The head of the prison in which a troubled teen killed herself denied on Monday knowing of the paralyzing confusion among guards about when to enter her cell to save her.
Testifying at the inquest into Ashley Smith's death, Cindy Berry said guards were to stay outside unless Smith was in "medical distress."
"If she wasn't breathing, she wasn't responding, she was losing consciousness," Berry said.
"The officers would have to assess that."
The inquest has heard how guards, believing Smith to be in grave danger, would rush in and cut ligatures off her neck.