On tape, a manager reacts

Recording captures deputy warden after hearing of young Ashley Smith’s death

They are audio tapes of the staff conversations that are automatically recorded in federal prisons, in this instance almost eight minutes of various calls made the morning that teenager Ashley Smith wrapped a ligature around her neck for the last time.

The tapes never would have become public were it not for the fact that the 19-year-old died in her segregation cell at the Grand Valley Institution for Women in Kitchener.

In that sense, the recordings document some of management’s authentic response, certainly to the early reports that Ashley was “tying up” again, and then to the news, that this time, it was different.

As deputy warden Joanne Pauline said bitterly after correctional manager Travis McDonald phoned to tell her that “inmate Smith is not breathing” and that an ambulance was on the way, “Great.”

It appeared to be the spontaneous annoyed reaction of a bureaucrat who now would have some explaining to do.

McDonald is the first supervisor — the first member of the Grand Valley management team, albeit not one of senior rank — to testify at the Ontario coroner’s inquest now probing Ashley’s death.

He quickly confirmed what COs Blaine Phibbs and Charlene Venter said in their earlier testimony — guards were under new orders not to remove the homemade ligatures she wrapped tightly around her neck if she could be seen “to be talking, moving around or breathing.”

These new marching orders — in stark contrast to what had been the usual practice at the prison, when the guards would rush into Ashley’s cell to cut off a ligature as soon as they saw one on the teenager’s neck — came in late September of 2007, McDonald said, less than a month before the Moncton, N.B., native asphyxiated.

During her first stay at Grand Valley that spring, he said, “There were no restrictions on when to enter, not enter: If she had a ligature on her neck, we were going in to get that ligature.”

But by the time she was returned to the prison on Aug. 31, senior managers were minutely involved in Ashley’s case, McDonald said.

The prison officer-incharge, a role he sometimes filled, was under orders to call either warden Cindy Berry or deputy Pauline about any incidents involving the 19-year-old. And at the daily operations briefings, he said, Ashley warranted her own “daily behaviour report.”

He was personally notified of the change in a call from Pauline, he said.

Senior management, as they always do in any socalled “use of force” on an inmate, had reviewed videos of an incident involving Ashley earlier that month, and the deputy warden told him, “Travis, you guys didn’t need to go in … you went in too early.”

McDonald said he was “a little puzzled” by the change in direction, because from what he knew of that particular incident, “Ashley appeared to be blue in the face.”

Though such cell entries are classified as use-of-force incidents — and certainly involved some physical force on Ashley — all were made so the guards could cut off the ligatures and save the young woman from injury.

But despite his doubts, McDonald didn’t challenge Pauline’s order. “She’s my supervisor, my deputy warden,” he said. “I took at face value she knew what she was talking about.”

His admission marks the first time that a member of the prison’s management team has publicly acknowledged the COs were under increasing pressure from their bosses to toe the new party line.

And that pressure was ramping up, McDonald said.

In mid-September, a use-offorce trainer named Ken Allan was brought into the prison from regional Correctional Service of Canada headquarters in Kingston.

Though purportedly a general refresher on use-of-force, it was in fact Ashley-specific, McDonald said.

Attendance for mid-level managers like him was mandatory, and he said Allan’s message was that “if you can see Ashley is breathing, you don’t need to go in.”

Instead, he said Allan told the managers, guards should “withdraw and reassess.” Allan even suggested staff start timing Ashley’s breaths. “If she’s breathing,” McDonald quoted him, “what are you going in there for? You don’t need to be going in there as long as she’s breathing.”

His evidence explains what occurred on Oct. 19, when guards — paralyzed by the new orders, their self-confidence eroded by their bosses telling them they were wrong and even disciplining them — stood outside Ashley’s cell for almost 10 minutes, one counting her breaths, before they rushed in, too late, to cut off the ligature.

McDonald said his own reaction to Allan’s instruction was, “I couldn’t believe it. It wasn’t what I was going to do.”

Yet sadly, that’s precisely what he did that last terrible morning, before he learned the dreadful breathing-not breathing game imposed on the guards had backfired.

CO Gaetan Desroches answered his call, told him what he had already been told by Phibbs — Ashley had tied up again.

“They haven’t gone in the cell yet have they?” McDonald asked nervously. “No,” Desroches replied. “OK, well as long as she’s breathing, then we don’t need to go in …” McDonald told him.

He repeated the advice: “Well, all right, so as long as she’s breathing, we don’t need to go in.”

“We’ll phone you before we open the (cell) door,” Desroches promised.

“Unless, uh, you know she’s … she’s suddenly stopped breathing,” McDonald said. “Then go ahead.”

Not much later, Desroches phoned McDonald back to report that the guards had gone in and cut off the ligature, but that Ashley didn’t ‘seem to be breathing.’”

McDonald asked if staff was doing CPR, and Mr. Desroches said yes, but said they needed a nurse immediately.

“Great,” said McDonald, echoing what Ms. Pauline would all too soon say to him.