The official behind a report on the death of Ashley Smith, the New Brunswick teenager who committed suicide while in custody at a federal prison, says the young inmate was seeking attention and likely expected that correctional staff would remove the ligature from around her neck.

Smith, 19, had been in federal custody for 12 months when she choked herself to death at Ontario's Grand Valley Institution on Oct. 19, 2007.

Howard Sapers, Correctional Investigator of Canada, said Smith had tied ligatures around her neck on several occasions prior to her death and staff had been successful in negotiating with her to remove it or forcibly removing it themselves.

"It was a way that Ashley gained attention and gained some human contact," Sapers told CTV Newsnet Tuesday, hours after releasing his report on Smith's death.

"The morning of October 19, I'm sure that it was the same thing happening again -- that she would tie the ligature around her neck probably with the expectation that correctional staff would enter the cell and remove it."

Instead, there was a delay before staff finally entered the cell.

According to court transcripts, seven guards watched as Smith choked herself to death because they had been instructed not to intervene.

"When staff finally did remove the ligature they exited the cell without providing any sort of medical intervention and then subsequently went back into the cell a second time where they began attempts to preserve life," Sapers said.

"Eventually paramedics showed up, transported Ashley to an outside hospital, where she was pronounced dead."

Correctional staff traumatized: union

Jason Godin, Ontario regional president of the Union of Canadian Correctional Officers, said the staff members who witnessed Smith's death have been permanently traumatized by what they saw.

"The last moments of Ashley Smith's life were extremely traumatic for our members and they're going to suffer with that for the rest of their lives," he told CTV Newsnet on Tuesday afternoon.

Godin said the Grand Valley Institution staff members were "exceptional correctional officers" who had "quite a relationship" with the New Brunswick teenager they had saved from death on several occasions.

In the report on Smith's death, Sapers said the young inmate's death was "preventable."

"The teenager died following the inability of federal and provincial health care and correctional systems to provide her with the care, treatment and support she desperately needed," the report said.

In specific reference to Smith's care while in custody of the CSC, Sapers said in his report that "a culmination of failures" contributed to her death.

"The tragic incident continues a disturbing pattern of deaths in custody which are the result of ill-functioning and under-resourced correctional and mental health systems," the report says.

In Smith's memory, Sapers said "we must and we can do better" in the future.

He is calling for a national strategy that would build bridges between the correctional and mental health systems.

"We have to integrate all of those systems together so that there is a more seamless delivery of mental health," he said.

Godin said his union is "fully supportive of a public inquiry."

"We believe there has to be major reform," Godin said.

"We don't want to ever see this happen again. We want to make sure that none of our members are ever exposed to this and that this situation doesn't repeat itself."

Sapers said his report has been well received and that hopefully governments will act on the recommendations quickly.

Three correctional officers and a supervisor were fired after Smith's death.

Four other employees were also suspended without pay for 60 days.

With files from The Canadian Press