Michelle Bridgen, a middle manager at the Grand Valley Institution in Kitchener, Ont., said it was the warden and deputy warden who decided essentially that guards should intervene only if Ashley Smith risked imminent death.
"When she had a ligature, sometimes it was not tied tightly around her neck," Bridgen testified.
"Sometimes she would even tie it in a bow around her neck and put her fingers through it and say, 'See, it's not tight'."
The choice became whether guards should frighten Smith by rushing into her segregation cell to retrieve the ligature or "empower" the inmate by allowing her to give it up without force, Bridgen said.
Still, the ligature tying never became part of Smith's written "management plan," the blueprint for how guards were to deal with her.
The issue of what guards were ordered to do when Smith was seen to be strangling herself is one of the crucial questions at the inquest into her death.
"You have to have just cause to enter a cell," Bridgen said she told them.
At one point in October in 2007, authorities sent regional manager, Ken Allan, to talk to front-line staff about "compliance issues" and when to enter Smith's cell.
Bridgen suggested Allan go down to the cell to see for himself what staff were dealing with. She knew they were being disciplined over the issue.
He told her it wasn't his job.
"I was very frustrated when he said no," Bridgen said.
She said she was fed up with "armchair quarterbacks" who second-guessed the guards after reviewing videotapes of incidents.
On Oct. 19, 2007, just days after Allan's visit to Grand Valley, Smith, 19, of Moncton, N.B., choked herself to death in her segregation cell as guards, who believed they were under orders not to intervene as long as she was breathing, watched her die.
The inquest heard the warden and deputy warden were concerned by the number of times guards were using force on Smith, who became increasingly prone to self-harming.
"There was no end to her ligature use," Bridgen said. "She fashioned them readily from her gown."
Still, premature or unnecessary cell entry was not discussed frequently, said Bridgen, who often could not recall specifics.
Guards should have gone into the cell if Smith was in "imminent danger," something Bridgen said entailed a combination of factors.
"She would have the ligature tied very tightly around her throat. She wouldn't be able to breathe very well. She would be turning a different colour," Bridgen said.
"I never said (don't go in) as long as she's breathing."
She did admit to ordering guards out of Smith's cell on one occasion after another manager had ordered them in, saying she worried about their safety.
Bridgen said she told guards that dealing with Smith would "test their convictions" because they would have to ignore the tendency to rush in and help Smith until they had a proper intervention plan in place.
Bridgen, who had decades of experience working with male offenders and was on a temporary assignment to Grand Valley, said she had never seen anyone tie ligatures around their necks before Smith.
She also said she did not know Smith, who had spent most of her three-year incarceration in segregation, had mental-health issues.
Correctional Service Canada suspended Bridgen for 20 days for her role in Smith's death, a punishment that was later reduced to 10 days.
She faces further cross-examination Thursday.