Nebraska
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:
- 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.
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.
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.
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.
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.
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:
- 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
- The department should review its policy regarding psychological autopsies and whether or not they have been completed or remain necessary
- The prison in Tecumseh should remove second bunks and cabinets from its cells
- Body cameras should be implemented with staff on each shift’s emergency response team
- 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:
“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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College Football’s 2026 transfer portal process is in its very early stages. Right now, we’re in the period where teams are losing players into the portal, while hosting visitors they hope to sign and bring in sometime in the next couple of weeks. So pretty much everyone is a net negative at this moment.
With that being the case, the negative impact of the portal for Nebraska so far has been minimal…if you consider losing your former five-star, two-year starting quarterback minimal.
Dylan Raiola is the only Husker of real note to enter the portal thus far. Former starting kicker Tristan Alvano and legacy defensive lineman Maverick Noonan announced early, along with several others. The small number (13 so far) is a win. Several starters and reserve contributors have also confirmed they are staying put, while the reserve players who are leaving are presumably looking for a chance at more playing time and/or a slightly bigger payday.
Next season will be the second year of college football under the NCAA mandated roster limit of 105. Teams will still be allowed to go slightly over that limit to accommodate returning players being “grandfather in.” This exception is for players who have been in their program prior to last season when the rule took effect. It allows them to exhaust their eligibility. Right now, Nebraska still has over 100 players on the roster, so depending on how many players stay and how many more they sign out of the portal, some level of roster reduction will still likely need to take place.
As for who head coach Matt Rhule and his staff are targeting, that list starts with now-former Notre Dame quarterback Kenny Minchey. Minchey lost out on the starting job for the Fighting Irish last preseason and played only sparingly 2025. He’s set to visit Lincoln soon.
With only TJ Lateef returning as a scholarship QB, Rhule will likely need to also bring in a second transfer portal signal caller for depth purposes. Nebraska has not signed a quarterback in it’s 2026 high school recruiting class.
Also targeted and set to visit are several of the defensive players transferring from San Diego State, where new Husker Defensive Coordinator Rob Aurich coached last season. At the top of that list is All-Mountain West Linebacker Owen Chambliss. Chambliss racked up 110 tackles during his Aztec career, plus 9.5 tackles for loss that includes four sacks. He’ll have two years of eligibility remaining. Chambliss was one of six Aztecs to garner All-MW honors last season, and at least two of these former SDSU standouts are set to visit Aurich at his new job site.
Right now, the visitor list is extensive, which is a good thing for Rhule considering the players he’s chasing will all have multiple other offers. When his contract extension was announced back on October 30th, Rhule pointed out that he expected Nebraska to have a good deal more financial resources available to help lure transfers to Lincoln starting this off season. That time has arrived.
Mark Knudson Mark is a former MLB pitcher for the Houston Astros, Milwaukee Brewers and Colorado Rockies. He’s the only person ever to play high school, college and professional baseball in Colorado. Mark earned a BA in Technical Journalism from Colorado State University and has worked in radio, television and print sports media since 1994. He’s the co-author of “Pitching to the Corners” with former teammate Don August and the author of “Just Imagine,” a historical fiction novel about The Beatles.
Mark is currently a feature writer and columnist for Mile High Sports in Denver and recently joined the team at Heavy.com. Mark is also a high school baseball coach in the Denver area. More about Mark Knudson
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The stage is set for Utah and Nebraska to go toe-to-toe in the 2025 Las Vegas Bowl.
The Utes (10-2, 7-2 Big 12) and Cornhuskers (7-5, 4-5 Big Ten) are set to kick off from Allegiant Stadium on Dec. 31 at 1:30 p.m. MT. Fans not making the trip to Las Vegas will be able to tune in via ESPN.
With several bowl game opt-outs and a significant head coaching change headlining the major storylines, here’s what to watch for when Utah and Nebraska take the field on New Year’s Eve.
Morgan Scalley Takes The Wheel
Kyle Whittingham’s expedited takeover in Ann Arbor, Michigan, puts Utah’s longtime defensive coordinator, Morgan Scalley, at the helm of the Utes for the first time as the head coach.
Scalley was previously in charge of the Utah defense for 10 seasons, helping reaffirm the same principles Whittingham established when he was the team’s defensive coordinator; relentless, smart, tough and not prone to giving up a lot of points.
Since 2019, the Utes have held opponents to 15 points or fewer in 36 games, including seven times during the 2025 regular season. Scalley’s defense in 2025 ranked No. 5 in the Football Bowl Subdivision in passing efficiency defense, No. 15 in interceptions (14) and No. 16 in scoring defense, allowing just 18.7 points per game. Utah was No. 2 in the Big 12 in passing yards, allowing 177.5 per game.
It’s safe to assume the transition to Scalley — a Salt Lake City native who’s been on the Utes’ sidelines in some capacity since 2007 — will be seamless for the most part, and that Utah’s defense will continue to be stout as it faces a Nebraska offense that’s being led by a true freshman making his fourth career start. How the Utes as a whole come out of the gate and their intensity and focus on both sides of the ball after the abrupt head coaching switch, will be worth monitoring, though.
Utah’s Bowl Game Opt-Outs
From the sidelines to the field itself, Utah will be without several key figures for its postseason game.
The offensive line, especially, won’t look the same, as both Spencer Fano and Caleb Lomu have opted out of the Las Vegas Bowl while declaring for the 2026 NFL Draft.
It’ll be interesting to monitor how the Utes — who averaged the second-most rushing yards per game (269.8) in the Football Bowl Subdivision in the regular season — function without their two best offensive linemen bookending their front line against a Cornhuskers defense that allowed the third-highest yards per carry average in the Big Ten (4.8).
According to reports, Keith Olsen and Zereoue Williams will fill in for Fano and Lomu along the offensive line. Olsen, a 6-foot-6 junior, started at right tackle for the Kansas game and has allowed one pressure and one hurry in 64 pass blocking opportunities this season, according to Pro Football Focus. Williams, a 6-foot-8 Arizona native, played in all 12 regular season, mainly at left tackle, and recorded 79 total snaps, including 59 on run plays.
As for the other side of the ball, Utah will be down without its main edge rushers in John Henry Daley and Logan Fano. Daley’s absence has been felt since his season-ending injury against Kansas State in November; Logan, meanwhile, recently announced with his brother that he’ll be entering the 2026 NFL Draft.
Utah’s Offensive Play-Calling
First-year offensive coordinator Jason Beck has orchestrated the Utes offense to the tune of 41.1 points per game — the third time since 1930 that Utah averaged over 40 points per game — and 478.6 total yards of offense per game, ranking No. 6 in the Football Bowl Subdivision. He’s been creative, too; from wildcat packages, flea flickers, defensive players lined up at skill positions and designed run plays for both the starting and backup quarterback.
A standalone postseason game to cap off the 2025 campaign will give Beck more opportunities to show what he’s got up his sleeves as a play-caller. And given his name has been attached to the list of assistants Whittingham will reportedly target to join him at Michigan, it’ll be interesting to see how Beck approaches what could be his final game as the Utes’ offensive coordinator.
Not to mention, Utah won’t have its top two tackles leading the way in the run game. If the Utes can’t move the ball with the same consistency they had in the regular season, it’ll be worth monitoring how Beck adjusts.
Will Ryan Davis Play?
Utah’s top receiver wasn’t involved during the home finale against Kansas State and was ruled out for the Kansas game in the days leading up to kickoff. It’s unclear what sort of ailment Davis has been dealing with, though he’d certainly like to be on the field for what will likely be the final college football game of his career.
Davis, a New Mexico transfer who began his career at UAB in 2019, led Utah with 659 receiving yards on 57 receptions, hauling in four touchdowns across 11 regular season appearances.
Nebraska Without Emmett Johnson
The Cornhuskers were middle of the pack in the Big Ten in rushing, averaging 144.7 yards per game during the regular season, due in large part to Emmett Johnson’s success on the ground. The 5-foot-11, 200-pound junior from Minnesota was named the Big Ten Running Back of the Year after totaling 1,451 rushing yards and 12 touchdowns, plus 46 catches for 370 yards and three more touchdowns. His 1,821 scrimmage yards ranked No. 2 in the country.
The Utes won’t have to worry about trying to slow down Nebraska’s dynamic tailback, though, given he’s already declared for the 2026 NFL Draft.
Utah struggled defending the run down the stretch of the regular season, giving up 275.3 rushing yards per game and yielded 7.1 yards per carry in November, including 472 yards on the ground to Kansas State on Nov. 22.
MORE UTAH NEWS & ANALYSIS
The Las Vegas Bowl offers a spotlight for Nebraska players looking to further cement themselves with the current coaching staff or showcase their abilities for future ones, potentially in the transfer portal.
That makes the New Year’s Eve bowl game an important one for a variety of reasons, not the least of which is the Huskers having a chance to end the season on a strong note after back-to-back ugly losses to Penn State and Iowa to close the regular season.
A lot of focus will be on Nebraska’s offense, as the Huskers have plenty of questions about how TJ Lateef plays with more lead time, how they replace All-American running back Emmett Johnson and what offensive coordinator Dana Holgorsen can cook up after an up-and-down season. But some of the most interesting players for the bowl game are on the defensive side, including freshman linebacker Dawson Merritt.
2025 stats
- Eight tackles
- One tackle for loss
What to know
It isn’t a new feeling for Nebraska fans to be excited about seeing a true freshman linebacker get more opportunities in a bowl game. Just a year ago, Vincent Shavers was in the same spot Merritt is now and turned in a strong performance during the Pinstripe Bowl. Merritt has had plenty of time to get healthy and to learn more of what Rob Dvoracek wants. Could that put him in a position to play more in Las Vegas?
What’s at stake
Merritt could go a long way in helping fans and coaches feel better about a linebacker room that wasn’t Nebraska’s biggest problem, but was far from the level of play the Huskers received in Matt Rhule’s first two seasons.
Merritt has shown himself to be an intriguing player who has flashed when he’s been in games, but clearly also needs more time and more reps to fully become the player he was recruited to be after the Huskers flipped him from Alabama last fall.
Merritt’s bowl game and expected ascension make for an interesting picture at linebacker. The Huskers have to see what the portal holds, both in terms of linebackers leaving and the need to add veterans for depth, as players like Merritt, Christian Jones and others continue to grow and develop.
Spotlight series
- Opportunity Knocks for TJ Lateef in Las Vegas Bowl
- Nyziah Hunter’s Chance to Reassert Himself As Top Receiver
More From Nebraska On SI
Stay up to date on all things Huskers by bookmarking Nebraska Cornhuskers On SI, subscribing to HuskerMax on YouTube, and visiting HuskerMax.com daily.
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