Opinion ID: 4548568
Heading Depth: 2
Heading Rank: 1

Heading: Intake

Text: In the early morning of Saturday, April 21, 2012, police stopped Edward Burke for a suspected hit-and-run. Pulera, Burke’s cousin, was in the car’s passenger seat, drunk. Oﬃcers arrested both men: Burke for the hit-and-run and Pulera for drinking in violation of a condition of his bond pending trial on state battery charges. According to the arresting ofﬁcer’s report (the accuracy of which Pulera does not dispute), Pulera appeared drunk but exhibited no suicidal behavior while in transit. When Pulera arrived at the facility, the intake oﬃcer on duty, Victoria Sarzant, and her supervisor, Dennis Zawilla, reviewed the arresting oﬃcer’s report and placed Pulera and Burke in temporary holding cells across from each other. Burke testiﬁed that he could just barely see and hear Pulera through their respective cell doors and the distance of the hall, but what he witnessed alarmed him. Though the solid door muﬄed the sounds and the small cell windows constrained his view, Burke saw that Pulera was “dragging his No. 19-2291 3 thumb across his neck as if he was going to harm himself” and muttering “I’ll just take myself out” because he was “done,” all of which Burke understood by reading Pulera's lips. This went on for a while, and Burke testiﬁed that unidentiﬁed ofﬁcers “in the vicinity” should have seen and heard Pulera, too. After about an hour, though, an oﬃcer took Burke out of his holding cell and booked him into the facility proper. Burke told the oﬃcer who transferred him, as well as one or two others, that he was concerned about Pulera hurting himself. Each brushed Burke oﬀ and, a few hours later, he left the facility. Meanwhile, Pulera stayed in his holding cell. Although Sarzant had reported that Pulera was cooperative, if intoxicated, at 2 AM, he started to become more disruptive. By 5 AM, he was standing on a bench, pounding the door, and shouting. Based on this behavior—which Pulera explained was because he was cold and wanted a jacket—Sarzant held oﬀ on booking him and, near the end of her shift, prepared a report explaining why. Sarzant wrote that she saw no evidence Pulera was suicidal, just combative and possibly still intoxicated. Zawilla reviewed this report, too, and Pulera does not dispute the accuracy of its contents either. After the shift change, Shane Gerber began the booking process. He screened Pulera using a standard form with medical and mental health questions and wrote down that Pulera’s mother had died a month ago (but not that she had committed suicide) and that Pulera was prescribed medications. Pulera testiﬁed that he may have told Gerber of his mother’s cause of death and that his brother had also committed suicide about a year before. The rest of the form Pulera thought 4 No. 19-2291 accurate. It reﬂects that Gerber saw no behavior suggesting a risk of suicide, and that Pulera answered “no” when asked whether he had ever contemplated or was presently contemplating suicide and to a battery of questions reﬂecting possible suicide risk factors. Gerber also checked the facility's database for a “mental health special instruction” connected to Pulera but found none. This procedure resulted from a 2011 policy change to reduce the risk of inmate suicides after a string of attempts at the facility. The facility’s database includes an instruction in the ﬁle of any arrestee who its oﬃcials had previously placed on “level one” suicide watch (the more restrictive and protective of the two levels the facility recognized). If a booking ofﬁcer saw the instruction, he had to alert a supervisor, who would then perform a second, more thorough mental health risk assessment. During a prior stint at the facility in 2011, a crisis worker had placed Pulera on suicide watch after he told a nurse that he felt “really depressed” and his “mind was mess[ed] up” after his brother’s suicide. The parties agree that the worker ordered only the less restrictive level two watch, however, so Pulera’s ﬁle did not contain a special instruction in 2012. Without the instruction, the facility’s policy required Gerber to order the additional risk assessment only if Pulera showed signs of contemplating suicide or had three risk factors. The death of a family member was one such factor, but Gerber found no others, so he placed Pulera in general population without requesting a second look. No. 19-2291 5