Under cross-examination, Cindy Berry was adamant she had no idea guards were under orders to stay out of Ashley Smith's segregation cell as long as the inmate was still breathing.
"I did not give any such direction," Berry said repeatedly.
Berry insisted she relied on her deputy Joanna Pauline to tell guards at Grand Valley Institution in Kitchener, Ont., when to enter Smith's cell.
Pauline has testified the instructions to guards came from Berry, who described her deputy as incompetent and prone to speaking "gibberish" in a crisis.
Several middle managers have also testified to raising their concerns directly with Berry, and challenging her on the instructions as to when to intervene with Smith.
The rookie warden, who had arrived only a few months before Smith died, either denied such interactions or said she could not remember any of them.
No one appears to have taken any responsibility for Smith's death, a juror noted.
One guard has testified he told Berry he would rather face discipline for intervening too soon than for doing so too late.
"I did not hear his comments," Berry said.
Numerous incident reports sent to Berry describe in graphic detail how Smith, 19, of Moncton, N.B., would turn purple or show other clear signs of her self-strangulation.
Those reports also show guards' distress at being disciplined for rushing in to save the deeply disturbed Smith from choking herself with ligatures.
Berry essentially ignored the reports as she signed off on criticism of the officers for using inappropriate or excessive force.
"Reading them now, after six years with a different mindset, staff should have gone in," she said of one incident.
She said she could not explain why she was unaware of the direction circulating throughout the prison that guards were to stay out of the cell if Smith was still breathing.
Guards were supposed to intervene, she said, when Smith was in medical distress. It was up to them to use their discretion, experience and training to assess that point.
"That's become quite a mantra for you," Smith's family lawyer Julian Roy retorted.
In hindsight, Berry said later in the day, "Each and every time somebody has a ligature, (guards) should go in, regardless."
In her report to higher-ups shortly after the tragedy, Berry said the prison's response to warnings that Smith was at extreme risk of suicide was to have an officer watch her through her cell-door window.
"This officer was able to observe subtleties in breathing changes," Berry wrote.
Berry said she did not remember the head of prison health care warning her about the physical toll the repeated self-harming episodes were taking on Smith.
"We can add that to the list of things you didn't know," Roy said.
In the early morning of Oct. 19, 2007, when Smith killed herself as guards videotaped but did not intervene, Berry rushed to the institution.
She met a distraught middle manager, whom she proceeded to chastise for not being in uniform.
"It was very inappropriate to do that at that time," Berry testified.
In light of the tragedy, Correctional Service Canada fired Berry in May 2008. She was reinstated retroactively in 2010 after a mediated settlement, and now works at regional headquarters as a project manager.
She no longer wants to be a warden, she said, choking back tears.
"I'm no longer willing to accept that kind of responsibility again."