WINNIPEG — A Manitoba judge has made no recommendations in the death of a young woman suffering mental problems who hanged herself a month after being released from jail.
The 18-year-old, who can’t be identified under the Youth Criminal Justice Act, died in August 2010 after serving two years for manslaughter at the Manitoba Youth Centre.
The inquest was not called until the fall of 2012 and was completed in September.
Judge Marvin Garfinkel, who presided over the inquest, says the delay means any recommendations he could make to prevent similar deaths would be irrelevant.
The woman, who was a former ward of Manitoba Child and Family Services, had attempted suicide four times at the Youth Centre and was diagnosed with depression and anxiety.
After her death, the chief medical examiner ruled no inquest was needed, but that decision was reversed a year later.
No reason was given for the change.
"Candidly, I must say that I am not inclined to make any formal recommendations," Garfinkel wrote in his report released Wednesday.
"Throughout this report I have made observations and comments about the process. For example, the need for inquests to be held within a reasonable time after death."
He also suggested that young people serving time for an offence should be brought before the court at least 30 days before they are released from custody in order to review their case in preparation for serving the community supervision part of their sentence.
The woman was brought before the court the day before she was released.
The inquest report notes that the woman had a troubled life and was taken into government care when she was five years old.
She was then transferred to Anishinaabe Child Family Services and was sent to about 20 different placements while in care.
The report says that along with the suicide attempts the woman was placed under observation about 28 times.
Her behaviour never improved to the point where she was allowed unescorted leave from the Youth Centre to help her reintegrate into the community, Garfinkel wrote.
