Cindy Berry, former acting warden of Grand Valley Institution for Women in Kitchener, is shown outside the Ashley Smith choking inquest in Toronto on Monday.
"I did not give any such direction," Berry
relied on her
deputy Joanna Pauline to tell guards at Grand Valley Institution
in Kitchener when to enter Smith's cell.
Pauline has testified the instructions to guards came directly from Berry, who described her deputy as incompetent and prone to speaking "gibberish" in a crisis.
Several middle managers have testified to raising their concerns directly with Berry
, and challenging her on the instructions as to when to intervene with Smith.
either denied such interactions or said she
could not remember any of them.
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
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.
essentially ignored the reports as she
signed off on criticism of the officers for inappropriate or excessive use of force.
"Reading them now, after six years with a different mindset, staff should have gone in," she
said of one incident.
could not explain why she
was unaware of the direction circulating throughout the prison that guards were to stay out of the cell if she
was still breathing.
said guards were to intervene when Smith was in medical distress.
In her report to higher-ups on 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
On the morning of Oct. 19, 2007, when Smith killed herself as guards videotaped but did not intervene, Berry
rushed to the institution.
"It was very inappropriate to do that at that time," Berry