Opinion ID: 2339470
Heading Depth: 1
Heading Rank: 2

Heading: Detention Center Operation and Suicide Prevention Policy

Text: Tipton was the guard on duty in the Close Observation unit where Stapleton was housed. Tipton had received initial training in suicide prevention and had undergone further training every 6 months. Biltoft, the assistant shift supervisor in charge of the Detention Center on the day of Stapleton's suicide, also had received initial and in-service training in suicide prevention. During Gillespie's tenure as Director, which began in August 2000, before Stapleton's suicide, there had been three suicides at the center. Gillespie did not receive any formal job performance evaluations from the commissioners or anyone else, although she testified that she received informal evaluations. After each suicide occurred at the center, Gillespie spoke to the commissioners. At the time of Stapleton's suicide, the Detention Center had in place policies and procedures regarding the health care of inmates, including a suicide prevention policy. The policy [t]o prevent inmates from self-harm and death while in the custody of the Adult Detention Center instructs staff to be alert to indicators of potentially suicidal behaviors and make immediate, appropriate referral(s) to determine degree of risk for self-harm and/or suicide when the indicators occur. Appropriate action shall be taken to protect the inmate. The policy's definitional section labeled Suicide Watch stated in pertinent part: Continuous supervision provided to an inmate who is considered to be at imminent risk for suicide. When the inmate is assigned to a cell that is protrusion-free, the officer assigned to suicide watch duties shall observe the inmate(s) frequently, at least every 4 minutes, and document the observations as they are completed. The definitional section for Close Observation stated in pertinent part: Close monitoring and supervision of an inmate who is not imminently suicidal but who possesses one or more suicide risk factors. . . . Staff shall observe these inmates with greater frequency than general population, but at a minimum, shall conduct 15-minute health and well-being checks of inmates placed on this status. The relevant segments of Section I of the PROCEDURES section of the policy on Observation of Suicide Risk Factors provided: B. Staff who work directly with inmates shall consistently monitor inmates under their supervision for any of the following risk factors or behaviors: . . . . 6. weight loss or loss of appetite, . . . . 13. crying frequently, . . . . 19. expressing suicidal thoughts or plans, 20. composing a suicide note, 21. talking of death and/or afterlife, . . . . 23. highly agitated, afraid, or angry, . . . . C. Staff who observe any of the risk factors or behaviors noted . . . shall immediately report the behavior(s) verbally and in writing to the shift supervisor. The relevant segments of Section II of the PROCEDURES section of the policy on Screening for Risk of Suicide provided: B. Whenever a shift supervisor has been notified about potentially suicidal information and/or behaviors regarding a specific inmate, the shift supervisor shall assign a line supervisor to complete the Screening Form . . . as soon as possible. 1. Staff shall ensure that the inmate in question is monitored carefully until the screening is completed. Section III of the policy dealt with Intervention to Prevent Suicide, the majority of it devoted to how to evaluate and react to the Screening Form. But its Subsection D stated: Immediately following an unsuccessful suicide threat or attempt, the inmate shall be placed on Suicide Watch. Section IV of the policy, labeled Suicide Watch, stated in its Subsection A that the purpose of Suicide Watch shall be to prevent an inmate who is imminently suicidal from actually committing the act of suicide or otherwise harming himself or herself. Additional relevant subsections provided: B. Suicide Watch shall include: 1. assignment to a single, protrusion-free cell ...; 2. removal of all property; 3. a mattress for sleeping; . . . . 7. frequent/continuous supervision by staff. . . . . I. The officer assigned to supervise the inmate on Suicide Watch in a protrusion-free cell shall monitor the inmate's behavior on a frequent basis, observing and recording the inmate's behavior at least every 4 minutes. 1. Under no circumstances shall there be longer than 4 minutes between checks of each inmate under Suicide Watch. Section V, Subsection A of the policy on Close Observation Status read: The purpose of Close Observation Status shall be to more carefully monitor the behavior and actions of an inmate who is not imminently suicidal but who possesses one or more suicide risk factors. Its other relevant subsections read: B. Close Observation shall include: 1. assignment to a double cell within a designated Close Observation unit, unless serious security concerns cause double-celling to be inappropriate for a specific inmate; . . . . 4. frequent observation by staff with a minimum of 15-minute health and well-being checks; . . . . 7. frequent shakedowns of each cell, at least one time per shift on the first and second shifts. . . . . D. If a Close Observation inmate becomes seriously insubordinate and/or violent, the inmate shall be secured in a protrusion-free cell for Suicide Watch. The policy permits only mental health professionalsdefined as persons who have specialized training and skills in the nature and treatment of mental illness, including licensed psychiatrists, social workers, psychologists, and psychiatric nursesto determine when an inmate should be removed from Suicide Watch or Close Observation. The Close Observation classification system had been initiated by Gillespie, who testified in her deposition that mental health workers were brought in to the Detention Center to provide suicide prevention training to center personnel. Supervisors were given additional training in conducting suicide risk screenings beyond that required for all officers. Evidence before the district court also established that it was rare for someone other than an inmate with suicidal issues to be placed in Close Observation. At the time of Stapleton's suicide, inmates in Close Observation were supposed to be out of their cells as much as possible to socialize and improve their function. According to Tipton's deposition testimony, Tipton was not told or informed of the reasons a specific inmate was assigned to Close Observation. The role of guards in Close Observation was to watch all of the inmates, to follow the policy of checking on each inmate visually every 15 minutes, and to conduct cell shakedowns once per shift. Guards on duty were responsible for reporting to their supervisors if there were changes in an inmate's behavior symptomatic of suicide, based on the training the guards had received. Pursuant to the suicide prevention policy, the supervisor was then to see that a suicide risk screening was conducted. Also, according to Gillespie, although the policy was not written to cover the subject at the time, it was always communicated clearly that inmates in Close Observation were not allowed to cover their cell windows. Gillespie also said that she could not recall if it had been specifically stated in Detention Center policies at the time, but it was certainly understood that a guard could not watch television during his or her shift. Tipton testified in his deposition that, at the time of Stapleton's suicide, inmates would put cardboard over the windows of their cells when they used the toilet. Tipton testified that no one had reprimanded him for allowing inmates to do this. Biltoft testified that, as assistant shift supervisor, it was his job to make sure everyone showed up to work, to make sure everyone was given the proper equipment, to make sure that all the duty posts were covered, to ensure guards were properly performing their jobs, to take formal head counts, to conduct searches of cells housing Suicide Watch inmates, to answer questions and resolve problems on the units, and to take care of any miscellaneous business. He also testified that supervisors like him were involved in evaluations of whether inmates should be placed on Suicide Watch. Other staff members, including social workers, also were involved.