Last weekend, August 1-4, 2019, coroner Graham Hetrick, the star and host of the TV series, THE CORONER: I SPEAK FOR THE DEAD, served as special guest speaker at MurderCon in Raleigh, N.C.

During his talks, Hetrick detailed low-hanging suicides committed by a victim who ties a rope, cloth, twisted garbage bag, shoestring, belt, or other material, to a doorknob, bed post, etc., and then places the other end—a loop—around the neck. The victim then, with practically unbelievable willpower, simply leans forward to tighten the “noose” around the neck thereby shutting off the oxygen supply to the brain. The end result is, of course, death. All without the body dropping from a platform, chair, ceiling beam, etc.

In this type of suicide by hanging, the person committing the act must overcome the body’s forceful urges to live. They must resist ripping the ligature from their body in order to take another breath—to ignore the begging and pleading of the lungs, demanding that the brain immediately intervene.

These people often have a very strong desire to die, and they do. Maybe not on the first attempt, but kill themselves they do, eventually. Somehow, someway. Others, however, use a suicide attempt to escape intense emotional pain, not necessarily to die.

Was it possible that Hetrick had some sort of premonition? After all, he’s quite the insightful man.

Whatever brought the coroner to discuss this sort of suicide tactic remains to be seen but, ironically, it was a mere few days later when 66-year-old Jeffrey Epstein committed suicide in the protective housing unit, 9 South, at the Metropolitan Correctional Center (MCC), a federal prison in Lower Manhattan, And he did so in the precise manner detailed by Hetrick.

Back in the day, during my time as a state corrections officer, when working in the segregation units we were required to make rounds every 30 minutes, 15 if the prisoner was on suicide watch. We took that a step further by stationing an officer outside the suicide watch cells.

During the course of those 30 minute rounds in segregation it was mandatory to sign and timestamp a logbook positioned at each block of cells. The log station was in a location where each cell was clearly visible to the officer. The logbook was attached to a podium and could only be removed by a watch commander.

We were required to make verbal contact with each inmate. In return, they were to respond to the officers questions. We were required to see and make note of signs of life, meaning the inmate must move, sit, stand (speak) or, if asleep, we were to observe the chest rise and fall normally. If not, we were to wake the inmate. They were not permitted to sleep with blankets covering their heads.

Things Could Go South in a Hurry!

One night, while making my rounds in the segregation unit, I found a young inmate hanging by the neck from a bedsheet attached to a steel bedrail that was no more than three or four feet from the concrete floor. He’d simply tied the sheet around the steel rail and leaned forward until his airway became constricted.

I saw him the moment I rounded the corner. His facial skin was beginning to turn a slight grayish hue. His eyes were open and and slightly bulging and his tongue protruded from between his lips just a bit, much like a thirsty dog’s tongue. It had only been 15 minutes or so when I last passed by his cell. We’d even exchanged a few words of small talk on my last round. He’d seemed fine.

I used my radio to call for help and for control to unlock the cell door. I managed to raise the man’s body to the bed and then released the sheet from his neck. Medical staff arrived and took control. The inmate survived the suicide attempt. All of this took place within minutes. Mere minutes.

Suicide attempts in jails and prisons across the U.S. are not uncommon and those who try often succeed.

In one U.S. jail alone, the county lockup in Traverse County, Mi., there were 51 attempted suicides and two suicides during the years between 2011 and 2018. Marilyn Lucille Palmer and Alan Bradley Halloway hanged themselves in the shower sections of their cells. They accomplished the task by attaching nooses to small openings in the steel walls. These two deaths occurred nearly ten years apart, to the day.

Bedsheets are a common instrument used in inmate hangings. So much so that jail officials in Cleveland, Ohio have eliminated bedsheets from all cells housing inmates at risk of suicide. In lieu of sheets they’re issued an extra blanket. The decision to replace sheets with the thicker and tougher-to-tear blankets came after five prisoners committed suicide, including Nicholas Colbert, who hanged himself in the military veteran’s pod section of the jail.

In North Carolina, a record 12 inmates died by suicide, in 2018, while in state custody. This is compared to six inmate suicides in 2017 and seven in 2016. To help tackle the problem of inmate suicides, the state is recruiting prisoners who will watch over other inmates who are considered suicide risks. Each the selected prisoners will receive specialized training and take notes every 15 minutes during their assigned shifts. If trouble should arise they’ll hen call for staff members. The same policy is already in place at the federal level (see below).

Epstein’s Death Was More Than Likely Just As It Seems, a Suicide

As much as folks from all spectrums of the conspiracy theory trail would like to believe, prison suicides occur far more often than the public generally hears about. They’re not reported by the media because they don’t involve high-profile prisoners, like Jeffrey Epstein. Nor do those suicide cases come at a time when the death conveniently saves the day for a lot of high-profile politicians, businesspeople, etc. (Please, I’m begging you to not turn this into a political discussion or debate. I’m merely reporting fact, not opinion).

Unfortunately for Epstein and his family, and for the victims who wanted to face him in a court of law and to see him rot in a prison cell for life, it seems that the corrections facility staff dropped the ball due to staffing shortages, rules that weren’t followed, unreliable and unprofessional officers, and a perfect storm of other issues that could’ve gone unnoticed during a typical day in prison, if the deceased had not been connected to high-profile folks.

The Metropolitan Correctional Center’s website issues an Admission and Orientation manual for pre-trial inmates. Jeffrey Epstein was one of those pre-trial prisoners. The first paragraph of page five of the manual is dedicated to inmate suicide prevention. It reads:

“It is not uncommon for people to experience depression and hopelessness while in jail or prison, particularly if they are newly incarcerated, are serving a long sentence, are experiencing family problems or problems getting along with other inmates, or receive bad news. Sometimes, inmates consider committing suicide due to all of the pressure they are under. Staff are trained to monitor inmates for signs of suicide, and are trained to refer all concerns to the Psychology Department. However, staff do not always see what inmates see. Ifyou are personally experiencing any ofthe problems noted above, or you or another inmate are showing signs of depression (sadness, tearfulness, lack ofenjoyment in usual activities), withdrawal (staying away from others, reducing phone calls and/or visits), or hopelessness (giving away possessions, stating that “there is nothing to live for”), PLEASE alert a staff member right away. Your input can save a life.”

Finally, in case you’d like to learn more about the BOP’s policies on suicide watches …

From the Federal Bureau of Prisons (BOP)

OPI: CPD/PSBNUMBER: P5324.08DATE: 4/5/2007

SUBJECT: Suicide Prevention Program

RULES EFFECTIVE: 3/15/2007

SUICIDE WATCH

  1. Housing. Each institution must have one or more rooms designated specifically for housing an inmate on suicide watch. The designated room must allow staff to maintain adequate control of the inmate without compromising the ability to observe and protect the inmate.
  • The primary concern in designating a room for suicide watch must be the ability to observe, protect, and maintain adequate control of the inmate.
  • The room must permit easy access, privacy, and unobstructed vision of the inmate at all times.
  • The suicide prevention room may not have fixtures or architectural features that would easily allow self-injury.
  • Inmates on watch will be placed in the institution’s designated
  • suicide prevention room, a non-administrative
  • detention/segregation cell ordinarily located in the health
  • services area.  Despite the cell’s location, the inmate will not
  • be admitted as an in-patient unless there are medical indications
  • that would necessitate immediate hospitalization.
  • Placement of a suicide watch room in a different area may be
  • warranted given the unique features of some institutions.

However, designating a room for suicide watch outside of the Health Services area requires written approval of the Regional Director.  Such rooms must meet all of the requirements identified above.

Administrative detention and disciplinary segregation cells will not be designated or approved as suicide watch cells. Under emergency conditions a suicidal inmate may be placed temporarily on suicide watch in a cell other than the institution’s designated watch room. The inmate must be moved to a designated suicide watch room as soon as one becomes available.

  1. Conditions of Confinement. While on suicide watch, the inmate’s conditions of confinement will be the least restrictive available to ensure control and safety. The inmate on watch will ordinarily be seen by the Program Coordinator on at least a daily basis. Unit staff will have frequent contact with the inmate while he/she is on watch. Ordinarily, the Program Coordinator or designee will interview or monitor each inmate on suicide watch at least daily and record clinical notes following each visit.

The Program Coordinator or designee will specify the type of personal property, bedding, clothing, magazines, that may be allowed.

  • If approved by the Warden, restraints may be applied if necessary to obtain greater control, but their use must be clearly documented and supported.
  • Any deviations from prescribed suicide watch conditions may be made only with the Program Coordinator’s concurrence.
  • The Program Coordinator will develop local procedures to ensure timely notification to the inmate’s Unit Manager when a suicide watch is initiated and terminated. Correctional Services staff, in consultation with the Program Coordinator or designee, will be responsible for the inmate’s daily custodial care, cell, and routine activities.
  • Unit Management staff in consultation with the Program Coordinator will continue to be responsive to routine needs while the inmate is on suicide watch.
  1. Observation. For all suicide watches:
    • Any visual observation techniques used to monitor the suicide companion program will focus on the inmate companion and/or the inmate on suicide watch only.
    • The observer and the suicidal inmate will not be in the same room/cell and will have a locked door between them.
    • The person performing the suicide watch must have a means to summon help immediately (e.g., phone, radio) if the inmate displays any suicidal or unusual behavior.
    • The Program Coordinator will establish procedures for documenting observations of the inmate’s behavior in a Suicide Watch log book, which will be maintained as a secure document. Staff and inmate observers will document in separate log books. Post Orders will provide direction to staff on requirements for documentation.
  • Staff Observers. The suicide watch may be conducted using staff observers. Staff assigned to a suicide watch must have received training (Introduction to Correctional Techniques or in AT) and must review and sign the Post Orders before starting the watch. The Program Coordinator will review the Post Orders annually to ensure their accuracy.
  • Inmate Observers. Only the Warden may authorize the use of inmate observers (inmate companion program). The authorization for the use of inmate companions is to be made by the Warden on a case-by-case basis. If the Warden authorizes a companion program, the Program Coordinator will be responsible for the selection, training, assignment, and removal of individual companions. Inmates selected as companions are considered to be on an institution work assignment when they are on their scheduled shift and shall receive performance pay for time spent monitoring a potentially suicidal inmate.
  1. Watch Termination and Post-Watch Report. Based upon clinical findings, the Program Coordinator or designee will:

1) Remove the inmate from suicide watch when the inmate is no longer at imminent risk for suicide, or

2) Arrange for the inmate’s transfer to a medical referral center or contract health care facility.

Once an inmate has been placed on watch, the watch may not be terminated, under any circumstance, without the Program Coordinator or designee performing a face-to-face evaluation. Only the Program Coordinator will have the authority to remove an inmate from suicide watch. Generally, the post-watch report should be completed in PDS prior to terminating the watch, or as soon as possible following watch termination, to ensure appropriate continuity of care. Copies of the report will be forwarded to the central file, medical record, psychology file, and the Warden. There should be a clear description of the resolution of the crisis and guidelines for follow-up care.

At a minimum, the post-watch report will include:

  • risk factors assessed,
  • changes in risk factors since the onset of watch,
  • reasons for removal from watch, and
  • follow-up recommendations.
  1. INMATE OBSERVERS – INMATE COMPANION PROGRAM.
  2. Selection of Inmate Observers. Because of the very sensitive nature of such assignments, the selection of inmate observers requires considerable care. To provide round-the-clock observation of potentially suicidal inmates, a sufficient number of observers should be trained, and alternate candidates should be available.

Observers will be selected based upon their ability to perform the specific task but also for their reputation within the institution. In the Program Coordinator’s judgement, they must be mature, reliable individuals who have credibility with both staff and inmates. They must be able, in the Program Coordinator’s judgement, to protect the suicidal inmate’s privacy from other inmates, while being accepted in the role by staff. Finally, in the Program Coordinator’s judgement, they must be able to perform their duties with minimal need for direct supervision.

In addition, any inmate who is selected as a companion must not:

  • Be in pre-trial status or a contractual boarder;
  • Have been found to have committed a 100-level prohibited act within the last three years; or
  • Be in FRP, GED, or Drug Ed Refuse status.
  1. Inmate Observer Shifts. Observers ordinarily will work a four-hour shift. Except under unusual circumstances, observers will not work longer than one five-hour shift in any 24-hour period. Inmate observers will receive performance pay for time on watch.
  2. Training Inmate Observers. Each observer will receive at least four hours of initial training before being assigned to a suicide watch observer shift. Each observer will also receive at least four hours of training semiannually. Each training session will review policy requirements and instruct the inmates on their duties and responsibilities during a suicide watch, including:
  • the location of suicide watch areas;
  • summoning staff during all shifts;
  • recognizing behavioral signs of stress or agitation; and
  • recording observations in the suicide watch log.
  1. Meetings with Program Coordinator. Observers will meet at least quarterly with the Program Coordinator or designee to review procedures, discuss issues, and supplement training. After inmates have served as observers, the Program Coordinator or designee will debrief them, individually or in groups, to discuss their experiences and make program changes, if necessary.
  2. Records. The Program Coordinator will maintain a file containing:
  • An agreement of understanding and expectations signed by each inmate observer;
  • Documentation of attendance and topics discussed at training meetings;
  • Lists of inmates available to serve as observers, which will be available to Correctional Services personnel during non-regular working hours; and
  • Verification of pay for those who have performed watches.
  1. Supervision of Inmate Observer During a Suicide Watch. Although observers will be selected on the basis of their emotional stability, maturity, and responsibility, they still require some level of staff supervision while performing a suicide watch.
  • This supervision will be provided by staff who are in the immediate area of the suicide watch room or who have continuous video observation of the inmate observer.
  • In all cases, when an inmate observer alerts staff to an emergency situation, staff must immediately respond to the suicide watch room and take necessary action to prevent the inmate on watch from incurring debilitating injury or death. In no case will an inmate observer be assigned to a watch without adequate provisions for staff supervision or without the ability to obtain immediate staff assistance.
  •           THE DECISION TO USE INMATE OBSERVERS MUST BE PREDICATED
  •           ON THE FACT THAT IT TAKES ONLY THREE TO FOUR MINUTES
  •           FOR MANY SUICIDE DEATHS TO OCCUR.

Supervision must consist of at least 60-minute checks conducted in-person. Staff will initial the chronological log upon conducting checks.


Again, please, I’m begging you to not turn this into a political discussion or debate. I’m merely reporting fact, not opinion. Thank you.

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