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Unlucky Seven

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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.

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