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Inspector General’s Office investigates in-custody suicides with Nebraska Department of Correctional Services

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Inspector General’s Office investigates in-custody suicides with Nebraska Department of Correctional Services


LINCOLN, Neb. (KOLN) – An inspector general is recommending changes in the Nebraska Department of Correctional Services after reviewing three in-custody suicides.

A report released Tuesday details successes and failures made by staff and infrastructure within NDCS in the wake of three suicides between 2021 and 2023. The inmates died by hanging in each incident, but all under different circumstances.

Inspector General Doug Koebernick said in his report that NDCS has spent time looking into suicides in its facilities. A suicide work group had been established in 2018, led by the department’s medical director.

The group made multiple recommendations for the department which include:

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  • Distributing suicide awareness pamphlets to inmates, friends and family
  • Adjusting the staff training manual
  • Streaming a suicide prevention video in all NDCS facilities
  • Using an additional screening tool during transfers and intakes
  • Advertising a phone number that friends and family can call should an inmate make alarming comments

During his investigation, Koebernick found that NDCS only implemented the phone number to report suicidal comments made by inmates. However, the number did not work, and NDCS eventually phased the program out.

A review of three suicides then revealed a handful of policy and infrastructure failures within NDCS that resulted in incomplete investigations. He found that internal critical incident reviews, mandated reports outlining specific details in suicides, were not be sufficiently completed.

Similarly, a mental health team member is required to complete a psychological autopsy following a suicide. Koebernick requested the psychological autopsies in each case, but NDCS did not provide him with any.

Individual A:

The first inmate, identified as Individual A, a 45-year-old man, died by suicide at the Tecumseh State Correctional Institution in 2022. He was serving a life sentence after murdering his cellmate and had been incarcerated for a variety of charges beginning in 2006.

In August, correctional staff found the inmate lying with his left arm hanging off his bed. He had cut himself, and a pool of blood was gathering on the floor. Staff brought him to the medical unit and gave him stitches.

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He told staff that he was not suicidal, but a suicide note that had been tossed in the trash was later found in his room. The inmate was put under “Plan A,” otherwise known as suicide watch, and was given a security blanket, paper clothes and extra supervision.

A few days later, behavioral health staff downgraded his plan before returning him to his regular unit. The inmate had denied any suicidal intent when spoken to by staff.

Staff then found the inmate unresponsive in his cell just 16 days after he cut his wrists with a razor blade, Koebernick wrote. He wrapped a bedsheet around his neck and tied it to the top bunk of his bed. Staff attempted life-saving measures, but the inmate was pronounced dead.

Koebernick reviewed phone call the inmate made in the days before his death, and he discovered that the man had spoken to his mother on several occasions. Five days before his death, the inmate told his mother about his self-harm and indicated that he wanted to die.

The inspector general then interviewed inmates familiar with the man and learned that he may have been abusing K2 and possibly owed another inmate money for the drug. He noted that the review of phone calls and the interviews were not completed in the ICIR.

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Individual B:

In June of 2023, another 45-year-old inmate took his life in a similar manner to Individual A. He had been incarcerated since May of 2023, and his release was expected by the next year.

An emergency response team was activated after the inmate was found unresponsive in his cell one night. He was found face-down with a sheet tied around his neck that had been attached to a locker. Staff performed life-saving measures, but a paramedic with Lincoln Fire and Rescue ultimately pronounced him dead.

Further investigation revealed that not all cameras in the area were operational at the time, eliminating any view of staff outside the cell. Intelligence staff noted the issue a day after the death, Koebernick wrote.

Koebernick discovered that the cameras were not working due to a software update. The cameras should have been working at the time, however, but nobody bothered to check if they were actually functioning.

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Prior to the death, Koebernick check the inmate’s call records and discovered he’d made 99 outgoing calls on the day of his death. He learned that the inmate would regularly call a woman and get into an argument. Only two of the calls connected that day, and both devolved into “a very vocal argument,” Koebernick wrote.

The inmate’s cellmate was interviewed, and he shared a harrowing story from the night of the suicide. Staff woke him up once they found his cellmate unresponsive and yelled at him to untie the bed sheet. But staff burst in and ordered him back to his bed. He was handcuffed as staff performed CPR and later moved to the holding area.

His cellmate’s corpse was then left in the same holding room in full view of the inmate. He asked to be taken out of the room three or four times but was told no each time. After some time, staff returned him to his cell and then transferred him to a new cell the next day.

The inmate reported suffering a breakdown the day after the suicide, and he reported that mental health staff did not contact him despite his suffering.

During the interview, the inmate told Koebernick that his deceased cellmate had been abusing his prescription drugs in the days leading up to his suicide and often stayed up all night.

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Individual C:

Finally, the inspector general’s office investigated the suicide death of a 25-year-old inmate in December of 2021. The man had been incarcerated since 2019, and he was expected to be released in early 2032.

The inmate was not a sex offender at the time of his death, but he was slated to be sentenced for a sex-related offense in federal court the week following his death.

Correctional staff discovered the inmate unresponsive on his bottom bunk early one morning. Like Individual A, Individual C wrapped a bed sheet around his neck and tied it to his top bunk. Chest compressions were attempted, but the inmate was pronounced dead a short time after he was found.

A suicide note showed that the inmate did not want to be a sex offender. The ICIR showed that staff handled the incident well, but the inmate had been checked at “substandard” 30-minute increments.

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Another suicide at Tecumseh’s prison in 2016 involved the use of a bed sheet tied to a top bunk, and the ICIR in this incident recommended staff remove the second bunk and cabinets from the prison’s cells.

In his findings, Koebernick concurred with the ICIR’s recommendation and encouraged NDCS to removed second bunks and cabinets from cells in Tecumseh.

He also wrote that body camera footage from the incidents proved helpful in his investigation, but noted that those cameras aren’t in use at the Reception and Treatment Center which primarily handles cases involving mental health.

He then recommended the following actions for NDCS:

  1. NDCS should review the recommendations from the 2018 suicide work group and determine if a special team should be created to focus on suicides and suicide attempts
  2. The department should review its policy regarding psychological autopsies and whether or not they have been completed or remain necessary
  3. The prison in Tecumseh should remove second bunks and cabinets from its cells
  4. Body cameras should be implemented with staff on each shift’s emergency response team
  5. The ICIR process should be amended to include more investigatory means, including interviewing inmates and reviewing additional information in each incident

Inspector General Koebernick shared his findings with NDCS Director Rob Jeffries on June 10. He concluded his report with Jeffries’ response on June 25.

The director wrote back with the following after signing a policy directive for NDCS:

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“The mental health director/designee will designate a psychologist who is not assigned to the affected facility to complete a psychological autopsy for all suicides and, as he/she deems appropriate for attempted suicides.”

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In a first for Nebraska, federal judge awards attorney’s fees to immigrant who was detained without bond hearing

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In a first for Nebraska, federal judge awards attorney’s fees to immigrant who was detained without bond hearing


For the first time, a federal judge in Nebraska has awarded court costs and attorney’s fees to an immigrant who prevailed in a lawsuit challenging his detention without bond.

Senior U.S. District Court Judge John Gerrard, an appointee of former President Barack Obama, issued the ruling on Tuesday and awarded $1,535.23 to Edgar Eduardo Cadillo Salazar. Gerrard had previously ruled that Salazar’s detention at the Cass County Jail without bond was unconstitutional and ordered the government to provide him with a bond hearing or release him from custody.

Under the federal Equal Access to Justice Act, individuals and businesses that prevail in civil lawsuits against the federal government can file a motion to hold the government liable for attorney’s fees and court costs. Judges can order the government to cover those costs unless they find that the government’s position was “substantially justified,” or if “special circumstances make an award unjust.”

Before last summer, when the Department of Homeland Security revised its longstanding interpretation of statute, only immigrants who were encountered at the border or other ports of entry were subject to mandatory detention. Immigrants encountered after residing in the U.S. were typically subject to discretionary detention and eligible for a bond hearing.

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The new interpretation has led to detention without bond for tens of thousands of immigrants who would have previously been eligible to bond out – and it’s led to an endless stream of wrongful detention lawsuits in Nebraska and around the country. A Reuters investigation found that federal courts have ruled against the mandatory detention policy more than 4,400 times.

In Gerrard’s order granting Salazar’s request for attorney’s fees, he said the government’s position that all undocumented immigrants are ineligible for bond hearings was not substantially justified.

“This ‘new understanding’ of a decades-old statute has resulted in the government detaining hundreds of thousands of nonviolent individuals, often without due process or other constitutional protections,” Gerrard wrote. “It has also sparked thousands of lawsuits where courts have ordered release of those wrongfully detained, for which neither immigration courts nor the Department of Justice have seemed prepared.”

He continued: “The government has not provided any justification, let alone a substantial one, for its radical departure from the historical treatment of noncitizens who entered the United States without inspection. Its arguments rely purely on statutory interpretation; the government apparently expects it can transform an entire area of administrative law because it unilaterally decided that, for thirty years, everyone was wrong about what a statute meant.”

Salazar was later denied bond by an immigration judge and remains in custody, according to his attorney, Alexander Smith.

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Two similar motions were denied last month by U.S. District Court Judge Susan Bazis, an appointee of former President Joe Biden. In both cases, Bazis had ruled in favor of the detained immigrants, and they were later released on bond per her orders. But in her opinions denying attorney’s fees under the EAJA, she found that the government’s position on mandatory detention was “substantially justified.”

“The Court cannot say that the Federal Respondents’ pre-litigation decision to treat [the respondent] as being subject to mandatory detention, while not ultimately correct in this Court’s view, lacked a reasonable basis in law or fact,” Bazis wrote in a footnote of her opinions.

The issue of mandatory detention is currently under consideration by the 8th Circuit Court of Appeals, which covers Nebraska and other Midwest states. In oral arguments last month, the appellate court’s conservative judges appeared friendly to the mandatory detention policy.



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‘Best we’ve played all year.’ Trent Perry scores 20 points as UCLA routs No. 9 Nebraska

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‘Best we’ve played all year.’ Trent Perry scores 20 points as UCLA routs No. 9 Nebraska


The UCLA men’s basketball team made Senior Night one to savor Tuesday, dominating No. 9 Nebraska 72-52 at Pauley Pavilion for its 20th victory of the season and third over a top-10 ranked opponent.

The Bruins improved to 20-10 overall and 12-7 in the Big Ten with one regular season game remaining, Saturday at crosstown rival USC.

Trent Perry scored 20 points, Eric Dailey Jr. had 14 and three players — Tyler Bilodeau, Skyy Clark and Xavier Booker — each added eight points.

“Nebraska’s got a great team,” UCLA coach Mick Cronin said. “This is the best we’ve played all year — they brought out the best in us. We went from our worst defensive effort to our best. They outhustle everyone they play, but not us. Tonight we were great, but I love the way they play. If we had their attitude we’d have their record.”

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Eric Freeny had four points, five rebounds and three steals in 18 minutes for UCLA, which got 26 points in the paint and 17 second-chance points.

“Effort is what it takes to win in March,” Freeny said. “It was our last home game. Coach keeps on pushing me to be better everyday.”

Sam Hoiberg had 12 points to lead Nebraska, but Pryce Sandfort, who began the game leading the conference in three-pointers made per game, was held to nine points.

“Sandford has been unbelievable so to hold him to nine points is amazing,” Cronin said. “Brandon Williams was the unsung hero.”

Williams had six points and three rebounds in 12 minutes off the bench.

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The Bruins were in control from the opening tip-off and never trailed the Cornhuskers (25-5, 14-5). UCLA improved to 10-3 in all-time against Nebraska and the win greatly strengthened its resume for the NCAA tournament as the Bruins also beat then-No. 4 Purdue 69-67 on Jan. 20 and then-No. 10 Illinois 95-94 in overtime on Feb. 21 on Donovan Dent’s layup with one second left.

“We have to take attitude we came with tonight, bottle it up and take it on the road,” Dailey Jr. said. “We’ve got so much left. The season’s not over… we’re only as good as our last game. It’s all about how you respond. I love the fight that we played with tonight.”

This is the fifth time in Cronin’s seven seasons that the Bruins have won 20 or more games. They are 17-1 at home (their only loss in overtime to Indiana on Jan. 31).

“Since I’ve been here we don’t lose much at home.” Cronin said.

UCLA went ahead by 15 points, 37-22, on Perry’s three-pointer with 2:41 left and led 37-24 at intermission. The Bruins shot 50% from the field in the first half (15 for 30) while Nebraska was only 31% (nine for 29).

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The Bruins increased their advantage to 18 points on Dailey’s dunk less than five minutes into the second half and the visitors got no closer than nine the rest of the way.

Prior to pregame introductions the Bruins honored seniors Bilodeau, Dent and Clark; fifth-year player Jamar Brown; redshirt seniors Steven Jamerson II, Jack Seidler and Anthony Peoples Jr; and redshirt junior Evan Manjikian. In a media timeout, midway through the first half, former coach Jim Harrick (who led UCLA to its 11th national championship in 1995) was honored and got a loud ovation.

“I’m happy for our seniors, I didn’t want them to lose their last game at Pauley,” said Perry, who reversed a subpar performance at Minnesota, where he was 0-for-7 from the field with one rebound and one assist in 26 minutes. “I had to come out here tonight and bounce back for my team. I play for something bigger than myself and I’m fortunate to have the type of guys I do around me.”

UCLA guard Skyy Clark looks to pass while under pressure from Nebraska guard Sam Hoiberg and forward Berke Buyuktuncel in the second half.

(William Liang / Associated Press)

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Over the last four games, Dent has 46 assists and just two turnovers.

Bilodeau has scored in double figures in 26 of 28 games played, totaling 20 points or more nine times.

Dailey moved to within five points of reaching the 1,000-career point milestone.

UCLA has now made at least one three-pointer in 887 of 888 games dating to February 2000.

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“We had one practice this week, that’s it,” Cronin said. “We watched film, had a heart-to-heart talk and a shoot around today but that’s it.”



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4.1-magnitude earthquake hits south-central Nebraska

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4.1-magnitude earthquake hits south-central Nebraska


People across Nebraska and Kansas reported feeling an earthquake Sunday afternoon.

According to the U.S. Geological Survey, a quake measuring 4.1 on the Richter Scale struck around 1 p.m. about 3 miles east of the Webster County village of Cowles, which is in south-central Nebraska near the Kansas border.

A quake of that magnitude is considered “light” and not likely to cause damage.

But the USGS received dozens of reports from people who said they felt the quake, some as far away as Omaha and Manhattan, Kansas. Numerous people took to social media to report feeling the quake.

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Two aftershocks of 2.6 magnitude later occurred near the original quake site, one about 90 minutes after the initial quake and one later Sunday night.

Earthquakes are relatively rare in Nebraska, but the state does usually record one or two minor ones per year. The last time Nebraska recorded a quake of a magnitude 4 or above was in December 2023, also in Webster County.



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