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:

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:

“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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