The sound of gasping breaths followed by frantic chest compressions filled an inquest courtroom Monday as video of the last-ditch efforts to save a troubled teenager was screened for jurors.
But the 20 minutes of thump-thump would be too late to save Ashley Smith, who had strangled herself in her segregation cell.
For initial interminably long minutes, guards had simply watched Smith on the floor, wedged between a steel cot and the wall, as she occasionally heaved, her dying gasps audible.
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 dressed 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 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 and take over efforts to revive the teen.
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, Smith is finally wheeled out.
The video was taken by Valentino (Rudy) Burnett, a fill-in guard from another institution who had just completed a night shift and he was about to go home.
An all-call for help sounded and he went down to the segregation area, wearing his overcoat, Burnett testified.
"My first question was: What do you guys want me to do?" Burnett said.
"They asked me if I would be video camera operator. They told me they were going to possibly enter Miss Smith's cell."
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."
Burnett had been asked to fill in from his regular gig at another institution in Hamilton because he had previously worked at Grand Valley, where he was told staff members were "burning out" and "getting exasperated."
He told the inquest he knew almost nothing about 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. I didn't video her death. 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," Falconer persisted.
"No. That's not my job. I was just concerned with doing with I was asked to do."
"I'm going to suggest this has haunted you."
In a perfect world, 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 disobeyed the directive and went in anyway, Burnett agreed.
On his second fill-in shift there, he said, he had seen guards dragging 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."
Smith, 19, of Moncton, N.B., died Oct. 19., 2007 after tying a ligature around her neck, something she had done several times before.
The hearing continues Tuesday.