Guards and some middle managers at an Ontario prison were stressed and conflicted by orders to ignore Ashley Smith's self-harming behaviour as long as she was still breathing, according to information from labour hearings and internal prison investigations.

Smith, 19, died more than five years ago at the Grand Valley Institution, a federal prison for women in Kitchener, Ont. She choked to death after tying a piece of cloth around her neck while guards stood outside her cell door and watched.

In the documents, Smith was labelled "an extremely difficult inmate to manage" and was known to smash items in her cell, assault staff and harm herself by cutting and tying pieces of cloth around various parts of her body.

But each time guards entered her cell to remove ligatures or other items, it triggered a "use of force" procedure. That meant the incident had to be videotaped, documented and investigated.

Staff broke order on occasion

Senior managers at the prison ordered that staff only enter her cell in such cases if she was no longer breathing. But, on several occasions, staff broke that rule because they were concerned for Smith's safety.

"When you see someone struggling and you see they can't breathe, but you are told not to go in, it's very difficult to live with that," said one guard.

Howard Rubel, Union of Canadian Correctional Officers representative, said several guards were disciplined because they entered Smith's cell.

"Ashley Smith wasn't a regular inmate … everyone kept saying this is a very unique person. We've never dealt with anyone like this before," he said

But Rubel said the guards' concerns were ignored by senior managers. "They were repeatedly being told, no, we know what we are doing. You follow the treatment program. You follow the rules we have set."

Senior managers continued to insist Smith's problems were behavioural and attention seeking. The deputy warden even called it "auto-eroticism."

Alarms triggered in Ottawa, Kingston

Smith's case also triggered alarms in Ottawa and Kingston, the national and regional headquarters of the Correctional Service of Canada. Documents show a senior official was sent to Kitchener to counsel staff on Smith's case. Authorities were concerned that guards were entering her cell "too often" and that was triggering too many use-of-force reports which then led to outside scrutiny.

"It's outrageous," said Kim Pate, executive director of the Canadian Association of Elizabeth Fry Societies.

Pate said the system wanted to protect itself rather than help Smith. "It proves in fact that that is what was happening. They were trying to curtail the number of uses-of-force because it didn't look good."

An inquest into Smith's death resumes in Toronto Monday. Jurors are expected to see the video of what unfolded the morning Smith died and then hear from the guards who were on duty at the time.