Ashley Smith was serious about suicide
KITCHENER, ONT. — As is often the case, it was a juror at the Ashley Smith inquest who asked, in beautiful plain English, the best questions.
For the record, using one of the trademark homemade ligatures she kept hidden in her privates, Ashley asphyxiated herself in her isolation cell at the Grand Valley Institution for Women on Oct. 19, 2007.
Janice Sandeson, then a correctional manager at the Kitchener prison, wasn’t on duty that grim day. But in testimony last week at the inquest, she said that shortly before her death, the 19-year-old had become particularly despondent.
Sandeson found the change so worrisome, she told the warden and deputy warden Ashley was serious about wanting to die.
With Sandeson wrapping up her evidence on Monday, the five jurors had their chance to question her, as they do all witnesses.
The relevant exchange went like this:
Juror No. 2: “So, starting Oct. 12, Ashley was on a high suicide watch?” Sandeson: “Yes.” Juror No. 2: “How did you imagine she would commit suicide?”
Sandeson: “I suspected by ligatures.”
Juror No. 2: “So why are you hesitating in taking them off?”
And there in a nutshell you have it: Ashley was recognized to be at enormous risk, her correctional officers were increasingly frantic, but management was insisting they wait — “assess and reassess” this directive was called — before going in to save her.
It was that order and the undermining of COs’ confidence in their own judgment that it caused, which saw Ashley die as outside, all around her cell, paralyzed COs waited too long.
Sandeson’s first answer to the juror skirted this. She muttered about the possibility Ashley could have become combative and thus jeopardized “officer safety.” Only when pressed by the juror did Sandeson allow the “assess and reassess” marching order was likely part of the rationale.
The assess and reassess business is a horrid euphemism for a management edict that COs were not to enter Ashley’s cell to cut ligatures off her neck while she was still breathing. Instead, COs were to somehow confirm Ashley was still alive then withdraw to “assess and reassess.”
The order originally appears to have reared its head during the end of Ashley’s first stay at the prison four months before, in June 2007, when another correctional manager, Eric Broadbent, told guards not to go into her cell while she was choking herself as long as she was breathing. Sandeson herself strongly objected at that time.
By the fall, when the teenager returned to the prison, the edict was still in place, and less than two weeks before Ashley died, senior managers sent in special trainer Ken Allan to reinforce the message. His mantra, as a series of COs have testified, was, “don’t go in if Ashley is still breathing.’’
Since the young woman often blocked her cell camera and hid her face from view, it left the correctional officers in an impossible position — unable to easily tell if she was breathing, uninformed about what breathing patterns could mean and forbidden to enter the cell unless she had stopped breathing. All of this was as new to the COs as it was to Ashley.
During her first stint at Grand Valley, guards routinely rushed into her cell whenever they saw her with a ligature around her neck.
This was often — Ashley could tie up multiple times in a CO’s shift. And every time COs entered her cell to cut off a noose, it set in motion a lumbering bureaucracy and generated a mound of reports.
COs were “counselled” — it’s a form of discipline — for going into Ashley’s cell too soon, or too often. Instead, they were urged to use a new system whereby the door to her cell could be opened six inches, so as to afford them a better look at whether she was, in fact, still breathing. The practice, ingrained by the fall, was as follows: Ashley would be seen with a ligature, but would hide herself. COs would open her door six inches. If she was deemed to be breathing, the door would be shut. The COs would not be allowed in, and every 15 minutes, the door would be reopened.
On Oct. 15 that year, Sandeson followed that procedure, telling another manager in a recorded call that only if Ashley’s nose began to bleed and she was “really close to like passing out” COs would be sent in to cut off the noose.
“From oxygen deprivation?” lawyer Howard Rubel, the lawyer for the COs, asked. “Yes,” said Sandeson.
“That sounds pretty close to Eric Broadbent’s direction?” he said. “Yes,” Sandeson said.
As Juror No. 1 later coolly remarked, “You were very proactive (in fighting the new order) in June, but by the fall, you’d lost your voice.” It wasn’t a question, but a statement of fact.
Broadbent will testify Tuesday.