A girl who attempted suicide six times over five days at Don Dale Youth Detention Centre had just been returned from hospital for self harming and was put straight back into isolation.
The man in charge of Don Dale operations in March 2015, James Sizeland, told the Northern Territory juvenile justice royal commission he didn't have the authority to take the inmate out of lock down.
The girl, known as AN, had a history of trying to kill herself when placed in solitary confinement.
She had just arrived back at the jail from hospital after another self harm episode when she was put back in a cell for 34 hours with only a 30 minute respite, AN's lawyer Stewart O'Connell said.
Then "all hell broke loose" and the young offender was hospitalised three times over the next five days.
Last week, AN told the inquiry that "dying was better than staying in isolation", saying she constantly pleaded to be taken out.
The situation was completely out of control yet a mental health team didn't show up for four days, Mr O'Connell said.
"Did it ever occur to you that that decision was actually making the situation more traumatic and less safe for this young girl?" he asked.
"You doggedly pursued a process ... knowing you were actually increasing the risk of harm to this girl."
"If she was not in an at risk cell we could have very well lost her life," Mr Sizeland replied.
Co-commissioner Mick Gooda said doing the same thing repeatedly and expecting different results was the definition of insanity, and asked why alternative options to detention weren't explored.
But Mr Sizeland admitted the approach was ineffective, but said he didn't have the resources or a suitable facility, and putting the girl into normal cells placed herself, other detainees and staff in danger.
"If we dropped the ball it could have had a very tragic effect. That was the absolute best we could do in the situation we were in," he said.
Mr Sizeland said in January 2015 the girl was made to wear handcuffs during an ambulance ride to the emergency department after self harming, despite bleeding from an injured hand.
He said another incident where a group of guards cut the girl's clothes off with Hoffman knives while her hands were held through a Judas hatch wasn't a commonly practised move.
Earlier on Monday, another former Don Dale detainee said he was paraded in front of adult prisoners who yelled "fresh meat" and threatened to rape him when they were kept in the same court cells.
The hearing continues.
Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14.
Suicide Call Back Service 1300 659 467. Local Aboriginal Medical Service available from www.vibe.com.au.