Jail Policy Ignored in Inmate’s Hanging

Jail policy ignored in inmate’s hanging
By Tracie Simer
The Jackson Sun (TN)
January 7, 2012

Madison County jail employees consistently failed to follow policy for the frequency of inmate safety checks before Jonathan Lee Carter hanged himself on Dec. 20, according to logs released by the Sheriff’s Office on Friday.

Carter was on suicide watch in a cell by himself when he was found hanging from the sprinkler system just after 10 p.m. Dec. 20. Sheriff David Woolfork has said that inmates on suicide watch are to be checked every 15 to 30 minutes.

But logs released Friday show that more than 30 minutes passed between checks on Carter nine times after about 11 a.m. on the day he died. Someone had not checked on Carter in more than two hours when he was found hanging in his cell, according to the logs.

Woolfork said no policy changes are needed in the jail for suicide watch check-ins if deputies follow the 15-minute to 30-minute window. Some changes might take place, but not necessarily as a result of Carter’s death, he said.

“From time to time, we look at policies,” he said. “We look and see what policies may need tweaking. We’ll continue to do that.”

He said the department may look at making a more clear distinction between what it means to be on isolation watch and suicide watch.

Woolfork said he does not plan to require additional training for corrections officers as a result of what happened.

Lindsay Hayes is project director for the National Center on Institutions and Alternatives, which provides training on how to prevent inmate suicides. He said he hopes Woolfork will be open to a change in policy about suicide checks in light of Carter’s death. He said 30 minutes is too long of a gap between checks.

“There’s no such thing as a 30-minute level of observation,” he said. “It’s a complete disconnect to believe you can prevent a suicide in 30 minutes. That provides ample opportunity for inmates to kill themselves. That’s not an acceptable level of care.”

He said that a 15-minute level is acceptable under two conditions: If the checks are staggered so suicidal inmates can’t anticipate the next check; and if the inmate’s cell is suicide-resistant.

The fact that two shifts reflected in the jail logs had several violations of the 30-minute level of observation seems to indicate a systemic problem in the department, Hayes said.

“This was not one or two officers on a shift not doing their job,” he said. “If in fact it’s happening on other shifts, this is a larger problem than one or two officers.”

Hayes suggested that the department revise its policy to ensure no checks go beyond 15 minutes and that the staff is trained to understand “it is their responsibility to ensure the safety of inmates identified as suicidal,” and it “won’t be tolerated that officers are allowed to go for long periods of time without observations,” he said.

Woolfork said he does not plan to discipline three deputies who, according to the logs, monitored Carter from about 11 a.m. to 4 p.m. Those officers waited more than 30 minutes between checks on Carter six times. Those gaps ranged from 33 minutes to 44 minutes, according to the logs.

Woolfork said he was concerned about those gaps but noted that there were also gaps as little as five minutes in between checks by those officers.

Two other deputies who monitored Carter from 4 p.m. until his death had two gaps of more than an hour between checks and did their last check on him at 7:40 p.m., more than two hours and 20 minutes before he was found hanging in his cell. Those deputies, Tamara Taylor and Josh Hogg, have been suspended with pay during an internal investigation into the matter.

Action is being pursued against Taylor and Hogg because the gaps were much wider in between checks on their shift, Woolfork said.

“It appeared, in our opinion, it was a blatant disregard for the individual,” he said.

A disciplinary hearing for both deputies is scheduled for 2 p.m. Wednesday. Neither Taylor or Hogg could be reached for comment Friday afternoon.

The Jackson Sun obtained the jail logs through a request under the state’s public records law. Woolfork had previously refused to release the logs, saying they were part of an ongoing internal investigation and were, therefore, not public. But the law does not allow for such an exclusion in the release of records.

According to the department’s personnel files, Hogg was hired as a corrections officer in September 2007. In March 2008, he asked to be transferred from the jail to the patrol division. Several similar requests are in his file.

In November 2008, he was disciplined because a pocketknife was found in his office at the jail. His punishment was to re-read his jail procedures manual and sign a form saying he did.

Taylor was hired as a corrections officer in December 2000, according to her personnel file. Taylor has several requests in her file to be moved from the jail to any available position. In August 2002, she violated policy by letting an unauthorized person into the secure area of the jail, according to her file.

Taylor also has been disciplined for misuse of sick time, according to the file. She was required to bring a doctor’s note after future sick days for a period of six months after each incident, according to the file.

In a November 2005 letter to the sheriff, Taylor asked to be transferred from the jail because she was suffering from numerous “stalph (sic) infections” from poor conditions at the jail. She said in her letter that she felt she had served her time and hoped to move upward in her career with the department.
Jail death: ‘I can’t take it anymore,’ inmate wrote in transfer request before hanging
By Lauren Foreman
The Jackson Sun (TN)
December 29, 2011

Click here to read the article or read it below.

Johnathan Lee Carter begged officials to transfer him to state prison the day before authorities say he killed himself in the Madison County jail. “I can’t take being in p.c. [protective custody] no longer,” he said in an inmate request form on Dec. 20. “… I fell (sic.) like I’m going to hurt myself … I can’t take it anymore.”

The next day jailers found Carter, 24, hanging from the sprinkler system in the ceiling of his isolation cell, where he had been on suicide watch. Carter used a piece of cloth from a protective jacket to hang himself with, Sheriff David Woolfork said. Carter used a toilet and sink, which are connected, to reach the sprinkler, Woolfork said.

“It’s sad,’ he said. “But he made the decision to kill himself.”

An expert on preventing inmate suicides said, however, that an inmate on suicide watch should not be able to take his life if the proper measures are in place.

Woolfork said Carter was in a cell by himself before being placed on suicide watch. He said prisoners are sometimes placed in cells by themselves when they are not compatible with other inmates, but he did not believe that was the case with Carter. He said he was not aware of any previous problems with Carter or of him being harassed.

Woolfork said it is not uncommon for inmates to request transfers from the county jail to state prison because they have more freedom and may know more people in state prison. But Woolfork said he has never known the lack of a transfer to drive someone to kill himself.

A preliminary autopsy report confirmed suicide by strangulation as Carter’s cause of death. A final autopsy report has not been issued.

The Tennessee Bureau of Investigation has ruled out foul play in Carter’s death, and Woolfork said an internal investigation should be completed early next week.

Woolfork has said Carter had been sentenced to 10 years with the Tennessee Department of Correction. He was in Madison County Circuit Court on charges of aggravated robbery and failure to appear this month.

Woolfork has said that an aunt of Carter’s told him that Carter had been a member of the Gangsters Disciples on and off since he was a teenager. But Tracey Carter-Myles, Carter’s mother, said she had never known her son to be in a gang.

Carter-Myles said her son was trying to turn his life around. He read the Bible more and planned to get married, she said.

“I don’t think it really hit me till I saw his body at the funeral home that he was gone,” Carter-Myles said.

She said she and her husband, David Myles, had just gone to bed when Carter’s girlfriend called with the news that Carter had died. Carter-Myles said she screamed and yelled in disbelief. “He really was a good boy,” she said.

Carter was from Huntingdon and had four daughters: Olivia, 6, Riley, 5, Kileigha, 3, and 3-month-old Adasion Carter, his mother said. She described her son as a talented basketball player.

One of four siblings, he grew up in church and had an instinctively protective nature, his mother said. He would not allow anyone to speak negatively of his mother, brothers and sisters, she said.

“Lot of people thought I didn’t really care anything about my kids,” she said. “They really don’t know how close me and my kids were. We’ve been here for each other.”

Lindsay Hayes is project director for the National Center on Institutions and Alternatives, which provides training on how to prevent inmate suicides. He said an inmate should not be able to hang himself from a sprinkler head because jails should use heads with a 20- to 30-pound weight limit.

“An inmate on suicide watch should never be successful in committing suicide,” he said.

Hayes said there are generally two levels of suicide watch: Constant supervision, in which an officer monitors an inmate 24 hours a day, and close observation, when officials should check the inmate at least every 15 minutes but stagger the time periods so inmates cannot predict the monitoring frequency.

Hayes said upon strangulation by hanging, a person loses consciousness within the first one or two minutes and incurs brain damage within three minutes to five minutes. After 10 minutes to 15 minutes, a person cannot survive, he said.

Sheriff Woolfork said workers check inmates on suicide watch every 15 minutes even though local policy dictates checks must occur in 30-minute intervals. Woolfork declined to provide records showing when checks were made on Carter because they are part of his department’s internal investigation.

Woolfork said that in his experience, when a person decides he wants to commit suicide, there is not much anyone can do to stop him.

Hayes said that mindset prevails among many jail administrators, but his research has proven otherwise.

The rate of suicide has decreased from 107 per 100,000 inmates to 38 per 100,000 inmates since the 1980s, which means suicides can be prevented, Hayes said.

If jails have proper staff training, proper policies and procedures, qualified mental health staffing, and a safe environment to house inmates, suicides are less likely, he said.

“No one on suicide watch should ever be able to commit suicide,” Hayes said.



January 4, 2011. Two Madison County sheriff’s deputies have been suspended as the investigation into the death of a jail inmate continues.