Unlucky Seven

Faced with an unprecedented rash of inmate suicides, St. Louis was slow to respond. Now there's a new jailhouse boss in town.

As in other cases, jailers knew that Reeves had psychological problems. He denied any suicidal thoughts when he was booked on Feb. 28, 2000, but asked to see a psychologist a week later, saying he was unable to sleep and occasionally confused. He admitted that he had tried to kill himself the previous summer with a drug overdose. He also said he'd been treated for paranoia at a mental hospital and had been on psychotropic medication until a few months before his arrest. He was seen by the jail's psychologist and the staff psychiatrist. In April, a doctor prescribed trazadone, an antidepressant often used to combat insomnia. On June 8, the same doctor prescribed Zoloft, another antidepressant. But Reeves didn't get his Zoloft for 11 days. Jail records show he had to file a grievance before receiving the drug on June 19.

Jail investigators described Zoloft as a "mild antidepressant." Pfizer, the manufacturer, says the drug is used to treat major depressive disorders that interfere with daily functioning. It should be used, according to the manufacturer, if the patient's depression lasts for at least two weeks. Zoloft is also used to treat obsessive-compulsive disorder, panic disorder and post-traumatic stress disorder. Because depression is associated with all those conditions, the manufacturer warns that any patient prescribed Zoloft should be given the smallest possible dose to guard against suicide.

In a report written three weeks after Reeves' death, investigators with the Department of Public Safety stated the obvious: There were no belt cutters in the area, and too much time passed before Reeves was cut down, investigators wrote. Understaffing was also a problem, investigators said. There were just four guards on duty that night to cover four housing pods, each containing 56 inmates, and no supervisor was assigned to the pod in which Reeves took his life. They recommended that administrators review policies dictating when guards can enter a cell in an emergency. Investigators also noted the lack of CPR training among staff members.

Jennifer Silverberg
Guards on break at the St. Louis Medium Security Institution, 7600 Hall St.
Jennifer Silverberg
Guards on break at the St. Louis Medium Security Institution, 7600 Hall St.


Hanging oneself from a towel hook is a powerful statement on determination. A towel hook is not mounted high enough to permit full suspension of the body, and so the inmates who killed themselves that way were all found with their feet on the floor. Until they lost consciousness from lack of oxygen, they could have stood up and saved their own lives.

Given such strength of will, it's impossible to say whether inmates would have killed themselves even if the workhouse had top-notch medical treatment, state-of-the-art suicide-prevention policies and housing units devoid of towel hooks and sprinkler heads. "If somebody wants to hang themselves, they will find something, whether they tear up the sheets or blankets or whatever," says Frank Susman, a prominent local lawyer who represented inmates in a case that ended in April of last year, smack in the middle of the suicide spree. "If you want to leave them nude and leave them with nothing to hang themselves with and they sleep on a cold steel cot, you can probably prevent them. Or you can have a suicide watch where they're watched 24 hours a day. As a practical matter, you can't prevent them if someone's intent on doing it."

Even so, Susman says, the lack of CPR training, delays in cutting down inmates and other lapses documented in investigative reports are unacceptable. "I think those things are inexcusable," he says. "I see no reason why every correctional officer shouldn't know basic CPR. First of all, it's a basic course that the Red Cross gives for four hours, if nothing else." He also criticizes delays in calling the fire department. "That also sounds totally inexcusable," he says. "It's not like they don't have phones. The only explanation that would be justified -- and it isn't -- is that there's only one correctional officer, and if it's a choice between calling and administering CPR on the spot, he will administer CPR. But that's not the case. There's always somebody available to make a call while you're working on the guy -- always. "

Prompt help from paramedics is only part of the problem, notes Susman, who looked into the suicide spate before the federal court case ended. "The response time is not the answer, by any stretch," he says. "It's two or three parts. No. 1, it's not checking often enough. Most of the breakdown occurs because they do not perform the watches as they indicate." In investigative reports, guards typically say they checked inmates regularly and as often as every 20 minutes. Susman suggests that checks be frequent but not predictable. "If somebody knows it's every 15 minutes, they're going to wait," he says. "You have to break those up a little."

After 18 years of representing inmates, Susman isn't surprised by the problems described in the investigative reports. "Do I find this shocking and unusual?" he says. "No. Shocking, but not unusual."

Petty, the corrections officer, says he can't explain why the workhouse and jail had so many suicides in such a short time span. He does say some changes have been made. Administrators have made sure that every jailer has been trained in CPR. Belt cutters are easily accessible today, he says, and everyone knows where to find them. All towel hooks have been removed from cells, and garden-variety sprinkler heads have been replaced with heads designed to prevent suicides. The workhouse has also updated its suicide screening so that new inmates are questioned more closely, particularly by staff members with medical expertise. Inmates newly convicted of crimes carrying long sentences are now automatically placed on suicide watch. Guards have received more training in how to spot suicidal behavior. The jail has also begun training select inmates in suicide prevention and paying them to monitor fellow prisoners and report any signs of trouble to guards.

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