Inmate Susan Smith was transported to court from the jail at 0630 hours to have her sentencing hearing in circuit court followed by a child custody hearing in family court. Later in the day, the news she received was not in her favor. Smith was sentenced to three years state prison by the circuit court judge. In family court, her ex-husband received full custody of their two minor daughters. Smith was transported back to the jail and placed in a single-person cell for close observation, but not suicide watch.
The day before court, the female officer on duty noticed that Smith was talkative, happy, eating and had taken her shower. When Smith returned from court, the same officer noticed Smith would not come out of her cell for a shower, would not eat, would not get out of her bunk and would not talk. Noticing these changes in the inmate’s behavior, the officer started making dorm rounds at different intervals, changing up her times and making her visits less predictable. During one check, the inmate was covering her head with her bed sheet. The officer told the inmate to uncover her face and look at her. The inmate was instructed to keep the bed sheet off her face and asked if she was doing alright. The inmate responded, “Yes.”
Twelve minutes later, the officer returned three minutes early from the required 15-minute checks. The inmate’s skin color had changed and she was not responding to verbal instruction. The officer immediately called for backup and requested medical staff as she ran to the control room to obtain the Emergency Cutting Tool used for suicide prevention. When backup arrived, the officer went in and observed the inmate had tied her bed sheet around her neck with the other end tied to the bedrail. The inmate was unresponsive and in the laying down position. Medical staff arrived and administered life-saving steps until the inmate was revived. Smith was taken to the infirmary for recovery and observation. A few days later the inmate thanked the officer for saving her life.
The above scenario is based on a true story. The officer received a Meritorious Service Award for the lifesaving steps she took in this case. A good agency will reward officers for doing a good job even though it’s the officer’s job to provide professional care, custody and control of inmates. We can all be Monday morning quarterbacks, but let’s look at what the officer did correctly.
The officer:
- Noticed a change in behavior in the inmate from the day before;
- Did not assume the inmate was just sleeping with a sheet over her head;
- Made the inmate remove the sheet from her face and respond verbally;
- Changed her security checks from every 15 minutes to different intervals so she would not be predictable;
- Called for backup and requested medical assistance;
- Obtained the Emergency Cutting Tool;
- Did not go into the cell alone, but instead waited for backup in case it was a set-up by the inmate;
- Saved the agency from embarrassing negative news media.
Jails are known to have more suicides and suicide attempts than prisons, even though the prison system also has its fair share of suicides. Having worked both in the state prison system and the jail system, I agree that jails have more.
While in jail, inmates are confronted with long- term, life-changing events. News of long prison sentences, separation from family, divorce, loss of child custody, loss of home and car and fear of an unknown future. Officers must always be alert and aware of their surroundings and watch for the following indicators of a possible suicide victim:
- Changes in inmate behavior from quiet to extreme anger;
- Changes in inmate behavior after being notified of family death;
- Changes in inmate behavior after returning from court;
- Exhibiting bizarre, anxious or violent behavior;
- Refusal to eat or take showers;
- Giving away all of his or her belongings to other inmates;
- Shedding of clothing or nudity;
- Violently resisting application of restraints, such as handcuffs or leg shackles;
- Performing self-mutilation.
The point is for officers to recognize anything out of the ordinary and report it to supervisors and medical staff. Suicide prevention is always the goal.
Now let’s see what can happen if an officer and medical staff do not recognize or take seriously the proper signs and indicators of a suicide victim.
Inmate Jones was moved to a single man cell and placed on suicide watch in the Critical Housing Unit at the state prison. For his own protection, he was left in the cell wearing a paper gown so he would not use his clothing to hang himself. Everything appeared to be safe and the cell door was secured. When Jones refused to eat his meals, officers said he simply was not hungry. Jones would yell out from time to time, “Just let me die.” Again, officers did not take him seriously.
Unknown to the officers and medical staff, Jones had hidden the metal clasp to his inmate identification card in his cell. Jones used the metal clasp to slash and sever a vein in both arms. Jones was found by officers lying in a pool of his own blood with blood still gushing out of both arms. Medical staff was late in responding to stop the blood flow. Jones died twelve hours later. The autopsy report by the medical examiner indicated that the immediate cause of death was “blood loss that could have been prevented by appropriate medical attention.”
The above scenario is based on a true incident. I was assigned to investigate the in-custody death/suicide of inmate Jones.
My job was to determine several issues such as: Were department policy and procedures followed by staff? What could have been done to prevent this incident from occurring? Was this an administrative issue, criminal or both?
The following factors were discovered:
- Officers and medical staff should have taken inmate Jones’ threat of committing suicide seriously;
- A one-on-one suicide watch could have been ordered by supervisors;
- At minimum 10-minute visual checks should have been implemented and logged;
- A thorough cell search and body search should have been conducted before placing inmate Jones in the isolated cell;
- Someone, between the officers and medical staff, should have called in mental health staff;
- Medical staff failed to call in the after-hours on call medical doctor to assess the wounds;
- Medical staff cleaned and bandaged the wounds without stitching the bleeding veins or skin.
Many things were overlooked in this scenario and it cost several people their jobs. It also gave local news media a story to tell that portrayed the agency negatively.
It’s always much easier to go in with the attitude that all suspected suicide attempts are real. Take each one seriously and follow all agency rules and regulations. A positive attitude, vigilance and being attentive to detail when dealing with inmates on suicide watch, or inmates giving signs of suicidal tendencies, will reflect well upon the staff and the agency. We are professionals and we must work like professionals.
Training tips
Meaningful suicide prevention training should be provided annually, and not just a video to comply with accreditation standards. Agencies should utilize face-to-face training with role-play scenarios that involve real incidents that older officers have experienced. Learn from the positive results and the negative results others have dealt with.
Cross-train with other professionals in your agency so everyone is on the same page. Have mental health staff, medical staff and officers all train together so each group will have a better understanding of each department’s job functions when dealing with suicide prevention. Better understanding leads to better training which leads to better results.
When training staff in suicide prevention, think about meaningful answers they will need to know, such as:
- What are some signs of depression?
- What behaviors should I look for in a suicidal inmate?
- What should I do before placing an inmate on suicide watch into a cell?
- What are my agency’s policies and procedures on suicide prevention?
- Who should I notify?
The good news is that the majority of our rescue rates in corrections are done thoroughly as in the first scenario I gave. The bad news is the media will not print the positive stories. We save many more lives than we lose. Keep saving lives, give meaningful training, recognize each situation as it occurs and be well trained to handle this type of situation in your jail or prison.
