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.

Even before they got the call, Loretta and Willis Lloyd suspected something was wrong.

Their son Lee Daniel Lloyd had phoned his mother every day since being incarcerated at the St. Louis Medium Security Institution on Oct. 18, 1999 -- even today, she smiles at the memory of the phone bills. But Lee -- Danny, to his parents -- didn't call his mother or other relatives on Feb. 20, 2000. When Loretta went to the workhouse, 7600 Hall St., that day during visiting hours, she was told her son wasn't allowed to see anyone. No one told her why.

Her son had been in jail before, and Loretta made sure his jailers knew he had problems aside from legal ones. Lloyd, 34, had bipolar disorder, diagnosed about five years earlier at a Columbia, Mo., mental-health facility after a scrape with the law involving drugs, his parents say. When he was booked at the workhouse, he told medical screeners he was under a physician's care and had been on medication until two months before his arrest. His parents say he did well when he took Depakote, a mood stabilizer commonly prescribed to control manic episodes in people with bipolar disorder. Otherwise, he was prone to mood swings, going from upbeat and excited to depressed.

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.
JoAnn Williams: "I don't call it the workhouse anymore. I call it the crazy house."
Jennifer Silverberg
JoAnn Williams: "I don't call it the workhouse anymore. I call it the crazy house."
Frank Susman says he's not surprised by the problems uncovered by investigators: "It's shocking but not unusual."
Jennifer Silverberg
Frank Susman says he's not surprised by the problems uncovered by investigators: "It's shocking but not unusual."
Dora Schriro: "There's no place like home. I really love this work."
Jennifer Silverberg
Dora Schriro: "There's no place like home. I really love this work."

While on Depakote, Lloyd could hold a job, usually working as a laborer. "He never worked a job he couldn't go back to, and everyone liked him," his mother says. When he went off his medication, he was prone to crack binges. That only made matters worse. His parents believe a cocaine craving sparked the burglary spree that landed him in the workhouse. Lloyd was accused of breaking into 10 homes to steal mountain bikes, jewelry and computers, and his bail was set at $210,000. "He would do anything to try to not use drugs," his mother recalls. "He had tried to commit suicide because of the drugs."

Jail records and the Lloyds agree on at least one thing: Lee Lloyd had trouble getting Depakote and mental-health services in the workhouse. In mid-November, a nurse noted that his prescription was running low. By early December, Lloyd was complaining to his mother about not getting his medication and writing queries to jailers, asking to speak to someone about the problem. On Dec. 7, a nurse asked that a jail psychologist and psychiatrist evaluate Lloyd, who was almost out of his prescription, according to records. Loretta Lloyd says the situation was more serious than that. She says her son wasn't getting any drugs at all, and she had to take a supply from home down to the workhouse. She says her son told her the prescription got through. That she was allowed to get drugs to her son surprises her. "Why would they even let me give him medication from the outside?" she asks.

Investigative records don't mention that incident, but they do say Loretta Lloyd called the jail on Dec. 9 and told a captain that her son wasn't getting his medication and was threatening suicide. Loretta Lloyd says the files are wrong: Her son didn't threaten to kill himself at that time, but she acknowledges that he had been suicidal before his incarceration. The captain promised that her son would see a doctor soon. Four days later, a psychologist saw Lloyd and reported that he showed no suicidal signs. He was then allowed to call his mother, who also spoke with the doctor and told him that her son functioned well on Depakote. "He said, 'We'll take care of him,'" Loretta Lloyd recalls.

On Jan. 26, 2000, Lloyd asked to see a psychologist as soon as possible. It's not clear from jail records whether anyone responded, but a subsequent request for help on Feb. 16 wasn't granted. That wasn't uncommon, Loretta Lloyd says. "He asked to see him [the psychologist] a lot of times," she recalls. "He had written up a lot of requests to see him."

Four days after his last plea for a psychologist went unanswered, Lloyd began showing signs of breakdown. At 5:40 a.m. that Sunday, he got in an argument with another inmate, prompting jailers to move him to another housing area for his own safety. At dinner, he started throwing food trays. He told a guard he was angry because other inmates had been talking about his mother. Lloyd was ordered back to his dorm. When he got there, he discovered someone had stolen all the food he'd purchased from the commissary. While discussing the theft with a guard, he again began arguing with other inmates and was transferred to the pre-max unit, again for his own safety. The unit houses disruptive inmates, who are put in solitary cells, where they're supposed to be checked every 20 minutes. After his arrival, Lloyd complained to other inmates about not being allowed to use the telephone. "He was talking in a loud manner and sounded like he was very mad," a police detective later noted in a report of an interview with an inmate in a nearby cell.

At 8:34 a.m. the next morning, jailers found Lloyd hanging from a torn bedsheet tied to a ceiling vent. The knots were too tight to untie, and so jailers struggled to hold up Lloyd, who weighed 293 pounds, until a nurse arrived with a pair of scissors seven minutes later.

By then, it was far too late. Rigor mortis had set in, investigators reported; the medical examiner's office estimated Lloyd had been dead for approximately 90 minutes. Nonetheless, a jail nurse and a guard continued cardiopulmonary-resuscitation efforts until fire-department paramedics, who were called about the same time Lloyd was cut down, arrived at 8:50 a.m. After 11 minutes of trying, they realized they couldn't save him.

Robert House, the corrections officer assigned to make rounds, insisted that he'd checked the cell every 15 or 20 minutes in the two hours before Lloyd was found hanging, making his last check just 11 minutes before the suicide was discovered. Jail officials concluded that House was lying and had falsified records showing he had made mandatory security checks. Administrators tried to fire him, but he successfully appealed disciplinary action and is still employed as a correctional officer in the workhouse. The union retained a pathologist to dispute the medical examiner's opinion that Lloyd had been dead for more than an hour before he was found, and that made the difference at a civil-service hearing, says JoAnn Williams, business representative for Carpenters Local 795, the jailers' union. "We were sort of like the O.J. trial," she says. "We had dueling pathologists."

Williams dismisses any notion that Lloyd's death wasn't promptly discovered. "You explain to me, why would anyone perform CPR on someone in an advanced state of rigor mortis?" she asks. Jail policy, however, mandates that CPR be administered immediately and continued until the arrival of paramedics, regardless of the victim's condition.

There was more bad news when the toxicology report came back. "It was their autopsy report, and it said not even an aspirin was in his system," says Willis Lloyd, Lee's father. "Everyone knew he was supposed to be on medication. You'd think that even if people are locked up, they're supposed to be in a protected environment."

Loretta Lloyd says her son had complained for two weeks before his death that he wasn't getting his Depakote. Without the drug, Lloyd had trouble sleeping. The Lloyds believe their son would still be alive if guards had noticed his insomnia and gotten him medication and prompt psychological help. Loretta Lloyd also wonders whether her son would have killed himself if he'd been permitted to speak with her or visit the day before he died.

Before her son died, Loretta Lloyd says, jailers assured her that he was getting his drugs. "They lied," she says. In search of answers, the Lloyds met with Department of Public Safety officials shortly after their son's death. The parents walked away convinced that the workhouse staff hadn't done everything they could have to keep their son safe. "Something is wrong down there," Loretta Lloyd recalls telling one of the officials. "And he said, 'Yes, there is something wrong down here.'"


Lee Lloyd was the third workhouse inmate to hang himself in the span of four months. During the same period, an inmate hanged himself at the city jail, which was also run by the city's Department of Public Safety. The jail, which was located at 124 South 14th St., shut down in January 2000 to allow construction of a new facility on the same site, but the workhouse remains open. In the five months after Lloyd died, three more workhouse inmates hanged themselves, bringing the total to seven suicides in the city's corrections system in nine months.

By any measure, it's an off-the-charts suicide rate. By comparison, St. Louis County reported 10 jail suicides during all of the 1990s. National statistics are spotty, but a 1988 study funded by the National Institute of Corrections showed 107 suicides for every 100,000 inmates incarcerated in local jails, or slightly more than one suicide for every 1,000 inmates on an annual basis. More recently, a Corrections Compendium magazine survey of 86 jails with a combined average daily population of 68,781 inmates found that 27 inmates killed themselves in 1992 -- the highest number was at a Nevada lockup, which reported four suicides that year. On any given day, fewer than 2,000 inmates are confined in St. Louis Department of Public Safety detention facilities.

A review of investigative reports prepared by the city after each suicide shows that jailers kept making the same mistakes: Guards didn't know how to perform CPR. No tools were available with which to cut down hanging inmates. Inmates with mental problems had trouble getting psychotropic drugs and attention from psychologists or psychiatrists. And jailers were slow to call the fire department when inmates were found hanging.

The spate of suicides began on Oct. 4, 1999, when Tyrone McCullough hanged himself by tying a bedsheet to an air duct. Although an emergency physician questioned whether McCullough's injuries were consistent with suicide [Laura Higgins, "Case Closed," Dec. 15, 1999], police and the city medical examiner concluded otherwise. It seemed an isolated incident, the first suicide in the city workhouse for as far back as anyone could remember.

Then John Livacoli hanged himself with a sheet tied to a towel hook in his workhouse cell on Dec. 20, 1999. This time, the city called in investigators with the Missouri Department of Corrections. According to jail records, the state was summoned because several years had gone by without any suicides. Now, there had been two within three months.

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.

Judging from investigative records, the jail's initial response was quick: Less than five minutes passed before Theis was found, and first aid was prompt. However, fire-department paramedics weren't called until 7:23 p.m., about 15 minutes after Theis was discovered hanging. Paramedics arrived at 7:27 p.m. The fire department says it doesn't keep dispatch times for calls before Dec. 22, 1999, but available records show that jailers routinely waited five minutes or longer after discovering hanging inmates before calling the fire department. Bruce Petty, executive assistant to the commissioner of corrections, says he can't explain the delays.

Lloyd was the next to die. Then, two weeks later, on March 4, Edward Harris hanged himself in the workhouse the day after being convicted of murder, which carried a mandatory life-without-parole sentence. Again, jailers weren't prepared.

The day before Harris died, a guard saw him weeping after finishing a phone call. Knowing that Harris was facing life in prison, the guard asked him whether he was OK, even going so far as to offer him pamphlets on suicide prevention. Harris declined the offer. "I'm cool; that's the last thing I'll think about doing," he said. The guard reported that Harris later joked and laughed while playing basketball. That evening, an inmate also asked Harris how he was doing. "I'll be all right," Harris answered. "God has a place for me."

The guard assigned to Harris' housing unit the day he died wasn't aware of the pending prison sentence but later reported that Harris seemed fine. Indeed, he asked for an extra helping when the guard handed out food trays about 12:30 p.m. Other inmates, however, sensed that the conviction lay heavy on Harris' mind. Shortly after noon, an inmate told police that he had shown Harris a story about his conviction from that morning's St. Louis Post-Dispatch. After reading the article, the inmate told detectives, Harris went into his cell and sat on the toilet. The inmate said he could see beads of sweat forming on Harris' head.

An inmate received no answer when he knocked on the door of Harris' cell at 12:55 p.m. and asked whether he was asleep. About five minutes later, a guard found him hanging from a torn bedsheet tied to a towel hook. Jailers had trouble freeing Harris from his makeshift noose. While some guards struggled to hold him up, others tried unsuccessfully to untie the knots. There was nothing available with which to cut the sheet, and so Harris hung for approximately 15 minutes before someone finally used a cigarette lighter to burn through the fabric.

Quentin Davis, who was awaiting trial on murder charges, was the next to die. Neither guards nor paramedics attempted first aid. There was little point. By the time Davis, 21, was found hanging from a torn sheet attached to a towel hook at 7:18 a.m. June 23, 2000, his body was cool to the touch and stiff with rigor mortis. Police homicide detectives determined that Davis had used part of a ballpoint pen to push the torn sheet behind the supposedly suicide-proof towel hook.

Tony Gooch, the corrections officer assigned to make rounds in Harris' housing unit during the graveyard shift, told investigators he'd made required security checks of each cell in his assigned area, but at least three inmates reported that Gooch had made a bed by pulling chairs together near the beginning of his shift and napped through most of the night. Gooch resigned three days after Davis died, before being brought up on formal dereliction-of-duty charges.

Although Davis' workhouse file showed no history of suicide attempts or suicidal thoughts, other inmates told investigators he had shown signs of psychological breakdown. He had served 45 days in solitary confinement for an attempted escape in January and had told another inmate that the only way he was getting out of the workhouse was through escape or in a body bag. One inmate who spoke with him frequently reported that Davis had no visitors and no money for commissary and had told him that he felt as if everything was closing in on him. His court case wasn't going well, the inmate said, and he feared the prospect of execution or life in prison. Another inmate said Davis had been depressed since a visit with his attorney a few days before he committed suicide. A third inmate told investigators that Davis had been fascinated by a magazine article about suicide by hanging, repeatedly asking to see the story, which included several pictures showing how people hang themselves.

Michael Reeves, who was being held on charges of assault and armed criminal action, killed himself on July 10, 2000. By now, it was a familiar story: A guard found Reeves hanging from a torn bedsheet tied to a fire-sprinkler head in his cell. Reeves was standing at the door of his cell, looking out, when the officer checked on him at 3:15 a.m. Twenty minutes later, he was hanging and blue in the face. The guard did not immediately enter the cell. Rather, he called for backup and waited for the arrival of two more officers before unlocking the door and cutting Reeves down. Once again, no cutting tool was available in the housing unit -- officers had to retrieve a pair of belt cutters from a supervisor's office. Once again, paramedics weren't immediately summoned -- fire-department and jail records show that paramedics were called about 10 minutes after Reeves was found hanging. Jail records show that paramedics arrived at 3:55 a.m.; fire department records say paramedics arrived at 3:49 a.m. In any case, Reeves didn't receive CPR until the fire department got there. Once again, two of the three jailers who rushed to Reeves' cell didn't have proper CPR training. One had never received training, and another's certification had expired in 1998. Records don't reveal why a third officer whose training was up to date didn't initiate CPR.

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.


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.

"We are being more concerned with those mental problems associated with suicide, such as signs of anxiety, signs of depression," Petty says. "All of these things are being looked for in ways that might not have been looked for or were not prioritized prior to the rash of suicides." Petty isn't quite sure when the changes were made. "I would say that all of the practices went into effect sometime after the second suicide," he says. "I think we were putting things in place continuously."

That's not how Williams sees it. She says efforts to train guards in suicide prevention and response didn't start until September of last year, when guards picketed the workhouse to call attention to working conditions they believed were unsafe. By then, seven inmates had killed themselves. "There was no suicide-prevention policy at the time we picketed," she says. "Now, I can't say it wasn't developed and sitting on someone's desk, but it had not been distributed to correctional officers. It didn't take a rocket scientist to figure out something was wrong. The whole place is crazy. I don't call it the workhouse anymore. I just call it the crazy house." Noting that the workhouse population swelled when inmates from the now-closed city jail were transferred there, she says the lockup is understaffed to the point that prevention policies get short shrift. "They're too busy putting out fires to engage in preventive measures," she says.

Estimating that about 25 percent of the city's inmates have some kind of mental-health problem, Petty says there's no way of knowing whether any of the deaths could have been averted had new suicide-prevention and response measures been instituted earlier. He won't discuss cases such as Lloyd's and Reeves', in which inmates with documented mental-health problems were placed alone in cells with the means to commit suicide. "The main thing, I think, we have to realize is, with respect to all the suicides, there was no indication of problems with the inmates," he says.

Three days after Petty spoke with the Riverfront Times, the city hired a new commissioner to oversee the its corrections system. The former commissioner, Alice Pollard-Buckingham, was demoted to detention superintendent.


Dora Schriro's first day as corrections commissioner came with an unpleasant surprise. When she arrived at her City Hall office on Oct. 22, there was a brand-new suicide report on her desk. This time, the dead workhouse inmate was Bryan Williams, 30, who was facing charges of rape, sodomy and kidnapping and three counts of armed criminal action. He was found in the early morning hours the previous day. So far, jail administrators aren't releasing much other information, except to say he died of asphyxiation.

JoAnn Williams says the inmate somehow managed to choke himself to death in his cell by tying a torn sheet or some other material around his neck and wrists. He may have been dead for more than an hour before he was found, she says, because guards were not present in the housing area -- they'd been sent elsewhere in the workhouse to supervise other prisoners. Inmate suicide monitors in the unit were no help because they were locked in their cells while guards were absent, she adds. Schriro, however, says round sheets show that Williams was checked at 1:38 a.m., just 15 minutes before the suicide was discovered.

Bryan Williams' death "was the very first thing I learned of when I walked in the door," Schriro says. "Obviously it's commanded a lot of my attention in the past week." A 4-inch-thick stack of model suicide policies and reports on the previous deaths sits on her desk. She spends her first weekend as commissioner reading through the documents, first scrutinizing investigative reports on the seven previous deaths, then comparing St. Louis' suicide prevention and response policy to national standards developed by the American Correctional Association, the American Jail Association and the National Commission on Correctional Health Care. The workhouse suicide policy was updated in July 2000 after the city consulted with the state and the National Institute of Corrections, but, in light of Williams' death, Schriro plans to take yet another look. "I want to double back," she says.

By Monday, Schriro has found room for improvement. Eight days after Williams killed himself, she orders that all inmates returning from court be screened to determine whether they're suicidal. The goal is to identify inmates who may become suicidal in reaction to adverse court proceedings. Previously, inmates were formally screened only at initial booking. "We're doing a re-intake each time they come back from court," Schriro says. In addition, jailers last week began updating suicide-watch lists at least every eight hours to ensure that supervisors have the latest information on inmates deemed suicide risks. More changes are likely, Schriro adds.

Schriro has plenty of experience running jails and prisons. She was the workhouse superintendent from 1989-93, leaving that job to become director of the state Department of Corrections. Gov. Bob Holden replaced her in May, five months after he took office. Since then, she's been a finalist to head state prison systems in Idaho and Texas. If she's disappointed she didn't get those jobs, she doesn't show it. "I tell you, there's no place like home," she says. "I really love this work." Her experience shows during a recent visit to the workhouse. Just four days into her new job, inmates and staff alike call out greetings as she walks the corridors. "Ms. Schriro, come on in and visit us," hollers one inmate from a dayroom enclosed in steel bars. The familiarity is a function of Schriro's years spent in corrections and the frequency of her visits to the workhouse during her first days on the job. "It's pretty unusual, a commissioner here three times in one week," she says.

JoAnn Williams, who has represented jailers since 1986, is skeptical that Schriro will make a difference. "She's left and returned, and the condition of the facility is the same," she says.

Ed Bushmeyer, who took over as the city's public-safety director after Francis Slay became mayor, says he talked to Schriro about the suicides before hiring her. "He's very concerned," Schriro says. "We're both really committed to protecting the [inmate] population, as well as the staff." Besides suicides, Schriro is worried about a certain security problem in the workhouse, which she says she won't identify, at least until the problem is solved. Reducing the inmate population is also on her agenda. "The challenge is to earn public trust and maintain it over the long haul," she says.

But Schriro and other city officials will have to work hard to win the Lloyd's trust.

"I'm not money-hungry or whatever, but I think people don't change unless you start making them pay financially," Loretta Lloyd says. "I'm going to pursue it. For my child and other people's children, you can't treat them like that, even though they've done things to be incarcerated."

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