The sound of gasping breaths followed by frantic chest compressions filled an inquest courtroom on Monday as video of the last-ditch efforts to save a troubled teenager was screened for jurors.
But the 20 minutes of thump-thump was too late to save Ashley Smith, who strangled herself in her segregation cell.
For interminably long minutes, guards had watched Ms. Smith on the floor – wedged between a steel cot and the wall – as she occasionally heaved, her dying gasps audible.
Ms. Smith, in a restraint jacket, has her head pressed against the wall, a ligature around her neck. She is mostly motionless.
"It's been long enough for me to take that off," a guard calls through the door.
"Sit up so you can come over here and I can cut it off."
"Ashley. Can you get it off yourself?"
No one tries to get to her, as the video rolls, focused on the seemingly lifeless body, her face turning purple.
At 06:58:06, according to the video, guards in full gear enter the small cell. They don't touch her, but back out amid calls for a nurse.
"Ashley! Come on. Wake up."
They then go in, give her oxygen.
"Are you getting air in?" "No." "Ashley. Come on. Breathe."
A guard pumps Ms. Smith's chest while another gives mouth to mouth.
"Good job, guys. Just keep going," a woman urges.
They finally drag her from the cell as firefighters and paramedics arrive.
One female guard looks totally crestfallen.
"Analyzing rhythm," a mechanical voice sounds. "Do not touch the patient."
"Is she breathing or what? Ashley!" another inmate yells.
About a half-hour later, Ms. Smith is wheeled out.
The video was taken by Valentino (Rudy) Burnett, a fill-in guard from another institution who had just completed a night shift.
Mr. Burnett testified that an all-call for help sounded and he went to the segregation area, wearing his overcoat.
"My first question was: 'What do you guys want me to do?'
He was given a camera and he "basically hit record," he said.
"I do what they asked me to do. This was all new to me."
Mr. Burnett worked at an institution in Hamilton, but was asked to fill in because he had worked at Grand Valley Institution for Women in Kitchener, Ont.
He told the inquest he knew almost nothing about Ms. Smith, beyond picking up from other guards that she was a "problematic inmate."
"Will you agree with me, Mr. Burnett, that you in essence videoed somebody's death?" asked Julian Falconer, the Smith family lawyer.
"While I was videotaping her, I saw her chest rising on a number of occasions. I saw her breathing on a number of occasions. As far as I was concerned, I was videotaping a live person."
"Your position today is she wasn't in trouble. … She didn't need to be saved. Instead of videotaping her, you should have put the camera down and stepped in and saved her life," Mr. Falconer persisted.
"No. That's not my job. I was just concerned with doing with I was asked to do."
In a perfect world, Mr. Burnett said, he would intervene to try to save a life.
"In a correctional world, it's a different story."
Burnett was initially charged with criminal negligence in Smith's death, but the charge was later dropped.
He told lawyer Howard Rubel, who represents the jail guards' union, he could hear breathing in the cell before officers went in.
"I remember somebody saying: 'While she's breathing, we're not supposed to enter the cell.'
Guards went in anyway, Mr. Burnett agreed.
On his second fill-in shift there, he said, he had seen guards dragging Ms. Smith out of an interview room.
"She had something tied around her neck," he said.
"Did anybody tell you what you should do if you saw that happen?" coroner's counsel Jocelyn Speyer asked.
"No. I was not given any directives."
Ms. Smith, 19, of Moncton, died Oct. 19, 2007, after tying a ligature around her neck, something she had done several times before.
Earlier in the day, an assistant warden at Grand Valley denied authorities had spruced up the death cell before jurors toured last Thursday.
Tony Simoes, who led the tour, described photographs of the cells and what was in them.
Mr. Falconer suggested the steel cot in the cell would have been uncomfortable for anyone to sleep on.
"Is sleep deprivation part of [Correctional Service of Canada] punishment?" Mr. Falconer asked.
"I cannot comment on that," Mr. Simoes responded.
Mr. Simoes, in charge of the physical structure of the prison, said he had never slept on one of the cots, and that he didn't know enough to talk about the sleep-deprivation suggestion.
Jurors saw pictures of the segregation exercise yard, a drab, barren concrete slab of about three metres by 10.5 metres surrounded by high razor-wire topped walls.
The rules allow segregation inmates one hour of exercise in the recreation yard, Mr. Simoes said.
"The term 'yard' is much like the term 'bed,' isn't it?" Mr. Falconer asked.