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More than seven years after 30-year-old Terry Baker died while being incarcerated at Grand Valley Institution for Women, a coroner’s inquest will look into the circumstances of her death, including being held in segregation despite her mental-health struggles.

The inquest was supposed to take place last year but was delayed because the presiding coroner was concerned about access to documents from the Correctional Service of Canada (CSC).

In July, 2016, Ms. Baker was found unresponsive in her segregation unit with a ligature around her neck. She died two days later in hospital. Her mental-health issues were similar to those of 19-year-old Ashley Smith, whose death in the segregation unit in 2007 garnered considerable attention when it became public.

Ms. Baker died just over 30 months after an inquest examining Ms. Smith’s death condemned the use of segregation for women with mental-health challenges.

Kim Pate, a senator from Ontario who has been a long-time advocate for women in the penal system, said she hopes that what happened – and what didn’t happen – to Ms. Baker becomes clear to the public through the inquest process.

“The kinds of supports she needed and sought were often not available to her,” Ms. Pate said, adding Ms. Baker should never have been placed in a prison setting.

Ms. Pate also said there needs to be accountability for the actions of people who work inside the correctional system and there must also be a remedy for individuals who have their rights breached.

The inquest is expected to hear from approximately 18 witnesses and will last up to 15 days. David Eden will serve as the presiding officer for the process.

Under the Coroners Act in Ontario, an inquest is automatic when a death occurs while a person is in custody unless, in some circumstances, it is determined the death occurred from natural causes. The purpose of an inquest is to examine the circumstances of a death and to issue recommendations that are designed to prevent future deaths from occurring in similar circumstances.

Last April, Dr. Eden requested the release of documents from Correctional Service of Canada, particularly those related to two boards of investigation that CSC conducted before and after Ms. Baker’s death. He said at the time that he was disappointed by CSC’s response and that proceeding without the requested documents would not result in a “a full, fair and efficient” inquest into her death.

The Canadian Association of Elizabeth Fry Societies (CAEFS) said in a news release in April that it supported the decision to adjourn proceedings, echoing the presiding coroner’s disappointment about the requested documents. Executive director Emilie Coyle said then that in addition to uncovering specifics about Ms. Baker’s death, the organization expected the inquest would examine the ways society incarcerates and often segregates people with mental-health issues while failing to provide treatment or supports.

Stephanie Rea, an issues manager at the Office of the Chief Coroner, said in a statement that all parties are now ready to proceed with the inquest.

Ms. Pate, who when she served as executive director of the CAEFS knew Ms. Baker, said the 30-year-old had significant, well-documented mental-health issues and spent much of her time in prison in segregation. Ms. Baker was expected to be released from segregation within days of when she died, Ms. Pate added.

On Oct. 19, 2007, Ms. Smith died after she strangled herself in prison while guards watched. A jury that examined her death at an inquest deemed it to be a homicide, meaning that people contributed to her death.

The jury also recommended in 2013 that Ms. Smith’s experience within the correctional system be taught as a case study to all CSC management and staff at the institutional, regional and national levels. It said the case study could 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.”

Ms. Pate said a number of inquiries and inquests have made recommendations to improve the system that have not been acted on.

In 1996, former Supreme Court justice Louise Arbour conducted a commission of inquiry into the treatment of federally incarcerated women, and concluded that the use of segregation by the Correctional Service for inmates in distress, including those who are at risk of self-injury or suicide, is problematic.

Ms. Arbour told CBC Radio in 2016 that she was “outraged” after learning of Ms. Baker’s death.

Ms. Baker had been serving a life sentence for the 2002 murder of 16-year-old Robbie McLennan. She was 16 at the time of the murder. In 2006, she pleaded guilty to helping torture and murder Mr. McLennan with her 20-year-old boyfriend, as well as with another 16-year-old.

CSC spokesperson Esther Mailhot said that whenever a death in custody occurs, the incident is immediately referred to the relevant provincial coroner to determine the facts and circumstances that led to it, as was the case here. The agency will be an active participant throughout this inquest, she added.

“Out of respect for the integrity of this process, we will not be providing specific information about Terry Baker’s case here, but will do so during the coroner’s inquest,” Ms. Mailhot said.

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