Ashley Smith, 19, had repeatedly tried injuring or killing herself while being held at Grand Valley Institution, a women's prison in Kitchner, Ontario, prison officials said. After determining she was trying to get attention, prison managers ordered guards not to enter her cell if she was trying to injure herself unless she wasn't breathing.
Smith, guards said, would regularly cut herself with objects or tie bedsheets or clothing around her neck to try to choke herself.
Under Canadian law, any time a guard has to enter a cell to stop an inmate from injuring himself or herself, a full use-of-force report including video evidence and witness interviews must be produced.
Inmate advocates said Smith was allowed to die because prison officials had grown tired of generating the reports and thought she was making the prison look bad to federal officials.
A spokesman for the union representing the prison guards in an official inquiry into Smith's death by a Toronto inquest jury told the Canadian Broadcasting Corp. Monday guards had repeatedly expressed their reservations about failing to intervene but were under strict orders not to do so until the last possible moment.
"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," one unidentified guard told the CBC.
2014: The Year in Music [PHOTOS]