Ten men and one woman hung themselves in San Diego County jails during the last six years. They used socks or sheets, stringing handmade nooses from sinks, doors and bunks.
One inmate flung himself headfirst over the second tier of his unit. Two men intentionally overdosed on prescription medication. One drowned himself in a toilet. Another purposefully ingested a large amount of water so quickly that he died from acute water intoxication.
All counted, the San Diego County Sheriffs Department recorded 16 inmate suicides between 2007 and 2012. Among California counties, only Los Angeles, whose jail system is roughly four times the size of San Diegos, recorded more suicides—24—during that period.
The sad reality is that a person who is determined to commit suicide will commit suicide, and by using the everyday objects within their reach, Sheriffs Department spokesperson Jan Caldwell writes in an email. We train our deputies to look for signs of distress. However, drinking water would not be a recognizable signal for anyone.
But for correctional health experts, the countys high suicide and mortality rates signal something could be wrong in San Diegos five jails.
As we reported in the first part of our investigative series 60 Dead Inmates, between 2007 and 2012, San Diego County had the highest mortality rate among Californias 10 largest jail systems. Using the statistical method adopted by the U.S. Bureau of Justice Statistics (BJS) and the National Institute of Corrections—the number of deaths divided by each jail systems average daily population—CityBeat also found that San Diego had the second-highest suicide rate among the states large jail systems: 54 suicides per 100,000 inmates, more than 60 percent higher than the average.
Caldwell described the BJS methodology as mathematically exaggerated and argued that its more appropriate to compare the number of suicides with the total number of inmates who pass through the jail system annually. Using that method results in a rate of 2.8 suicides per 100,000 inmates.
If San Diego County wants to calculate their suicide rate based upon yearly admissions, theyre perfectly free to do so, says Lindsey Hayes, a suicide-prevention expert with the National Center on Institutions and Alternatives. But then they cannot compare themselves to others because no one else calculates the rate like that. Clearly, the average daily population rate has its drawbacks, but its the purest rate.
CityBeat obtained and analyzed medical-examiner reports, oversight-body findings and jail policies and interviewed family members to put together a picture of how suicides happen in jail.
When I investigate a jail system thats had  suicides in a six-year period, I tend to find that there were either bad practices or preventable deaths in many of the cases, Hayes says. You normally come to the conclusion that not all of those 16 deaths were preventable, but many of them were.
Hayes says he looks for problems with training, intake screening, inadequate medical and mental-health staffing and whether there are enough officers to do rounds at regular intervals.
There are usually multiple reasons why these problems exist, he says. You dont have to average two or three suicides a year in your jail system.
Blame is a hard thing to place when an inmate commits suicide. In a broad context, jail suicides can be viewed as a product of history, with the de-institutionalization of the mentally ill in the 1960s and 70s.
A lot of people have made the observation or argument that with that change in our mental-healthcare system, a lot of the chronically mentally ill who previously resided in state hospitals are now circulating between the streets and correctional settings, says Dr. Hal Wortzel, a University of Colorado professor whos examined suicidal behavior among inmates and recently released inmates. That may, in part, explain why we see so many suicides in correctional settings.
Caldwell describes the departments medical screening and care as excellent.
She acknowledges the Sheriffs Departments role as one of the countys largest mental-health service providers—roughly a quarter to one-third of inmates are on psychiatric medication, she points out.
Shanes parents, Wayne Hipfel and Peggy Leder, had been flying back and forth from Michigan, where they lived, staying for weeks at a time to check on their son. Theyre haunted by their decision not to bail Shane out of jail.
I wish to heck I had, Wayne says. I thought about it, but I wasnt really ready to do it, either, because I didnt know what we were going to do when we got him out.
In jail, they thought hed be protected from himself and receive treatment. Shane was a green-banded inmate, which meant he wore a fluorescent-green wristband to indicate he was highly assaultive. When his parents visited him, he was covered in bruises and abrasions and expressed fear that someone was going to kill him.
He would never say who, Wayne says. We didnt know if schizophrenia was going on with him or if somebody was threatening him in jail.
Shane was sentenced to a three-year term at Patton State Hospital in San Bernardino County, but the transfer was weeks away, if not months. The paperwork allowing psychiatric treatment to begin at the jail also was delayed by a backlog at the court.
New Years Day 2012 brought good news: Shane finally had been transferred to the jails psychiatric security unit, where he could be medicated.
Boy, that was the best call we got, Wayne says. We were so happy about that.
The next day, another call came. Shane was on life support after attempting to drown himself in his toilet. He died five days later.
Wayne and Peggy have yet to find closure; theres just not enough certainty. They remember Shanes fear, his injuries and how an independent pathologist said his autopsy pointed to homicide. But the pathologist never saw the video that reportedly captured Shanes death.
A San Diego attorney watched a portion of the video on behalf of the familys lawyer and said it was clearly suicide, but Wayne wants to see it himself, even if it means going to court.
If they do show me the video of him, I dont cherish seeing that, but at least Ill know.
In 2007, the Sheriffs Department—at the recommendation of the countys Citizens Law Enforcement Review Board (CLERB), the oversight body that reviews jail deaths and officer-related misconduct—implemented a new suicide-prevention training program to help staff better identify suicidal inmates. An April 2008 letter from CLERBs then-chair Robert Winston acknowledged the progress but demanded more after 21-year-old Adrian Correa, a schizophrenic whod threatened suicide in the past, fashioned a noose out of a blanket and hung himself from the top corner of his bunk.
CLERBs investigation identified significant gaps in how information regarding at-risk inmates is communicated between guards and support staff. The board advised the Sheriffs Department to include briefings during shift changes and implement a checklist system so deputies could better keep track of suicidal inmates.
There is no written guidance on the type of information passed from deputy to supervisor, or from supervisor to supervisor, Winston wrote.
It took the Sheriffs Department nearly two years to respond to Winstons letter.
In his response, Earl Goldstein, the jail systems medical director, downplayed the problem of suicide in county jails, saying that during a two-year period—July 1, 2007, through June 30, 2009—only four inmates had killed themselves.
His count, however, was off by two. Six inmates killed themselves during that period; a seventh committed suicide on July 3, 2009. In 2010, five people killed themselves in county jails—the most during the six-year period CityBeat reviewed.
The jail systems written suicide-prevention policies are brief. They state that, during intake, every inmates to be asked whether theyve considered suicide, attempted suicide or been hospitalized for suicidal thoughts. Inmates who answer Yes to Are you feeling suicidal? are either placed in a safety cell or refused entry to the jail and transported to the countys psychiatric hospital. After intake, [a]ll reports of suicidal behavior shall be considered serious, the policy says.
Once theyre on suicide watch, rarely does an inmate commit suicide, Hayes says. Suicides occur when theyre not identified properly and they slip through the cracks or theyre prematurely released from suicide watch and put back into the population, and then hours, days, weeks later, they commit suicide.
Sean Wallace is one such example. The 38-year-old had been moved back and forth from a safety cell to the general population several times, a medical examiners report notes. He was bipolar and schizophrenic, had repeatedly said he planned to kill himself and had reportedly tried to slice his wrists with a butter knife. On April 23, 2011, 48 minutes after hed been moved back to the general population, he was found hanging from his bunk by a bed sheet torn into strips.
Hayes says the standard of care is to closely monitor suicidal inmates—every 15 minutes for inmates at moderate risk—keeping in mind how quickly someone can kill himself.
Someone who is either threatening suicide and seemingly very serious about it, someone who has already attempted suicide—those are folks that almost everyone agrees are at high risk and you cant afford to put them on a 15-minute level of observation because it only takes three to five minutes to successfully commit suicide.
For some inmates, the warning signs arent as clear. They wont admit suicidal thoughts to jail staff because they dont want to be placed in a safety cell, or there will be a triggering event—a bad day in court, an upsetting visit with family—that might push an inmate over the edge. Hayes says hell do a psychological autopsy—go over an inmates medical and psychiatric records, talk to jail staff and family members, basically do everything possible to try to get inside a persons head.
Connie Jones is trying to do that. She doesnt want to think her son, Christopher Blenderman, killed himself. The medical examiner categorized Blendermans death as an accident, not a suicide, concluding that the 40-year-old overdosed on drugs, but not intentionally.
This doesnt jibe for Jones. Her son always stuck to his drugs of choice, cocaine and alcohol, but it was the odd combination of meth and heroin that were found in his system. And though he was a longtime addict, Chris never drugged when he was in jail, Jones says. He always went to the top of the class, and I would say, Why cant you live like this on the outside?
Blendermans criminal history was tied to his addiction— hed steal, often from family and friends—to buy drugs.
At the time of his death, hed been in jail for a year and was facing another year, his mother says. The last time she talked to him, he sounded forlorn. She wrote him a letter via the jails email system, but it didnt arrive until the day he died.
Prior to his last jail stint, Blenderman, who was bipolar, had been in Tri-City hospitals psychiatric ward at least twice, Jones says. The medical examiners report says hed tried to commit suicide in the past; another part of the report says he admitted to jail staff that hed thought about killing himself. Early on Sept. 7, 2012, he was found dead from a lethal combination of meth, heroin and antidepressants and anti-anxiety medication, some of which had been prescribed to him, some of which hadnt. His cellmate told a deputy that Blenderman had been hoarding medication.
In its September 2009 review of the death of James Phillips, a sex offender who took a lethal dose of the anti-depressant Doxepin, CLERB noted that other inmates had helped Phillips hoard the medication in defiance of the jails watch take program, in which medical staff members watch inmates take their prescribed medication. The review board didnt, however, offer any policy recommendations.
Jones wants to find her sons cellmate, to see what exactly he knew. Like other parents CityBeats talked to for this series, Jones has had trouble getting basic information from the Sheriffs Department.
She says her son should have been on watch. They knew hed been in the psych ward. He was on psych meds. So, if he stopped taking those meds on their watch, and if he used something on their watch, then that is their responsibility.