Opinion ID: 2339470
Heading Depth: 1
Heading Rank: 4

Heading: Stapleton's Suicide

Text: One or 2 days before Stapleton's suicide, a guard telephoned plaintiff Cathy Thomas, Stapleton's mother, to tell her that Stapleton wanted to tell her that he loved her. Thomas thought this was unusual, was concerned, and said so. Thomas also told the guard that her husband had committed suicide and that Stapleton had attempted suicide a month before his detention. The guard told Thomas not to worry because Stapleton was in a special unit and being watched. Thomas also testified in her deposition that, shortly before his suicide, Stapleton had not eaten for 3 days. Her son was permitted to call her as part of a deal with guards to ensure that he would start eating again. No one told Tipton that Stapleton's mother had expressed concern about her son's safety or the possibility of him committing suicide, nor was Tipton informed that Stapleton had previously attempted suicideeither 1 month before, as Thomas said, or 1 year before, as was recorded in Stapleton's mental health evaluation documentation. Tipton testified that he generally was not informed of the specific reason a particular inmate was placed in the Close Observation unit. Close Observation Progress Notes, completed on every inmate on the unit after each guard shift, show that Stapleton was crying 2 days before his suicide. The notes also indicate that Stapleton talked about getting high most of the day before his suicide. On the morning of his suicide, Stapleton got into an argument with guard Curtis Jones over the size of Stapleton's jumpsuit. Biltoft's Officer Report Sheet states that he received a call from Jones at 9:05 a.m. The Report Sheet further states that Biltoft and Jones discussed the option of moving [Stapleton] to [S]uicide [W]atch status due to his disruptive behavior. Biltoft heard Stapleton saying something in a demanding manner while he was on the phone with Jones. When Jones hung up and Biltoft called back, Biltoft spoke with Tipton. Biltoft's Report Sheet states that Tipton said that he thought [Stapleton] should go to special housing and mentioned that [Stapleton] had acted inappropriately toward Jones. Biltoft's Report Sheet also states that Biltoft went to talk to Stapleton. Stapleton appeared to be angry and told Biltoft that moving to special housing would just make him crazy. Biltoft's Report Sheet also states that Stapleton accused Jones of messing with him regarding the jumpsuit. After discussing the situation, Stapleton appeared to almost start crying and said that he thought he was always in the wrong. After talking to Stapleton, Biltoft left Stapleton in his cell and went to speak with Tipton. Biltoft told Tipton that he believed [Stapleton] would be all right. Then, according to Biltoft's Report Sheet, Biltoft again spoke with Jones. Jones told Biltoft Stapleton needed to be in special housing, because he was a disciplinary problem, not a suicide threat. According to Biltoft, Duty Station Reports from the day of Stapleton's suicide do not note that Stapleton left the Close Observation unit common area and went to his room. However, the Officer's Report Sheet completed by Tipton states that Stapleton finished a shower and went to his cell at the 10 a.m. head count. Tipton testified in his deposition that the cells in the Close Observation unit were within the direct sight of guards in the guard station. At 10:16 a.m., Stapleton's roommate said he could not get the door of their shared cell open. The window of the cell door had been covered. Tipton went to the cell and saw what appeared to be a sheet wedged in the door. Tipton found Stapleton hanging from the other side of the door, unwound the sheet from his neck, and placed him on the floor for medical attention. At approximately 10:20 a.m., according to Biltoft's Report Sheet, Tipton radioed with a medical emergency. When Biltoft responded, he saw Stapleton lying on the floor of his cell with Tipton performing rescue breaths and another inmate performing chest compressions. Biltoft heard Tipton say something like: I knew it, he should have [gone] to special. Darrell Myrick, another inmate in the Close Observation unit on the day of Stapleton's suicide, said that, after Stapleton's disagreement with the guards, he heard Stapleton say he was going to kill himself two or three times. Myrick further testified that Stapleton made these statements loudly enough to be heard by the guards, including Tipton, who was 15 feet away watching television. For his part, Tipton testified that the televisions in the unit were not visible from the guard station without a guard straining his or her neck. Myrick also testified about other observations of Tipton's behavior on the morning Stapleton's suicide. Myrick said that Tipton was sick that day and mainly sat at the guard station, missing his 10 a.m. and 10:15 a.m. checks. The Duty Station Report maintained by Tipton does not show any missed 15-minute inmate checks on the morning of Stapleton's suicide up until 10 a.m. It contains no entries between 10 a.m. and 10:45 a.m. that day. Myrick testified that Stapleton went into his cell before 10 a.m. and was found hanging at 10:20 a.m. When Myrick looked over at Stapleton's cell door, he said he could see a big ball with a knot 6 inches to 8 inches around hanging over the top of the door. A jail chaplain, Father Joseph Chontos, gave deposition testimony about a conversation he had with Tipton on the day of Stapleton's suicide. Chontos testified that it was his understanding, based on this conversation, that Tipton believed Stapleton should have been moved to Suicide Watch because he was a threat to himself, not because he was a discipline problem. In an affidavit attached to defendants' summary judgment motion, Tipton said that he never believed Stapleton was a suicide risk and had not told Chontos otherwise. Three suicide letters were found in Stapleton's cell after his suicide. One was dated November 3, 2002, another, November 23, 2002. The third was undated.