By Sam Levin
By Jessica Lussenhop
By RFT Staff
By Keegan Hamilton
By Gavin Cleaver
By Sam Levin
By Sam Levin
By Sam Levin
Investigators identified several problems.
Livacoli had hanged himself from a towel hook that was designed to prevent suicides -- a cam mechanism is supposed to cause the hook to collapse when force is applied. But the state investigators found that the hook had been installed upside down, rendering the cam useless. The improperly installed hook had been there for nearly three years. The state's examination of Livacoli's suicide also underscored the lack of medical expertise in the workhouse. Jailers almost immediately took Livacoli down after he was found hanging at 9:20 p.m., but no one started CPR until a nurse arrived six minutes later. The state found that two of the three jailers in charge of the unit, including a corrections officer and a lieutenant, had never received CPR training. The guard who did know CPR told investigators that he froze from the shock of seeing Livacoli hanging. He added that he wasn't aware of any policy stating he should have begun CPR, although the workhouse's policy for suicide prevention and response states, "Staff will begin first aid and/or CPR until the arrival of the medical staff or paramedics."
There was also a delay in getting expert medical help. Fire-department paramedics weren't called until 9:45 p.m. -- 25 minutes after Livacoli was found hanging -- and didn't arrive at the workhouse until 10:05 p.m., according to state investigators and jail records. An inmate in a nearby cell told the state investigator that he heard a guard ask a lieutenant three or four times whether he should call for an ambulance. Livacoli may have been dead when he was discovered, or maybe not. A nurse reported that he vomited during CPR, but she couldn't detect a pulse, his skin was cool to the touch and his pupils were fixed and dilated. Jail records show he was last seen alive 20 minutes before he was discovered hanging.
Before he killed himself, Livacoli showed signs of psychological problems, according to state investigative reports. Livacoli wasn't a violent criminal -- he'd been incarcerated the previous June for failure to pay child support. After three months in the workhouse, he began a hunger strike. It's not clear when he ended his strike, but his distress obviously got worse. On Oct. 28, he submitted a request to see a social worker, writing, "I asking you please get me out of here today. I can't stand it no more. I'm about to do something very wrong so please get me out." There is no record that anyone responded to that written request.
Livacoli was clearly agitated on the day he died. He had had a hearing that day and was certain the judge would free him, but he was ordered back to the workhouse, dashing his hope of going home for Christmas. When he returned to his cell, he was yelling and argued with another inmate, which was completely out of character, according to an inmate interviewed by a homicide detective. The day after Livacoli died, the jail psychologist who'd been on the job for two months told investigators that he'd never received a referral regarding Livacoli and that there was no information in his files indicating the former psychologist had seen him.
The state investigator exonerated the staff, stating, "This investigation has been unable to identify any culpable negligence on the part of the St. Louis City Medium Security Institution or any of its agents." Williams, the union representative, laughs at that conclusion. "That's a government agency," she says. "They do that for each other." As far as Williams is concerned, jail administrators have been slow to address issues -- in particular, low staffing levels and inadequate training -- that she believes have contributed to the suicides.
The Livacoli case marked the beginning of disturbing patterns in the city's response to suicides. 'Suicide-proof' towel hooks helped at least two more workhouse inmates kill themselves before the hooks -- and fire-sprinkler heads that offered convenient anchors for makeshift nooses -- were finally removed sometime in the spring or summer of 2000. Subsequent suicides also revealed gaps in CPR training for guards that persisted even after a half-dozen inmates hanged themselves. Despite a suicide rate that reached nearly one per month, guards still scrambled for tools to free hanging inmates. And there were substantial delays in calling the fire department when inmates were found hanging.
Five weeks after Livacoli's death, Donald Theis hanged himself in jail while awaiting trial on sodomy charges. Theis had just returned to his cell after a visit with his girlfriend, who told him their relationship was over. When Theis returned to his cell at 7 p.m. Jan. 28, 2000, he asked to talk to a guard. The guard told him he was going on break but promised to have a long conversation with him when he returned. He never got the chance.
Theis was fine when a different guard checked his cell at 7:05 p.m. He was hanging from a bedsheet tied to a ceiling vent when she walked past his cell again a few minutes later. A jailer detected a faint pulse after guards untied the sheet and laid Theis on the floor. A nurse arrived almost immediately and started CPR. Theis was pronounced dead at 7:59 p.m. after being brought to St. Louis University Hospital.
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