The Girls Rehabilitation Facility (GRF) is a small, dedicated wing for young women within San Diego County's main juvenile hall in Kearny Mesa. Run by the county Probation Department, GRF can hold up to 50 detainees, but for most of 2013, it averaged about 34. The unit is designed much like the rest of juvenile hall, except that cell doors don't lock and common areas are sparsely decorated to seem homier.
At 7:53 p.m. on a Monday night in September 2013, staff noticed that one cell's small, square window was covered over with paper. When they tried the door, they discovered that the detainee inside had secured it with a bed sheet between the knob and her bunk. They forced their way in and found a girl hanging from an air vent with another bed sheet. Although they were able to revive her pulse, Rosemary Summers was pronounced dead four days later at age 16.
Rosemary's suicide raises two serious questions for the Probation Department: Did staff do everything they could to prevent her death? And, what are authorities doing to prevent additional deaths as suicide attempts spike at the Kearny Mesa facilities?
To accept the official version of events, you must believe that Rosemary orchestrated and executed a complex suicide plan, timed perfectly between 15-minute safety checks. To exculpate county staff, you must also believe they had no reason to place Rosemary on suicide watch, requiring even more frequent checks and the removal from her cell of anything she might use to harm herself.
A lawsuit filed against the county this month by Rosemary parents, Cheyenne Chanterelle and Arthur Summers, argues that juvenile hall staff knew the teen was at risk for suicide: She'd been a victim of sexual exploitation and rape and had a history of depression, suicidal thoughts and self-mutilation. The lawsuit suggests she was overmedicated, having been prescribed a psychoactive drug that staff should've known had the potential to intensify suicidal thoughts. And, the complaint notes, the facility was understaffed the night of Rosemary's death and that staff, aware she was upset about two troubling events earlier that day, sent her to her room alone, with all the tools she needed to take her own life.
The credibility of San Diego's juvenile-detention system has come under fire this year amid a complaint that the Youth Law Center submitted to the U.S. Department of Justice in July regarding the use of harsh disciplinary measures on at-risk youth. In documented cases, staff used pepper spray on suicidal teenagers who refused to comply with strip searches. In many instances, suicidal teens were placed in solitary confinement for days.
In the months after Rosemary's death, Probation Department officials told oversight bodies that they'd reviewed and amended the suicide-watch policies at GRF. Meanwhile, suicide attempts at the larger Kearny Mesa complex increased from 10 in 2012 to 24 in 2013.
In July, CityBeat requested the new suicide-watch policies so we could have them reviewed by experts. Claiming it was not in the public interest to release the documents, county officials rejected the request—the administrative equivalent to putting paper over a cell window.
Rosemary Summers wasn't quite 15 the first time she was booked into juvenile hall, after being charged with resisting arrest and marijuana possession. She'd spend the next year-and-a-half in and out of the facility, sometimes turning to prostitution when she needed money.
It's tough to write Rosemary off simply as a delinquent teen. Slim and pretty, with an engaging smile, she filled the notebooks she kept in her cell with poems, drawings and song lyrics. She had a knack for leadership, her mom says, and a deep sense of justice. Her last stay in juvenile hall was because she'd attended a July 18, 2013, rally for Trayvon Martin and didn't notify her probation officer. Diagnosed with depression and suffering from frequent panic attacks, she'd write in her notebooks about how juvenile hall could better serve teens like her.
"Things that need to change," she wrote at the top of one page after being denied a request to see a counselor and instead had an officer come to her cell. "Officers not licensed counselors."
Stephanie Powell, a paralegal with the Singleton Law Firm, who filed the lawsuit on behalf of Rosemary's parents, has used these journals—along with medical and psychiatric records and staff notes—to piece together the last 18 months of Rosemary's life. Powell talks about Rosemary as if she'd known her.
"She understood what was going on and what needed to be fixed, but didn't understand how to take care of herself and her own emotions," Powell says. "It was lonely for her, I think, very lonely."
There are at least four documented cases of Rosemary being placed on suicide watch—twice in 2012 and twice in 2013, the last time just a month before she killed herself. Powell says records show Rosemary repeatedly asking to see a counselor, but her requests often went ignored; or, instead, she'd be sent to a nurse, or a probation officer would come talk to her. A number of times, records show, Rosemary told staff that she felt compelled to harm herself. She'd talk about wanting to strangle herself and would sometimes carve things into her skin with a pencil. After her death, the medical examiner noted the preponderance of small scars and carvings on her legs.
Six weeks before her suicide, Rosemary was placed in a single cell; officers reported that they could hear the teen talking to herself, Powell says. Also around this time, she was put on Abilify, an antipsychotic medication, despite warnings by the Food and Drug Administration and the drug's own manufacturer that it can cause suicidal thoughts in children, teens and young adults.
Several months ago, CityBeat requested from the county all training materials and guidelines for juvenile-detention staff regarding psychotropic medication. A document titled "Common Drugs and Psych Meds" fails to mention Abilify's most serious side effect.
Despite her bouts with depression, during her stays at juvenile hall, Rosemary sought to be appointed to the leadership position of dorm counsel.
"She wrote letters, she was actively making changes so that she would get the position," Powell says. "It meant a lot to her; she took it seriously."
Records aren't clear on when Rosemary was appointed to dorm counsel, but on Monday, Sept. 23, 2013, she was removed from the position. Earlier that day, she'd had a falling-out with her girlfriend.
State guidelines say juvenile detainees are to be visually observed every 15 minutes to ensure their safety. On Sept. 27, staff told a medical-examiner investigator that Rosemary was last seen at 7:43 p.m. and found hanging in her cell 10 minutes later, meaning that within that span of time, she'd covered her cell window, used one sheet to secure her door and a second to hang herself. By the time she was found, she wasn't breathing and had no pulse. Records from Sharp Memorial Hospital indicate that GRF staff told paramedics she'd not been seen for roughly an hour.
Records also show the facility was understaffed that night and when two female officers found Rosemary, they weren't strong enough to support her weight or loosen the sheet from around her neck. An incident report shows that they called for a pair of scissors but were still unable to cut her down, Powell says.
"So, she's still hanging with her body weight while all of this is going on. Finally, a male officer comes in, and he's tall enough and strong enough that he's able to cut her down."
Paramedics got Rosemary's heart beating again, but she'd been without oxygen for too long and was pronounced dead on Sept. 27.
In 2011, the Probation Department recorded only five attempted suicides at the Kearny Mesa facility, including GRF. Attempts doubled to 10 in 2012, then jumped to 24 in 2013. No conclusive explanation was provided to the two main county bodies that oversee juvenile halls—the San Diego County Grand Jury and the Juvenile Justice Commission—although staff suggested it was "due in part to some of the youth in the facilities attempting multiple times."
Both oversight bodies note Rosemary's suicide in their 2013 annual reports, referencing a "detailed review of policies and procedures" and a "newly developed Suicide Watch Protocol." In July, when CityBeat asked to inspect these documents under the California Public Records Act, the county rejected the request—and ignored a second request made on Nov. 20—claiming exemptions usually reserved for drafts of documents.
"[D]isclosure would expose an agency's decision-making process in such a way as to discourage candid discussion within the agency ." county spokesperson Michele Clock wrote. "Therefore, the public's interest in nondisclosure clearly outweighs the public interest in disclosure."
The county did not respond to questions by press time; neither did the head of the Juvenile Justice Commission. Another board tasked with investigating deaths in detention, the Citizens' Law Enforcement Review Board, has not yet issued its findings.
The night Rosemary was found in her cell, it wasn't county staff that notified her mom; it was Rosemary's girlfriend. Chanterelle can only assume that staff called the most recent number in her daughter's call log and not her emergency-contact list. Chanterelle had to track down where her daughter had been taken.
Chanterelle says she'd been told by staff that Rosemary's suicide threats weren't serious—that she was just trying to get moved out of GRF and into the larger juvenile-detention facility.
"It hadn't been expressed to me by any of the staff that she'd ever been really suicidal," she says.
It wasn't until after Rosemary's death that Chanterelle saw the extent to which her daughter was suffering.
"They could have called and let me know there was something going on, reached out to me that she needed somebody," she says. "Nobody reached out to me."