It took a full half hour between a teenage prisoner being found hanged and an ambulance coming to his aid, an inquest heard.
Paramedics first went to the wrong prison - Cookham Wood, Rochester - after the alarm was raised over 19-year-old Anthony Dunne.
When they finally arrived at Rochester Young Offenders' Institution, they had to wait another 13 minutes because Andrew Brown, the worker authorised to let them through, was busy giving Anthony CPR.
Retired deputy governor Frank Stoddart told an inquest: "It's quite shocking.
"I think hopefully all people involved in any prison death would get the ambulance to the injured party as soon as possible."
Anthony killed himself in the wake of a stormy affair with his prison counsellor, Anita Setz, then 43.
He had fled his probation hostel and lived at her home for three weeks, but ran out of anti-psychotic drugs and beat her savagely in September 2004.
He died a day-and-a-half after being recalled to jail.
Mr Stoddart was the most senior officer to give evidence to the six-day hearing.
He admitted: "There's not enough spent on psychiatry in my opinion. People who should be getting treatment I don't think get it - it tends to be those who shout the loudest, those who commit more serious crimes."
Former prison counsellor Anita Setz leaves the inquest
Mr Stoddart insisted Rochester had improved hugely since a riot in 2000, but Anthony's affair with a prison counsellor did not surprise him.
"In my 35 years in the prison service I've seen it happen in a number of cases," he said. "Unfortunately it's a closed environment so some men and women fall in love... I've seen corruption."
Anthony was being held unlawfully beyond his first night in jail. Mr Stoddart said if he knew, he would never have taken him in.
But he defended staff who changed Anthony's suicide watch from 15 minutes to hourly, even after he made a noose from a torn bedsheet.
"He was relaxed, chatty, wanted to talk," he said. "You soul-search and think 'would I have done things differently'. I must have read my statement 50 million times since that happened and I keep thinking 'should I have done this, should I have done that'.
"I don't know what I would do [differently]."
He added some procedures were changed after Anthony's death.
The inquest continues. The jury is due to retire to consider its verdict tomorrow.
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