Investigation uncovers suicide disaster in US jails

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The final time Tanna Jo Fillmore talked together with her mom, she was in a Utah jail, indignant, pleading and determined. She’d referred to as on daily basis that previous week, begging for assist.

I want my medication, she demanded.

I’ve to get out of right here, she screamed.

Fillmore was within the Duchesne County Jail on a cost of violating probation in a drug case; she had reportedly did not report a change of handle. At 25, she’d struggled with psychological sickness for years, however Xanax and hyperactivity treatment had stabilized her. Now, she instructed her mom, the jail’s nurse was denying her these capsules — and he or she couldn’t take it any longer.

That November day, she phoned her mom, Melany Zoumadakis, 3 times over an hour. Of their ultimate dialog, Fillmore’s voice was uncooked with rage. She blamed her mother, a nurse herself, for not doing extra. She threatened to kill herself, warning that if she did: ”‘You’re going to be the worst mom on the planet.’” Then she hung up.

Zoumadakis referred to as her daughter’s probation officer and instructed him she feared her daughter would die in jail, however he assured her Fillmore was being monitored.

The following day, Thanksgiving 2016, Fillmore’s sister, Calley Clark, acquired a Fb message. “I’m so sorry,” a pal wrote. Then one other observe arrived: “Please inform me it isn’t true.” In Texas for the vacation, Clark had an uneasy feeling and requested her boyfriend to name the jail. He returned with the information.

Clark dialed her mom, gasping so laborious she might barely converse and requested if she’d talked with Tanna that day. She hadn’t.

“Mother,” she cried, “she’s useless!”

On her ninth day within the Duchesne County Jail, Tanna Jo Fillmore hanged herself in her cell. She by no means did get her meds.


Learn the headlines on any given day throughout America and also you’ll discover proof of a disaster roiling the legal justice system: “Suicide main reason for demise in Utah jails.” ″San Diego County inmate suicide charge ‘staggeringly’ excessive.” ″Tried suicides at Cuyahoga County Jail tripled over three-year span.”

Tales like Fillmore’s have been instructed repeatedly and but the deaths proceed in jails giant and small.

Suicide, lengthy the main reason for demise in US jails, hit a excessive of 50 deaths for each 100,000 inmates in 2014, the most recent yr for which the federal government has launched information. That’s 2½ instances the speed of suicides in state prisons and about 3½ instances that of the final inhabitants.

It’s an issue generally blamed on the mere indisputable fact that extra mentally sick individuals are touchdown behind bars, a development that began after state psychiatric hospitals started closing within the 1970s and promised alternate options did not emerge. Extra just lately, jails have been overwhelmed with these hooked on opioids or meth, lots of whom wrestle with melancholy and withdrawal.

More and more, troubling questions are being raised in regards to the therapy of inmates in lots of jails, potential patterns of neglect — and whether or not higher care might have stopped suicides.

A joint investigation by The Related Press and the College of Maryland’s Capital Information Service finds that scores of jails have been sued or investigated in recent times for allegedly refusing inmates treatment, ignoring their cries for assist, failing to watch them regardless of warnings they may hurt themselves, or imposing such harsh situations that the sick acquired sicker.

Reporters spent months analyzing a whole lot of instances in native information stories, reviewing investigations of particular jails and compiling a database of greater than 400 lawsuits filed within the final 5 years over alleged mistreatment of inmates, most of whom have been mentally sick. Some 40 p.c of these lawsuits concerned suicides in native jails — 135 deaths and 30 makes an attempt.

The court docket information comprise 1000’s of pages of allegations and priceless clues about how and why this drawback persists. For instance:

  • A few third of jail inmates who tried suicide or took their lives did so after employees allegedly failed to supply prescription medicines used to handle psychological sickness. Some jail officers say withholding medicines for a brief interval isn’t dangerous and that some inmates attempt to manipulate the system to get medication. David Mahoney, a Wisconsin sheriff, disagrees. If inmates are taking psychotropic medication, he says, “now we have a ethical and moral accountability to proceed them.”
  • The primary week of an inmate’s detention is vital. Within the jail lawsuits, greater than half of suicides or makes an attempt occurred through the first seven days and plenty of of these have been inside the first 48 hours after consumption. These early days are marked by the sudden stress of confinement when inmates fear about shedding jobs, household response and an unsure future.
  • Inmates incessantly used clothes, bedsheets or bathe curtains to hold themselves. The assessment additionally revealed situations of inmates being given razors, regardless of clear warnings they may hurt themselves.
  • Many inmates weren’t checked commonly — often each 15-30 minutes — due to staffing shortages or insufficient coaching.

Of the 165 jail suicides and makes an attempt, about 80 p.c of inmates have been awaiting trial.

These lawsuits characterize a tiny fraction of the issue. An unique 50-state reporting effort to gather current information discovered greater than 300 suicides in native jails from 2015 to 2017 — in simply 9 states. The others didn’t present numbers or supplied incomplete information, a difficulty prompting some legislatures to contemplate payments that might require jails to supply higher details about these dying behind bars.

Dane County Sheriff David Mahoney stands in a solitary confinement cell in the Dane County jail in Madison, Wis.
Dane County Sheriff David Mahoney stands in a solitary confinement cell within the Dane County jail in Madison, Wis.AP

The 2014 federal statistics reported 372 suicides amongst some 3,000 jails surveyed.

What’s most annoying about these deaths, legal professionals and civil rights advocates say, is that they’re largely avoidable.

“The overwhelming majority are foreseeable and preventable,” says Lori Rifkin, a California prisoners’ rights legal professional. “However they proceed to occur as a result of, total, I feel there’s a cultural dismissiveness towards each the indicators that assist us predict suicide — and towards the steps needed to forestall them.”

Jonathan Thompson, head of the Nationwide Sheriffs’ Affiliation, calls that evaluation absurd and says whereas jail officers should take each step to guard inmates, they’ve been positioned in an unimaginable scenario.

“We’re not the nation’s psychologists,” he says. “We’ve got determined that as a society let’s simply warehouse the mentally sick in a jail … which is neither geared up for, skilled to deal with or capable of be most effective and efficient at fixing the issue.

“The failure right here isn’t simply what a deputy or an officer in a jail does or doesn’t do. The failure is that these individuals are being put in a legal atmosphere for psychological sickness.”


Tanna Jo Fillmore had a troubled historical past.

Jo-Jo or TJ, as her household referred to as her, was a fearless woman, competing in rodeo barrel races and using her horses by way of the woods into the rugged Uinta mountains. Her mom dubbed her “the horse whisperer.”

Issues began cropping up, although, throughout adolescence when she gained weight and classmates taunted her. She’d cry however would forgive. “She needed to be accepted by everybody a lot, even when they have been imply to her,” says her sister, Calley Clark.

Clark says her sister struggled with melancholy as a teen, however nobody actually addressed it. When Fillmore dropped out of highschool simply shy of commencement to look after her ailing father, Clark provides, “all her plans and desires went away.”

She was later identified with post-traumatic stress, anxiousness, panic dysfunction and melancholy and was prescribed Xanax and the stimulant D-amphetamine sulfate, based on a civil rights lawsuit filed in opposition to Duchesne County.

Fillmore married at age 21 and round then, her household says, she began utilizing methamphetamines and developed a repute as a “druggie” of their tiny jap Utah group, Tabiona. In 2013, based on court docket information, Fillmore pleaded responsible to drug fees and was positioned on probation. Two years later, Clark says she nonetheless gave the impression to be utilizing meth, although she flushed her medication down the bathroom and vowed to give up.

By November 2016, Fillmore, lengthy separated from her husband, had moved to Salt Lake Metropolis to stay together with her mom. She was speaking a few recent begin and ready for an open mattress in residential drug therapy. The household’s lawyer, Tyler Ayres, says Fillmore didn’t report her change of handle to her probation officer.

That led her to the Duchesne County Jail the place, based on the lawsuit, she instructed the reserving clerk about her prescriptions however, regardless of repeated requests, was denied them by Jana Clyde, a licensed sensible nurse who allegedly referred to as her a “drug addict.” The criticism claims Clyde, who can’t legally prescribe medication, didn’t “fulfill her gatekeeper function” by contacting the jail physician.

Dr. Kennon Tubbs, who contracts with the county, instructed the AP he didn’t obtain any request for treatment for Fillmore. Tubbs’ doctor assistant makes a weekly go to, however there’s no indication Fillmore noticed medical employees whereas locked up. Clyde didn’t reply to a message despatched to her by way of the county.

Ayres, the household’s lawyer, says Fillmore wasn’t suicidal and flourished whereas taking treatment: “All they needed to do was give it to her. … They’ve an obligation to supply satisfactory medical care.”

The lawsuit notes Fillmore additionally might have feared going through a prolonged sentence for her probation violation, though her court-appointed lawyer instructed the AP the possibilities of that have been exceedingly low.

Fillmore hanged herself with a bedsheet. Her court docket listening to was 4 days away.


Nationwide, jail suicide instances are resulting in substantial settlements over defective insurance policies or neglect; some lawsuits have been introduced by households who’d tried warning jailers of a beloved one’s situation.

In Grundy County, Iowa, Jared Slinker, a 26-year-old mentally sick father of three, tied a bedsheet round his neck and was left hanging for 13 minutes as a result of just one jail staffer labored that evening and doubled as a dispatcher. Coverage prohibited the guard from coming into the cell till one other employee arrived, says Dave O’Brien, a lawyer for the household, which final yr gained a $500,000 settlement.

Each Slinker’s father and a physician warned jail officers he was depressed and withdrawing from medication. Slinker instructed a jail official he was delusional and taking an antidepressant, however the reserving officer inexplicably answered “no” on an admissions type when requested about these very issues.

“Any affordable individual would haven’t missed these indicators that he was a psychological well being danger,” O’Brien says, noting Slinker would have been monitored extra fastidiously with the correct classification. The jail has practically doubled its surveillance cameras.

In Lake County, California, Elizabeth Gaunt, a 56-year-old former social employee, was jailed after appearing erratically however by no means charged. Gaunt, who had psychological well being and substance abuse issues, was positioned in a cell with a surveillance digicam and was alleged to be checked each 15 minutes.

Over 25 hours, she begged for a physician, repeatedly screamed “assist me,” tore a blanket into strips, checked their power on a sink and bathroom and used them to kill herself. A guard who seemed in by way of a cell window famous in an commentary log all was OK.

Dane Shikman, Gaunt’s son, says his mom ought to have been taken to a psychological well being middle, not jail and believes the guards didn’t care sufficient to intervene. The county settled a wrongful demise lawsuit for $2 million.

“It’s a failure of humanity and of our establishments that causes these tragedies,” Shikman says. “Once they see somebody who appears like they’re struggling, they don’t say, ‘Let me step in. That is somebody’s mother.’… They suppose this can be a girl on medication doing no matter she’s going to do, she’ll shut up.”

Dane Shikman holds a photograph showing him with his mother, Elizabeth Gaunt, at his home in San Francisco.
Dane Shikman holds {a photograph} exhibiting him together with his mom, Elizabeth Gaunt, at his dwelling in San Francisco.AP

In Delaware County, Pennsylvania, 35-year-old Janene Wallace, who suffered from psychological sickness and paranoia, was in solitary 51 of 52 days for a probation violation. She was locked up 23 hours a day on the George W. Hill Correctional Facility. When she threatened to choke herself in 2015, a guard instructed her to go forward. She did. The guard went to lunch with out checking on her and was amongst three staff fired.

“She wanted therapy,” says David Inscho, an legal professional for the household, which gained a $7 million settlement. “They gave her the alternative.”

Different instances element how comparable callousness or poor judgment can flip lethal: In Knox County, Tennessee, an inmate who tried to kill himself with a razor six months earlier was given one other one when readmitted on theft fees. A guard allegedly mentioned he ought to “have finished the job proper” the primary time. The inmate slit his throat.

Sheriffs incessantly complain they don’t come up with the money for to rent psychological well being staff, practice guards and make wanted enhancements to reinforce inmate monitoring.

Mahoney, the Dane County, Wisconsin, sheriff, has no separate housing for inmates with sure extreme behavioral, medical or psychological well being issues, in order that they’re confined to solitary, the place they’ll spend 23 hours a day in a 6-by-9 cell with the lights on nonstop. “It’s inhumane,” he says. “However we’re pressured right into a scenario to maintain these folks alive.”

Mahoney is making an attempt to safe funding to interchange a 66-year-old jail with one that may have a hospital-like wing. However searching for extra {dollars} isn’t a preferred request.

“When … we’re answering to the taxpayers, can we need to say we’re placing that cash towards bettering your roads, your faculties … or we’re placing it towards making inmates extra comfy?” says Christine Tartaro, a legal justice professor at Stockton College and creator of “Suicide and Self-Hurt in Prisons and Jails.”

The issue extends past budgets. Asking a jail to carry inmates awaiting trial and people serving brief sentences and likewise act as de facto psychological well being and drug therapy facilities, she says, is just too nice a burden.

“How a lot,” she asks, “are we anticipated to get out of 1 establishment?”


Fillmore wasn’t the primary individual to die contained in the Duchesne County Jail.

Inmates killed themselves in 2013 and 2015 and every week after Fillmore’s demise, Madison Jensen, a 21-year-old withdrawing from heroin, was discovered useless in her cell. The trigger: a possible cardiac arrhythmia attributable to extreme dehydration. She’d misplaced 17 kilos in 4 days, based on a lawsuit filed in opposition to the county, the sheriff on the time and jail officers together with Clyde, the nurse in Fillmore’s case.

Jensen, who’d been arrested on drug fees, was too weak to face at instances, vomited and had diarrhea repeatedly, the lawsuit says.

The Utah legal professional basic’s workplace charged Clyde with negligent murder. A Justice of the Peace threw out the case, however an appeals court docket reversed the ruling, paving the way in which for Clyde to face trial. The choice notes that aside from checking on Jensen’s blood strain and giving her a sports activities drink, Clyde didn’t take her important indicators, carry out different assessments or contact the doctor’s assistant even after Jensen stuffed out a medical request type.

Clyde instructed investigators she wasn’t conscious of the severity of Jensen’s sickness. Frank Mylar, her lawyer, says “primarily based on the data she had, she believed she did the most effective she might. After the actual fact, would she have finished one thing totally different? Completely.”

Duchesne County Sheriff Travis Tucker, who took workplace in January, declined to debate both case however says jail coverage does present for some prescription medicines. He additionally says a seven-bed medical wing is being added to deal with what he estimates is a tripling of inmates within the final decade, lots of them mentally sick or addicted. Registered nurses have been added, as nicely.

Tucker notes the state has a higher-than-average suicide charge, “so if it’s that method on the surface, what makes you suppose it isn’t going to be that method on the within?” He’s a part of a statewide group exploring how Utah jails can higher stop suicides.

Final yr, state lawmakers handed a measure requiring an accounting of jail deaths — a requirement initially met with “an absence of cooperation” amongst some sheriffs, based on Sen. Todd Weiler, the sponsor.

However they did comply. In November, the Utah Fee on Legal and Juvenile Justice reported 71 folks died in Utah jails from 2013 to 2017. Greater than half — 38 — have been suicides.


There’s no single repair for this, however sheriffs, lawmakers and advocates have some potential solutions.

Some jails have improved coaching, added psychological well being employees and positioned suicide-resistant mattresses in cells.

In Lake County, California, the place there was that $2 million settlement, Sheriff Brian Martin initiated reforms together with putting in a bigger surveillance monitor for guards to observe cells holding troubled inmates. The jail additionally changed blankets with tear-resistant ones; gave employees 4 extra hours of suicide prevention coaching; added a registered nurse; and changed paper logs with an digital system to trace cell checks. All jail clocks have been synchronized, too, so inmates are monitored on the appropriate intervals.

An inmate is shown covered in a tear-resistant blanket sleeps at the Lake County Jail in Lakeport , Calif.
An inmate is proven coated in a tear-resistant blanket sleeps on the Lake County Jail in Lakeport , Calif.AP

“We don’t need this to ever occur once more,” Martin says.

In Texas, the Sandra Bland Act turned legislation in 2017, mandating psychological well being coaching for legislation enforcement and making it simpler for these arrested to obtain a private bond if they’ve a psychological sickness or substance abuse drawback. The measure is called after a black girl who killed herself in 2015 after being jailed in Waller County for a minor visitors violation.

Different Texas counties have carried out adjustments.

In Bexar County, dwelling to San Antonio, 21 inmates killed themselves from 2011 to 2018. Now, a particular crew of deputies roams the jail to establish inmates who could also be suicidal. The sheriff is also working with county officers to safe the discharge of nonviolent mentally sick inmates who might languish in jail as a result of they will’t afford a $250 bond.

In Harris County, dwelling to Houston, the sheriff’s workplace teamed up final yr with psychological well being officers for a pilot program to present inmates entry to a suicide hotline. “It acted like a strain valve,” says Sheriff’s Main Mike Lee. This system is predicted to change into everlasting.

“The options … don’t contain reinventing the wheel,” says Aaron Fischer of Incapacity Rights California. His group spent 2½ years investigating San Diego County jails, the place there have been 17 suicides from 2014 to 2016 and issued a report criticizing the system for extreme use of solitary confinement and punitive therapy of the mentally sick. San Diego officers say they’re investing sources into coaching and recruiting.

Fischer says it’s essential to demystify psychological sickness to a public which will mistakenly consider inmates who kill themselves are “wholly in charge” or deserve what occurs to them in the event that they find yourself in jail.

“These are individuals who had households, individuals who had desires and strengths and weaknesses,” he says, “people positioned in a particularly harsh and punitive setting and denied care that they wanted, resulting in a demise that didn’t have to happen.”


Tanna Jo Fillmore had dreamed of rebuilding her life.

5 days after her demise, her mom acquired a name from the residential therapy middle her daughter had deliberate to enter. It was her check-in day and the caller questioned why she wasn’t there. Her mom relayed the information.

Greater than two years later, Fillmore’s mom nonetheless grieves. On Easter she visited the cemetery, sharpening her daughter’s gravestone, placing down flowers and propping up household pictures. The tears flowed, as they do each time she visits.

When she stopped crying, she stood on the grave and in a powerful, clear voice spoke to her misplaced daughter:

“Expensive Jo-Jo,” she mentioned, “we love you and we miss you and we take into consideration you each single day. Preserve dancing within the sky.”