Staff tried to help Smith: psychologist
But testimony riddled with inconsistencies
It may be the most telling aspect of Cindy Lanigan’s testimony, that when she wept, it was during an emotional rendition of just how hard she and other staff were working to keep Ashley Smith alive.
The acting senior psychologist at the Grand Valley Institution for Women when the teenager asphyxiated in her cell there on Oct. 19, 2007, ms. Lanigan was testifying monday at the Ontario coroner’s inquest examining Ashley’s death.
The psychologist had just been asked for her recommendations to the jurors, a standard question asked of witnesses.
“One thing that strikes me is we were all working to help her when [she died],” ms. Lanigan said, tearing up and stumbling for a minute. “That everybody was burned out, everybody was working so hard every day,” ms. Lanigan said, still crying.
“We need to have something in place for the staff, because when you’re burned out, it affects your family and the rest of your practice.”
It was a jarring moment in a day of testimony riddled with inconsistencies. In her evidence-in-chief, ms. Lanigan insisted she never knew about the new orders that were paralyzing Ashley’s guards and keeping them from rushing into her cell to cut off the ligatures she used compulsively.
The jurors have heard weeks of testimony, from a plethora of witnesses, that the correctional officers were being constantly criticized
and even disciplined for entering Ashley’s cell too soon.
The new edict from senior management called for them to go in and remove a ligature only if the 19-year-old wasn’t breathing.
In fact, there is considerable evidence before the jurors that this order, which preoccupied s t aff at the Kitchener, Ont. prison, was utterly unworkable: Ashley routinely covered the camera in her cell and hid in corners where she couldn’t be seen by her guards, making it virtually impossible for them to know how she was, let alone if she was breathing, unless they charged in.
But ms. Lanigan maintained she’d never caught a whiff of all that turmoil.
“And if you’d heard discussions about how long to wait, you’d remember?” coroner’s counsel marg Creal asked.
“Absolutely,” ms. Lanigan snapped.
“I didn’t know that until after Ashley died, and I was being interviewed by the police and I would have been in shock,” she said. “I would certainly have challenged that [order].”
She stuck to that narrative during the first part of her
everybody was burned out, everybody was working so hard
cross-examination too, telling Breese davies, lawyer for the Association of elizabeth Fry Societies, that she “never, ever” heard any discussion of a change in orders.
“you never heard guards talking about it?” ms. davies asked. “Never,” ms. Lanigan said. She said she “vaguely” remembered guards being “concerned” about a “use of force” issue.
(That this was the selfsame issue — the reason for the new order was management’s unhappiness with the use-of-force reports being generated every time COs entered Ashley’s cell — appears to have escaped ms. Lanigan.)
“you would have been horrified if you knew” of the new order, ms. davies asked. “yes,” ms. Lanigan said.
“Would you have gone to the warden or deputy warden and said, ‘What’s going on?’” ms. davies asked.
“yes, I would have,” ms. Lanigan replied.
( T hat appears a dubious proposition, since ms. Lanigan admitted that if she could have done anything differently, she “would have stood up” more for her own assessments rather than wait for approval from the “nonclinical staff ” she seems to have resented.)
But using documents that are inquest exhibits, ms. davies then took ms. Lanigan to notes of operational briefings she attended where guards clearly recorded the effect of the new orders — they were leaving Ashley with her face going purple from a ligature around her neck — and their unhappiness with them.
At one such briefing, held just 10 days before Ashley’s death, one of the topics for a roundtable discussion was that just that morning, Ashley “appeared to be breathing fine” but “had a ligature around her neck.”
“you would have heard that discussion?” ms. davies asked.
“I would have,” ms. Lanigan replied.
The psychologist was so concerned about Ashley’s deteriorating condition — where once she denied trying to hurt herself with the ligatures, she was now overtly depressed and suicidal — that on Oct. 12, she recommended that in addition to being “on camera” with a guard monitoring her that way, another CO should be posted outside her cell 24/7 “to ensure that she is breathing.”
For someone who claimed not to be aware of the new order, ms. Lanigan’s language perfectly echoed the overriding concern at the time — whether Ashley was, or wasn’t, breathing when the guards went in to cut off her homemade nooses.
ms. Lanigan said the double guard arrangement lasted only a week before deputy warden Joanna Pauline told her there “was too much overtime and it was too expensive” to have one guard watching Ashley on the camera and another outside her cell.
Though Ashley was formally diagnosed with borderline personality disorder, a difficult-to-treat and serious mental illness, ms. Lanigan said an inmate’s diagnosis was less important, because staff “deal with what we see.”
Ashley, she confirmed, “was never in any treatment” at Grand Valley.