the opportunity to speak with any female inmate, including those in segregation. These discussions will take place in private, out of hearing of staff.
  79. That CSC improve the layout of the electronic control panel that opens pod and segregation doors to minimize human error. Specifically, do not have segregation buttons directly beside pod buttons.
  80. That an enhanced Code of Ethics be created that explicitly applies to all Correctional Service of Canada employees, from the Commissioner down to frontline staff; and that this enhanced Code will:
    1. address preservation of life;
    2. include provisions with the following language: “staff should be allowed to refuse to follow orders or directions without fear of discipline or reprisal whether they are right or wrong as long as there was an air of reality to the ethical/legal objection”;
    3. include a provision that affirms the right of all CSC staff members to report an order they believe to be illegal without fear of reprisal;
    4. include a provision that addresses the individual accountability of all CSC staff and management, for example:
      1. “Prison staff at all levels shall be personally responsible for, and assume the consequences of, their own actions, omissions or orders to subordinates”; and
    5. include a provision that addresses the obligation of all CSC staff to respect and protect everyone's right to life, the obligation to ensure the full protection of the health of persons in their custody and the obligation to secure immediate medical attention whenever required.
  81. That this enhanced Code of Ethics be taught in CORE and management training. Additionally, refresher courses will be conducted at the institutional level for all CSC staff; contract and otherwise.
  82. That all management are responsible, and held accountable, for ensuring that this enhanced Code of Ethics is communicated to their staff.
  83. That inmates who have experienced mental health issues within correctional systems be involved in planning, research, training and policy development with respect to the provision of mental health care for female inmates.
  84. That CSC repeal the section dealing with “Involuntary Admission and Treatment” in CD 803, or revise it to conform with community medical practices to ensure equivalency of care for inmates. Specifically, that CSC revise or repeal the requirements that:
    1. a physician must assess a patient in-person before providing orders for involuntary medical treatment; and
    2. all orders for involuntary health interventions be made in writing.
  85. That CSC establish separate and distinct policies for young adults, that is, 18-21 year olds, within adult institutions which will be geared toward their cultural and developmental needs (e.g. educational, vocational, therapeutic, as appropriate to specific needs and situations).
  86. That, upon recognizing burnout in themselves, staff are responsible for raising their concerns to management, and further, that management is responsible for acting upon these concerns and facilitating support.
  87. That, to alleviate pressures and avoid staff burnout, the Institutional Head implements mandatory regularly scheduled respite intervals to frontline staff who primarily deal with complex high needs inmates.
  88. That CSC develop training to prepare staff to recognize and respond to the particular issues faced by young adults housed in an adult penitentiary.
  89. That managers and frontline staff who are designated to support high needs female inmates with mental health and/or self-injurious behaviours be offered training in the following areas:
    1. fundamentals of mental health issues and self-injurious behaviours;
    2. First Aid/CPR (current certifications based on community standards);
    3. impacts of segregation on mental health, including that of young adults;
    4. trauma-informed care (e.g. post-hostage-taking); and
    5. medical distress and its intervention (delivered by an external clinician).
  90. That all newly appointed Wardens and Deputy Wardens (whether the positions be on an acting or indeterminate capacity) have weekly mentoring sessions with an experienced mentor. These mentoring sessions will take place for at least one full year to provide the mentee with guidance, advice, and support throughout their first year in their newly appointed position. Ideally, the mentor is located in a region different from the mentee.
  91. That CSC provide training and education to staff on restraint minimization and de-escalation techniques, and that any such training includes hearing from persons with lived experience who have directly experienced being placed in restraints.
  92. That CSC provide all management and staff with essential refresher training to ensure they maintain the appropriate knowledge and skillsets to fulfill their roles and responsibilities.
  93. That the Deputy Commissioner for Women has direct line authority over all matters relating to female inmates. This gives clear authority and accountability to a single body that provides specialized correctional services to female inmates.
  94. That the female inmates' institutions be grouped under a reporting structure independent of the Regions.
  95. That, in the formation of this new reporting structure, careful consideration is given to the assignment of new positions specifically so that current employee's qualifications, skill sets and competencies are considered for best fit into the newly formed positions.
  96. That CSC foster working relationships with qualified mental health professionals from academic health sciences organizations (e.g. Centre for Addiction and Mental Health) and research universities. These partnerships will focus on developing treatment strategies and therapeutic practices, as supported by current literature of evidence of effectiveness, specifically for women with mental health illnesses including those engaging in self-injurious behaviour and those in segregation.
  97. That CSC revitalize and continue with the research on the emergence of the third group of women who do not respond to psychotherapy or dialectical behavioural therapy.
  98. That CSC implement communication structures between units conducting research at National Headquarters (e.g. Research Unit and Women Offender Sector) and local institutions to effectively disseminate information to staff through regular institutional visits. Research staff will share relevant literature on effective therapeutic interventions with health care, mental health staff and senior management.
  99. That CSC implement ongoing, internal communication structures between frontline, mental health, and health care staff as well as senior management, to effectively disseminate information. Health care and mental health staff will allocate time to meet and discuss relevant literature, complex cases and effective therapeutic interventions with frontline staff and senior management.
  100. That an independent, external audit be contracted by the Minister of Public Safety of CSC's compliance with this jury's recommendations. This audit will be conducted in consultation with the Office of the Correctional Investigator, and the results of such audit will be released publicly during the 2016-2017 and 2023-2024 fiscal years.
  101. That the Auditor General of Canada conduct a comprehensive audit of the jury's recommendations and that the results of such audit be released publicly in 2019-2020.
  102. That this jury's verdict and recommendations regarding the Inquest into the Death of Ashley Smith is posted in writing in every institution and treatment facility operated by the Correctional Service of Canada, in a place accessible to all staff, within thirty (30) days of the receipt of the verdict and recommendations.
  103. That an electronic copy of this jury's verdicts and recommendations is made available for the public on the CSC website for staff's reference on the CSC intranet, and that staff are immediately made aware by management.
  104. That the Office of the Correctional Investigator monitor and report publicly, and in writing, on the implementation of the recommendations made by this jury annually for the next 10 years.