A Ontario coroner's jury has ruled the self-inflicted choking death of Ashley Smith in her segregated prison cell was a homicide.
Smith, 19, choked to death in a prison cell at the Grand Valley Institution in Kitchener, Ont., in 2007.
She had tied a piece of cloth around her neck while guards stood outside her cell door and watched.
They had been ordered by senior staff not to enter her cell as long as she was breathing.
Presiding coroner Dr. John Carlisle read the jury's findings Thursday afternoon.
Among its recommendations is that the Smith case be used as a case study to demonstrate how Smith was failed health staff and the Correctional Service of Canada.
Kim Pate, executive director of the Canadian Association of Elizabeth Frye Societies - a group that works with female inmates - had hoped the jury returns with a verdict of homicide in Smith's death.
"Many staff members have reported that she did advise them that she knew what she doing was dangerous, but she also knew it was their job to save her,” said Pate.
“So it is very clear that a combination of the order not to intervene that was sanctioned, seemingly right up to national headquarters of Correctional Services Canada, combined with the impact that had on staff, is really a major contributor to her death."
Homicide is defined as the killing of a human being due to the act or omission of another.
Pate said a verdict of homicide would not mean any criminal or civil responsibility, it would only indicate Smith's death was preventable.
The five women who comprise the jury heard from 80 witnesses in almost 11 months of testimony before presiding Coroner Dr. John Carlisle. There are more than 12,000 pages of evidence to consider.
Smith was from Moncton. In the last year of her life, the mentally troubled teenager was shuffled 17 times between nine institutions in five provinces.