Report: Rash of suicides at D.C. jail points to deep problem with inmates’ mental health care

Health providers and corrections officers at the D.C. jail are poorly trained to identify potentially suicidal inmates, take shortcuts in assessing and monitoring their mental conditions, and in some cases leave inmates naked and in isolation for days, according to a highly critical report released Thursday.

The report comes after four suicides in less than 12 months at the District’s Central Detention Facility, where the suicide rate catapulted to three times the national average, jail officials said.

The assessment was conducted in late August by Lindsay M. Hayes, a national expert in the field, but the city’s Department of Corrections did not release the report until Thursday, when D.C. Council member Tommy Wells (D-Ward 6), chairman of the judiciary committee, began a long-awaited hearing on the string of in-custody deaths.

Wells blasted Corrections Director Thomas Faust for the delay, questioning whether he and the administration of Mayor Vincent C. Gray (D) were trying to subvert the council’s oversight responsibilities.

Faust said he did not want to release the report until he had a plan to combat the problem, and he came to the hearing armed with a schedule to ramp up training next year and to spend $600,000 removing welded towel bars, clothing hooks and other items apparently used in suicide attempts at the nearly 40-year-old jail complex.

In the report and in testimony offered Thursday, however, critics painted the city jail as a place lucky to have not recorded additional suicides in the past year. The jail has only nine “suicide resistant” cells, which as of late August housed 1,739 inmates. About 40 percent were believed to have mental-health issues and a higher risk of suicide.

In a two-year period beginning in 2011, 165 attempted suicides were logged at the facility, jail officials acknowledged Thursday.

One of those occurred in late August as Hayes was conducting his assessment.

An inmate in isolation was found with “something tied around his neck and attached to the ceiling. His feet barely touch the floor, his eyes were bulging, saliva was coming from his mouth, and he urinated on himself,” Hayes wrote, quoting an internal jail report on the incident.

To Hayes’s surprise, he wrote, “despite the seriousness of the incident,” the inmate was later returned to an isolation area, where he might be checked only once every 60 minutes, rather than placed on constant suicide watch.

It was at least the fourth time in two months, Hayes wrote, that internal documents showed the inmate had attempted to hang himself, and the situation did not appear uncommon:

“This writer observed that there were more than nine inmates on observation status each day during this on-site assessment that resulted in several inmates being housed in non-suicide resistant cells on the mental health unit. Several of these . . . contained several dangerous anchoring devices, including a towel rack on the desk, a towel rack on the sink, ventilation holes in bunks, large holes in ventilation grates, and clothing hooks.”

During Thursday’s hearing, Faust disclosed for the first time that a D.C. corrections officer was fired after the Nov. 30, 2012, suicide of Michael English, a then-recent college dropout with a history of violence and mental illness.

English’s parents and probation officer had repeatedly warned of his condition, and when he died, he was two weeks away from a scheduled court hearing about his mental health.

Faust said the officer falsified records regarding how frequently English had been observed in his cell.

In his report, Hayes said published procedures on suicide prevention at the District’s jail weren’t the problem.

Many were quite good and comprehensive, he wrote, but their implementation was another story. In many areas, he said, the jail and health-care provider — Unity Health Care — should take “immediate” corrective action.

“Correctional officers that are assigned to the mental health unit . . . do not receive any specialized mental health and/or suicide prevention training,” Hayes wrote, and in practice, he said, the entirety of all suicide-prevention training for corrections and Unity staff is a 39-slide PowerPoint presentation that is titled “Suicide Prevention (Module 16),” which lasts one hour and is offered to new employees and repeated once a year.

Vincent Keane, president and chief executive of Unity, testified Thursday that one long-time mental-health clinician was recently removed as an instructor. Critics of the instructor, whom Keane did not identify, said he had characterized most suicide attempts as attempts to seek attention or misbehave.

Keane and Faust said they hope to ensure that Unity psychiatrists and social workers who conduct psychological screenings of incoming inmates have access to the filed charges and other court information that could shed light on their mental states.

All four men who committed suicide between November 2012 and August of this year were being held on charges of sex crimes.

Hayes also said he observed the current screening being conducted poorly.

More troublesome, he wrote, corrections and Unity personnel appeared to routinely place and classify inmates in a “behavioral observation” unit, rather than on suicide watch, out of a “misguided belief that most inmates who threaten suicide . . . are simply manipulative.”

Hayes said inmates in the observation unit are stripped of their clothes, blanket and mattress and restricted from calling family members.

They are issued only a paper grown, which in some cases is taken away, too, and they are kept in isolation except for a shower once a day.

Hayes said the practice seems punitive and isolating for a person potentially suffering from suicidal thoughts.

He also said the entire classification seems designed, at least in part, to duck the requirement to monitor clear suicide threats very 15 minutes.

Rohini Singh, a lawyer with the D.C. Jail and Prison Advocacy Project, said that when the system fails, it reverberates negatively throughout the inmate population.

She said that after the June suicide of Paul Mannina, a senior Labor Department attorney charged with sexually assaulting a co-worker, two inmates were assigned to mop up his blood-soaked cell.

One of those inmates, she said, has a bipolar disorder and a history of trauma from being the first to discover a friend’s body as a child and has suffered a mental-health setback because of the macabre scene in the cell, requiring therapy.

Aaron Davis covers D.C. government and politics for The Post and wants to hear your story about how D.C. works — or how it doesn’t.
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