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· Dangerous housing conditions. Although they weren't identified as suicide risks, four of the five inmates who killed themselves in the months before Hayes' report were in housing units designed for suicidal prisoners. Those cells in the workhouse pre-max unit included vents, bars and hooks that made convenient anchors for makeshift nooses. Inmates deemed suicidal were routinely stripped of their clothing and placed in the cells, contrary to widely accepted standards that say suicidal inmates should not be placed in isolation unless absolutely necessary, Hayes wrote. After the fourth suicide, male inmates at risk of suicide were placed in less dangerous, but hardly ideal, housing areas -- the cells included black curtains over door windows, making it difficult to monitor inmates. Female prisoners identified as suicidal were still placed in the pre-max unit, which Hayes called "grossly inadequate for housing suicidal inmates."

In addition, Hayes found that first-aid kits were missing latex gloves, protective shields for mouth-to-mouth resuscitation and other basic lifesaving equipment. There were no tools in the housing units that could be used to cut down hanging inmates. Noting that guards had trouble freeing three hanging inmates, Hayes wrote that specially designed cutting tools that could not be used as weapons cost as little as $7.30 and should be placed in all units along with first-aid kits. The kits should be regularly inspected, and the workhouse should conduct suicide drills to ensure the staff knows how to respond to suicides, he wrote. Contrary to national standards, at least one guard assigned to each housing unit is not certified in first aid or CPR, Hayes found. "This writer found that the DOC had grossly inadequate practices regarding intervention measures following discovery of a suicide attempt," he wrote.

Hayes also recommended that the city remove supposedly suicide-proof clothing or towel hooks that two inmates had used to hang themselves -- the city had already removed, inspected and then reinstalled the hooks. But problems lingered after Hayes put the city on notice. Six weeks after Hayes submitted his findings, guards couldn't quickly free Michael Reeves when he hanged himself because no cutting tool was available. In Reeves' case, guards also hadn't been trained to perform CPR and had to wait for paramedics. Corrections officials in October assured RFT that all hooks have been removed, cutting tools are readily available and every guard in the workhouse has received CPR training.

· Poor monitoring. Although all inmates are supposed to be checked every 15 minutes, that wasn't the case, Hayes found. Log sheets showed that checks were routinely made every 20 or 30 minutes, and 15-minute checks are "grossly inadequate for acutely suicidal inmates," he wrote. Hayes found no written documentation that required checks had actually been performed. "In fact, one correctional officer told this writer that he 'tries to see an inmate on suicide watch every 15 minutes or so,'" Hayes wrote. "This practice is also grossly inadequate and increases the agency's liability by not being able to demonstrate in writing that an inmate is being properly observed. Suicidal inmates should be observed commensurate with their behavior, not the availability of staff."

Dora Schriro, hired as the city's corrections commissioner in October, says Hayes' report was balanced and "quite thorough." The city is now rewriting its suicide prevention and response policy, she adds.

"This is beyond regular," she says of the pending policy revision. "I felt that I had a good enough working knowledge that there were some changes that needed to be made and I felt they were important enough that I didn't want to wait for an annual review."

Already Schriro has ordered workhouse staff to screen inmates when they return from court to identify any who may be at risk for suicide. All first-aid kits were inspected shortly after she arrived, and she has issued orders that all kits be inspected on a daily basis to make sure they're properly equipped. She's planning a drill to make sure guards know how to respond to suicides. She also made sure all housing units had functioning televisions for the Thanksgiving holiday -- TVs help reduce isolation, she explains. And she plans to allow contact visits in time for Christmas. As it stands, glass windows separate inmates from visitors.

"That would give people something to look forward to, indeed, to live for," she says. "While I can't do much immediately about overcrowding, there were things I could do to reduce the idleness."

Former public-safety director Martie Aboussie says he thinks the city is making progress. Aboussie, who was replaced when Francis Slay became mayor earlier this year, says he repeatedly told former Mayor Clarence Harmon that the city needed a new corrections commissioner before work was completed on the new jail, which is scheduled to open next year.

"I said numerous times to the administration, 'We are not prepared to run that new jail with the people who have operated it," Aboussie says.

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