OTTAWA - The death of a Moncton, N.B., teen in a federal penitentiary was the "entirely preventable" result of a series of systemic failures, says a report from the federal correctional investigator.

The report by Howard Sapers says the October 2007 death of Ashley Smith followed "the inability of federal and provincial health care and correctional systems to provide her with the care, treatment and support she desperately needed."

"None of the systems or programs or professionals that Canadians would reasonably expect to have been available to Miss Smith were there to help this young woman and to keep her safe and to respond to her needs," Sapers told a news conference on Tuesday.

"Simply and sadly put, if not for the glaring void of mental-health service for children, youth and offenders in Canada, Ashley Smith would likely have never ended up in a federal penitentiary where she ended her life."

Sapers' report says "the tragic incident of Ashley Smith continues a disturbing and well-documented pattern of deaths in custody which are the result of under-resourced and disjointed correctional and mental-health-care systems."

Court transcripts say seven guards looked on as a New Brunswick teen choked herself to death in her Ontario prison cell because they were instructed not to intervene.

One guard testified that Smith slowly strangled herself as the guards at the Grand Valley Institution for Women in Kitchener urged the troubled 19-year-old to remove a garrotte she had placed around her neck.

Sapers said "persistent issues and systemic failings within Corrections . . . contributed to Ashley Smith's death."

"She did not receive the care, treatment and protection from the service that are not only mandated by law but are also required by their own policies."

Smith never received a comprehensive psychological assessment nor adequate mental-health care while in federal custody, despite her troubled history, Sapers said, listing several other violations of federal corrections policy.

He recommended more thorough assessments, more vigorous preventative measures, and more training for federal prison staff. He said federal, provincial and territorial governments also need to develop a national strategy to better co-ordinate correctional and mental-health systems across the country.

"A start would be to ask the Canadian Mental Health Commission to address this on an urgent basis."

The system "must and can do better."