Just a few weeks before Ashley Smith choked to death in October 2007, Travis McDonald said a regional trainer told guards they were going into her segregation cell too often.
"If she's breathing, what are you going in there for?" McDonald said the trainer, Ken Allen, told those in attendance.
"Most of the group was shocked. Shocked and confused, really. I just couldn't believe it."
The inquest into Smith's death has heard how the 19-year-old frequently tied ligatures around her neck, often turning blue or purple in the process.
McDonald told the hearing Smith even threatened to kill herself on his watch, something that left him feeling stressed and helpless.
"Nothing was being done about this continuous ligature use."
The supervisor at the Grand Valley Institution in Kitchener, Ont., fought back tears as he testified at his distress at learning Smith had succeeded in choking herself to death.
"I was distraught to say the least. I could barely string two words together to make a sentence."
The inquest heard that senior management became increasingly critical of how front-line correctional officers dealt with the troubled teenager.
In early September 2007, guards intervened when they discovered Smith with a ligature tied tightly around her neck.
Several weeks later, McDonald said, deputy warden Joanna Pauline called him on the carpet.
Guards had intervened too quickly, and as long as Smith was breathing, McDonald said he was told, officers were not to go into her segregation cell.
McDonald said he didn't question Pauline.
"She's my supervisor. She's my deputy warden," McDonald said.
"I took it at face value that she knew what she was talking about, so I didn't question it."
Smith's "management plan" — drawn up by senior managers without front-line input — called for the development of an "immediate action plan" to preserve her life, the inquest heard.
"It didn't make sense to me ... because it was asking us to pre-plan the use of force, which was against policy," McDonald testified.
"I felt that if we needed to go in, we would go in."
Smith spent two stints at Grand Valley — in the spring of 2007 and again that fall.
The inquest has heard how guards, who frequently intervened to save her, were initially praised for doing so.
But even then, senior management seemed to find fault with how front-line officers were dealing with the troubled and troublesome teen.
"It seemed to be that we never got it right," McDonald said. "We always seemed to be criticized."
McDonald said he had little direct contact with Smith, of Moncton, N.B., but he recalled one conversation before her first transfer out of Grand Valley.
They talked about her going to a different prison where she could start afresh as a "new person," he said.
"She gave a devilish type of giggle," McDonald said.
McDonald and three front-line officers were charged with criminal negligence causing Smith's death and fired.
The charges were dropped after the Crown discovered Correctional Service Canada failed to disclose critical material about the orders the accused were given.
Two years after Smith died, Corrections compensated and reinstated McDonald.