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Unlucky Seven

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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."

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