Why have jail suicides soared under Sheriff Ortiz's watch?

Why have jail suicides soared under Sheriff Ortiz's watch?
Chuck Kerr

Robert Rodriguez's behavior grew increasingly erratic his final days in lockup this summer. Arrested days before on misdemeanor drug and trespass charges, Rodriguez, 29, began to fear inmates and guards in his unit were out to hurt him. "[Floor sergeant] believes the inmate is mental," noted one detention guard's report. In the middle of the night, Rodriguez would wake up in a panic screaming, "Go ahead and kick my ass, get it over with."

Although he was detoxing off Klonopin — a prescription drug used to treat both seizure and panic disorders — when he entered the jail, Rodriguez was more than once cleared by jail mental health staff and sent to general population, according to facility records. But detention officers had their reservations. "Inmate seems to be mental and has a hard time grasping his situation of being in jail," one guard wrote.

Requesting protective custody, Rodriguez wrote on June 23, 2012, that he suffered major anxiety, problems with "mind and body," and that he wasn't getting his regular doses of Xanax, another prescription drug used to treat panic disorders. Three days later jail officials approved his transfer, but he became combative when they asked him to trade his orange jumpsuit for the red one worn by protective custody inmates. The red jumpsuit meant a transfer to state prison, he insisted. An emergency response team was called in to subdue Rodriguez and force him into protective-custody reds.

The next morning, staff took Rodriguez to the jail's infirmary for his regular dialysis treatment. Rodriguez broke down. In the middle of his treatment, he ripped the two needles from his arm. "I need help," he cried. "I really fucked up this time. There's no help for me."

As he wandered back to his cell, Rodriguez continued to cry. "I need help. The past is haunting me."

A half hour later in his cell Rodriguez stabbed a plastic spoon into his dialysis shunt and bled to death.

Rodriguez is just the latest in a stream of suicides that have plagued the Bexar County Adult Detention Center since 2009, the year Sheriff Amadeo Ortiz took office and assumed control of the jail, county government's single largest expenditure. During that time 14 out of 25 of the facility's in-custody deaths, well over half, have been from inmate suicide. Many of those who took their own lives were awaiting trial on charges ranging from minor misdemeanors, such as Rodriguez, to murder.

Despite his bizarre behavior, Rodriguez was never placed on suicide watch. Documents obtained from the county through open records requests over the past year document the suicides of detainees who asked for help, who threatened suicide to other inmates in their units, or who pleaded for physical protection from guards and other inmates.

So far in 2012, two jail inmates have taken their own lives, a sign, Ortiz insists, that changes made under his watch are starting to work.

Up until 2009, suicides were rare at the Bexar County jail. More common were inmates dying from natural causes, like liver failure or complications from lung cancer. But during Ortiz's first year as sheriff, suicides at the facility shot to an all-time high — all of 2009's five in-custody deaths were suicides by hanging. Another inmate outsourced to a Crystal City jail because of intense overcrowding in Bexar County also took his life that year.

Management of the jail and public spats over the appropriate level of detention staffing between sheriff and county officials has grown to define Ortiz's re-election fight this year as he faces retired Air Force Maj. Gen. Susan Pamerleau, who continues to hammer Ortiz for alleged mismanagement of the facility.

Ortiz has claimed the staffing crunch has forced detention officers to work overtime, even sometimes back-to-back eight-hour shifts. Bexar County Jail Administrator Mark Thomas says about 10 officers quit every month. At one point this summer, 14 left in less than two weeks. Ortiz insists that inmate suicide is a problem his staff has little control over, but allows that fatigue could play a role, saying, "It's a known fact that if an officer has to be in a cell block for 16 hours straight, he's not going to be as alert at the end of that shift."

Compared to other large jails, Bexar County's numbers stand out. Bexar County's jail population, the third largest in Texas at about 3,800 inmates, is dwarfed by the state's two largest jails, some 2,400 prisoners below Dallas County's jail population and over 5,000 inmates shy of Harris County's. But of Dallas County's 39 in-custody deaths since 2009, only four were suicide. Four of Harris County's 74 in-custody deaths during that period were suicide.

"There's no excuse," says Ana Yáñez-Correa with the Texas Criminal Justice Coalition, which has worked closely with Bexar County commissioners, particularly Tommy Adkisson, to greatly reduce the local jail population in recent years. "Texans cycle through the local jails every year," she said, "and let's not forget many of these people haven't yet been convicted of anything. … What is the culture inside that jail? How is suicidal behavior being handled? I mean, even one suicide is way too many."


A study Bexar County commissioned in 2003 projected that by this year the jail would regularly house some 4,800 inmates and that the jail would need more space and more money. Necessity being the mother of invention, over the past three years county officials have begun to prioritize jail diversion over warehousing. While the average daily inmate population in Bexar County was 4,600 for June 2009, according to county figures, it dropped sharply in June 2010 to 4,100. In June 2011, population was down again at about 3,800. This past June, the jail saw lows of 3,500 inmates. The population as of September 1, 2012 was back up to 3,800.

This summer when the Texas House County Affairs Committee held a hearing to highlight issues facing county jails, Bexar County Judicial Services Director Mike Lozito testified to the local successes of pre-trial diversion keeping people out of lockup. But Lozito also noted a concerning trend. While the jail population had gone down overall, demand for mental health beds had shot up, he said. "Even though our jail population has gone down almost a thousand, our mental health beds are going up, they're increasing," he said. Officials began to notice that mentally ill inmates were cycling through the jail so frequently, it became apparent they were using the jail as their primary source for mental health care, Lozito said.

"Our jail is essentially another mental health facility," Joel Janssen, president of the Bexar County Deputy Sheriff's Association, the union representing jail guards, told the Current earlier this month, a symptom of the state's dismal funding of mental health care. "We're dealing with a different class of inmates than when I started 30 years ago, I can tell you that for sure."

Martha Rodriguez, head of Detention Health Care System, a wing of University Health System that provides health care inside the jail, echoed the sentiment, calling the jail "another state hospital, like a mini state hospital."

That can play a role in how many potentially suicidal inmates pass through the lockup, she said. In 2009, UHS' suicide prevention log showed inmates expressed suicidal thoughts 769 times, Rodriguez said. That number jumped to 1,071 in 2010. There were 1,038 entries to the suicide prevention log in 2011. As of this month, 2012 has seen 785 entries.

UHS did not answer specific questions regarding the suicide of Robert Rodriguez, or why he wasn't flagged for mental health or suicide precautions.

The U.S. Department of Justice's Bureau of Justice Statistics sought in 2007 to track suicide in jails across the country. It found the rates were typically higher in jails holding 50 or fewer inmates, with a rate of 167 per 100,000. With less population, each suicide would pack a greater punch, statistically speaking.

But in the nation's largest jails (Bexar County was among the 20 largest jail jurisdictions for the study) the average suicide rate tended to be around 27 per 100,000 inmates. That means, statistically speaking, Bexar County shouldn't see more than one suicide a year. Bexar County was right at the national average for the period between 2000 through 2007, that report shows. While the jail had no suicides in 2008, by 2009 local inmates were taking their own lives in record numbers.

Included were two inmates whose families went on to sue the county. One, Jonathan Ramirez, was a 19-year-old epileptic transferred to county jail from a juvenile facility. After fighting constantly with guards and other inmates, Ramirez threatened to kill himself. But mental health professionals at the jail deemed he wasn't suicidal and returned Ramirez to his unit, where he eventually hung himself.

A judge last year dismissed the lawsuit, brought by Ramirez's father, because his parental rights were terminated in 2004. With the statute of limitations up, another family member couldn't re-file.

The family of Harlan McVea, who hung himself in his cell in 2009 while going through acute heroin withdrawal, also sued. But that lawsuit, along with two others against the county for wrongful deaths, was dropped this summer. All were represented by the law firm of Isabel De La Riva and Associates.

"Bexar county had been just incredibly uncooperative with everything. The parties had to weigh whether being involved with this for, potentially several years, was what they really wanted to do," said Chuck Goldman, a legal investigator with the lawfirm.

"So much of what the county does, they do behind closed doors. And when people like this family come to ask questions about how this happened, why it happened, can it be prevented, they're stonewalled," De La Riva attorney Jesse Hernandez told the Current earlier this year. The county, he contends, hid behind a veil of privacy on each case, failing to give the families any information. "And it leaves them no choice but to come to folks like us and to file a lawsuit just to get the basic courtesies of finding out what happened to their loved ones," he said. "We don't know where the system failed these folks, and that's the problem. … We have to file a lawsuit just to find out what went wrong and how it could have been avoided."


Joe Anthony Lopez, 26, was the jail's first suicide of 2010, found hanging by a towel in his cell during a routine inspection just after 11 p.m. on February 23. Lopez had been in jail for over a year awaiting trial on arson charges. A month before his suicide, the jail passed its annual inspection with no deficiencies. But records from the jail show Lopez had been in off-and-on fights with other inmates throughout his time in lockup. One cellmate, he told a guard a year before his death, continued to beat and harass him. In May 2009, Lopez walked into an officers station with a bloody nose, saying he'd been beaten by two inmates in his unit. The next month guards were called out to Lopez's cell. They found him crouched on the floor as another inmate beat him. Lopez didn't fight back, one guard noted in his report.

In January 2010, a month before his death, Lopez complained again to staff that he feared for his safety. A review of the log books reveal a detention officer failed to do his last round of checks before leaving the night Lopez died — the sheriff's office later fired the guard for the infraction. When the relieving guard started his first round of Lopez's unit, he found the cell window covered with cardboard. After three knocks and no answer, he noticed a foul odor coming from inside. When the cell opened, the guard found Lopez slumped next to the sink, a towel wrapped around his neck. Lopez's death occurred just weeks before Sheriff Ortiz brought in outside help to evaluate the jail's suicide precautions.

Nationally recognized suicide prevention expert Lindsay Hayes delivered a blistering report to the county in April 2010, documenting a long list of failures on the part of both UHS and the sheriff's detention staff in recognizing at-risk inmates. He offered a long list of recommendations to reduce the risk of suicide — some but not all of those recommendations have been implemented. Since Hayes' visit eight more inmates have taken their lives at the jail.

Jail and medical staff had the proper screening tools, they just weren't using them, Hayes wrote at the time. He called the Suicide Prevention Unit at the jail a "misnomer," saying the 10-cell unit only occasionally housed inmates on suicide precautions, and that other than two detention officers and a medical staff, there were not any "appreciably enhanced services."

"It would appear that the jail system has an unexplained tolerance for potentially suicidal behavior that has resulted in the under-utilization of the Suicide Prevention Unit, as well as other units, for the housing of suicidal inmates," Hayes wrote.

The most disturbing findings had to do with the jail failing to follow its own written procedures. According to policy, jailers aren't supposed to take away suicidal inmates' personal items unless the inmate is aggressive toward others or themselves. In practice, suicidal inmates were and are routinely stripped, put in "safety smocks," also called "pickle" suits, without undergarments, and confined in isolation cells for 24-hour stretches. That kind of confinement "only enhances isolation and is anti-therapeutic," Hayes wrote.

Maybe that's why those smocked inmates spent so little time on suicide watch — an average of 24 hours, "considerably less than this writer's experience in consulting with other correctional facilities throughout the country," Hayes wrote. He worried suicidal inmates could be lying about a change of attitude simply to get de-smocked.

Bexar County Jail Administrator Mark Thomas and Sheriff Ortiz, in an interview last week, both pointed to a new Special Observation Unit in the jail's basement to house suicidal inmates. It's an open bay environment with some 30 cots where inmates are in close proximity, all under constant staff supervision. But when the Current toured the unit last week, it was empty. Jail staff says it has yet to be used.

Detention staff wasn't getting annual suicide prevention training back when Hayes visited. Two years later, they're still not. On a two-year training cycle, Ortiz says officers take the suicide prevention course every other year. Officers are also set to take a prison rape elimination course next year, something that will include more suicide prevention training, Thomas said.

UHS says it implemented an annual, comprehensive 3-hour mandatory suicide prevention course for all its staff working in the jail.

Hayes also noted problems with the jail's booking area, saying stations used in booking to complete the mental health and suicide forms were "noisy and lack sufficient privacy to ask sensitive questions regarding a detainee's health care status." When Hayes observed the jail, one detention officer walked in and interrupted the mental health screening on one inmate so he could complete a form he didn't finish in booking. Thomas and UHS insisted staff has worked hard to make the booking and screening processes more private.

Numerous times during Hayes' observation nurses didn't ask about anxiety or mental problems, history of victimization, or other standard questions on the jail's form to screen for mental illness and suicidal behavior. In fact, two inmates who committed suicide in 2009 didn't even get psychiatric screenings, he found.

Hayes wrote that inmates give off certain signs that could foretell a possible suicide, even if they don't come out and say it. They may even deny being suicidal. He recommended a daily mental health shift report be distributed to all the appropriate detention, medical, and mental health personnel within the jail — another recommendation that hasn't yet been followed.

Just after Hayes' report, a guard on rounds found Nicholas William Tucker, 22, hanging from a bed sheet inside his cell just after 11 p.m. on May 28, 2010. He'd been arrested two days earlier on assault charges related to a fight he'd had with his girlfriend, according to his family. Tucker told intake officers he was going through heroin and methadone withdrawal, and that it had been hours since he last used, a lawsuit his family filed against the county states. Tucker also "verbalized suicidal ideation," the suit says. Despite jail records noting Tucker's well-established history of depression and drug addition, guards took no special precautions.

The morning after Tucker's suicide, one inmate in Tucker's unit approached a detention officer, saying he heard Tucker arguing on the phone in the unit's dayroom, just before dinner, according to jail records recently released to the Current. Tucker threatened to kill himself if he couldn't get out of lockup, the inmate said.

Though the officer noted in his report someone would conduct a follow-up interview with the inmate about what he heard, there's no indication from documents provided to the Current that the interview ever took place.

Tucker's family declined to comment on the suicide or the lawsuit.

Then on November 28, 2010, a deputy making rounds found Mark Montoya, 22, kneeling next to his bunk. When he got closer, the officer saw a sheet tied around his neck, the other end secured between the upper bunk and the wall. Montoya had been convicted of aggravated sexual assault of a child, sentenced to 8 years in prison, just a week before.

In the days leading up to his suicide, an officer's report notes, Montoya had made numerous comments to other inmates "that he would rather die" than to go to prison "because he was afraid of what other inmates might do to him."

It was other inmates that found Anthony Tootle, 43, hanging from a towel inside his cell on January 22, 2011. Before detention staff could get to him, other inmates in Tootle's unit had carried him out of his cell on a mattress. One inmate had already started CPR on Tootle before guards took over.

It's unclear why Tootle took his life — his family couldn't be reached for comment. Officers note in the report that at no point did Tootle ask to be seen by medical or mental health staff. Guards wrote he hadn't displayed any bizarre behavior and wasn't flagged for suicide watch.

Officials said neither mental health screenings at the City Magistrate nor the jail indicated Adrian Rodriguez, 31, was suicidal, though records say he was put in detox upon intake. Still, two days after his arrest on robbery charges on June 21, 2011, Rodriguez hung himself with a sheet in his cell. Transferred to University Hospital, he died three days later. While in the hospital, Rodriguez was given a personal recognizance bond. The Texas Commission on Jail Standards, which tracks in-custody deaths, ruled the death wasn't officially "in-custody," meaning it doesn't show up in the agency's records.

Rodriguez had a long history of addiction and mental health problems, says his mother Sylvia Gonzales. In a tearful interview this month, she recounted how at age 4 he was molested by a man who had been living with the family. Rodriguez could never get the counseling he needed, she said, and by the time he was a teenager drugs and alcohol kept him bouncing in and out of the criminal justice system. "It affected his whole life. Adrian never felt complete, he never trusted people," she said. "He always had nightmares." Family members note Rodriguez had recently completed a rehab program and was holding down a steady job before his arrest. Gonzales and Jeanette Guajardo, Rodriguez's older sister, said they've yet to get answers or records from the county explaining the death.

Leroy Sanchez, was found in his cell on July 25, 2011, a week after his 25th birthday, hanging from a torn T-shirt. He died at Santa Rosa hospital days later. Records from the jail only indicate that he had a "bad " phone call before dinner that night.

Roger Peters, found hanging by a towel in his cell, was the jail's fourth suicide of 2011. Other inmates in his unit discovered him the morning of October 14, 2011, and called out for help. Peters had a history of credit card abuse and boosting cars. Officers were unable to locate an Ambu-bag, used for resuscitation attempts, in the unit. One detention capitain's report noted, "there is no indication that anyone began CPR attempts, chest compression, or rescue breathing, prior to medical assistance arriving."

One responding officer wrote that "at no time did inmate peters approached (sic) me with any problems or talk about hurting himself, or thoughts of suicide. At no times inmates discuss or approached (sic) me of inmate Peters having bizarre behavior or talking about committing suicide."

Like other families of inmates who have died in custody the Current spoke with, Peters' father says he has never been given a full account of what happened to his son. "The sheriff's office has been completely uncooperative," said father Roger Peters, Sr. He wanted medical examiner reports, incident reports, a list of guards and inmates there at the time of his death. "All I kept getting was the vanilla responses. It became clear they were never going to explain this to me."

The family has many unanswered questions. Peters had been in jail a number of times before — on previous charges, he'd opted for time served in lieu of paying off fines. "It wasn't like jail was this big, frightening thing for him," said stepmother Debra Vinson.


Of the four wrongful death lawsuits filed against the Bexar County jail over the past two years, three involved suicide — Harlan McVea, Jonathan Ramirez, and Nicholas Tucker. The other involves a woman who died while detoxing from heroin. Pamela Anguiano was left "unmonitored for an egregiously long period of time in her cell," according to claims in the lawsuit. Anguiano's death remains a mystery for her family. A medical examiner's report, an autopsy, and toxicology report "shows no injuries or natural disease process that would indicate a cause of death." Jail officials haven't come forward with an explanation, says Anguiano's mother, Gloria Bustos.

Local attorney Sonia Rodriguez, who's currently looking into one jail suicide case, that of Adrian Rodriguez, says it's still unclear, given the way the courts have ruled, how any family can win in a wrongful death suit against a jail. She points to a case filed in federal court in Fort Worth in 2006. Tarrant County jail inmate Ignacio Nunez had been jailed for public intoxication. When he became combative with officers during intake, guards put him in a cell to calm down at about 9:30 p.m. According to the lawsuit, guards left Nunez there unmonitored until just before 6 a.m. the following day. Officers found him hanging by his shoelaces.

Dismissing the case on summary judgment in 2007, a federal judge wrote, "Although hindsight might show that the officer's choices were ill-advised, even grossly neligent," the plaintiffs couldn't prove "subjective deliberate indifference to a substantial risk of harm" to the inmate. "How are you ever going to prove that? Number one, someone was aware of the fact that someone was going to hurt themselves, and number two, that they drew that inferrence and didn't care?" Rodriguez asked. "I've been looking and looking and looking to see if a court has ever found 'subjective deliberate indifference' in any of these cases. I can't find a single one that has."

As Ortiz approaches re-election, his jail has so far seen two suicides in 2012.

Corey Hiller, 36, took his own life in the jail's infirmary, hours before he was set to appear at his first pre-trial hearing on charges he fatally stabbed his ex-girlfriend, her good friend, and seriously injured his ex-girlfriend's son. One officer reported he saw Hiller sitting on his bed at 3:10 a.m., according to jail records, but by 4:15 a.m. Hiller wouldn't respond to questions. Surprisingly, the report says the observation log books showed "all checks were conducted within the 30 minute time frame."

"[I]t appears as though the Decedent committed suicide by tying a sheet to the base of the hospital bed, and used the electronic controls to elevate the bed; thus strangling himself," one incident report notes.

The Current couldn't reach the family of Robert Rodriguez, the inmate who self-reported that he suffered major anxiety, problems with "mind and body," and wasn't receiving previously prescribed medication, but his mother told officers the day after his death he'd long had problems battling both physical and mental illness. "As far as placing them on suicidal watch, it's not our call," said Bexar County Jail Administrator Thomas. "From past experiences, we can identify actions, we can identify the things we think are out of the ordinary, and we did here. But ultimately we don't have the authority to say, 'Yea, he's suicidal.' We may feel someone's acting out or mental or something, but we don't make that call."

Rodriguez's cellmate had just moved into the cell on June 27, 2012. He noticed Rodriguez seemed upset when he returned from the infirmary just after noon. Rodriguez, according to records, told him "he was tired of being in jail and was only here for misdemeanor charges yet had been here for two weeks."

Lying on the cell's top bunk, the cellmate heard Rodriguez below him muttering, "I'm sorry God" as he worked the plastic spoon into his shunt. The cellmate then heard what he thought was running water. He hit the cell's call button, frantically pounding on the door, when saw it was blood.

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