Since June 2019, the El Paso County Criminal Justice Center has reported four suicides, a sharp increase since the last previously reported suicide in 2009. According to recent reporting by Reuters, which filed more than 1,500 public records requests to compile data on inmate populations, health care and deaths from 500 jails across the nation, suicide is the second leading cause of death in Colorado jails after illness. Between 2009 to 2019, in Colorado, 64 inmates died by suicide. Colorado’s inmate death rate is 1.64 per 1,000 inmates, compared to the national inmate death rate of 1.46. The factors that contribute to inmate suicide are varied and complex, and the rise in suicides at the El Paso County Jail coincide with both a change in medical service providers and ongoing issues with El Paso County Sheriff’s deputies completing required inmate checks, which has also led to inmate injuries from fights going unnoticed by jail staff.
Statistically, El Paso County Jail’s suicide numbers are actually better than most jails in Colorado. According to the Reuters data, El Paso County Jail has the second-highest average daily inmate count, 1,548 in 2019, of the 10 Colorado jails named in the report. Only Denver County, with 1,886, had a higher average population.
In terms of total suicides from 2009 to 2019, El Paso County also compares favorably, with only four. Adams County had the most, at 14. Boulder County had 12 suicides, Jefferson County had nine, and Arapahoe County had eight.
The Vera Institute of Justice, which works on reforming the criminal justice system, proposes using sentinel event reviews to address suicide in correctional settings. A “sentinel event” is a medical term that refers to an unanticipated event in a health care setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. They use the sentinel review model because, generally speaking, people aren’t supposed to die in jail.
The Vera Institute’s report on the sentinel review process, titled Creating a Culture of Safety, notes, “The reasons for elevated rates of suicide and self-harm in correctional facilities are myriad, ranging from the characteristics of the population, to the experience of incarceration, to the common features of the environment. Many people enter the correctional system with multiple risk factors for engaging in suicide or self-harming behavior, including having a serious mental illness and/or substance use problems, a history of trauma, and a history of self-harm, suicide attempts, and recent suicidal ideation. These individual risk factors, combined with environmental risk factors, such as the stress of the correctional environment and the trauma of arrest, place detained people at a particularly high risk for suicide and self-harm.”
The institute also notes, “Current responses [to inmate suicide] are often fragmented and fail to account for the multiple systems and actors (such as health providers and correctional officers) involved in the operations of a correctional facility.”
Health providers in jails often play a role in inmate suicides. According to Jacqueline Kirby, public information officer for the El Paso County Sheriff’s Office, “A medical screening to include mental health is conducted as part of the jail’s intake process for new admits. These screenings are done by WellPath staff.”
Judy Lilley, vice president of corporate communications and public affairs for WellPath, a private, for-profit health care firm, notes that there are procedures for patients identified as at-risk. “All incoming patients are screened according to industry standards, which utilize evidence-based methods to identify patients who are at risk for suicide,” she says. “Patients identified as being at risk for suicide, whether during the intake process or afterwards, are placed on ‘suicide watch’ until a qualified mental health professional evaluates them and determines they no longer pose a risk to themselves. Once placed on suicide watch, a patient’s personal property is temporarily removed from their possession, they are housed in a specific area of the facility, and they are subject to frequent, staggered checks by both corrections and medical staff.”
El Paso County signed an $8.7 million contract with WellPath to be the health care provider for the jail in December 2019, after the previous contractor, Armor Correctional Health Services, refused to renew the contract. El Paso County originally chose Armor in 2017 after Correctional Medical Group Companies merged with Correct Care Solutions, the previous provider, to form WellPath. Since WellPath took over in 2020, El Paso County has had two additional suicides. WellPath was also the health care provider for eight of the 10 jails in the Reuters investigation. In Adams County, seven suicides took place during WellPath’s tenure. WellPath was the only provider for Jefferson County, and their nine suicides. Arapahoe County reported four suicides since WellPath took over.
The issue of inmate suicides can become a liability for jails. The family of Holly Peck, who died by suicide on June 4, 2019, threatened El Paso County and Armor with a $10 million lawsuit. WellPath is no stranger to such litigation. In November 2020, WellPath paid $100,000 to settle a lawsuit from the suicide of a Macomb County, Georgia, inmate. WellPath is currently named in a lawsuit filed in April 2020, stemming from a woman’s suicide in Josephine County Jail, Oregon. The company is also facing a class action lawsuit in Michigan, from those who claim they were denied access to medication while in the Traverse County Jail. Correct Care Solutions, prior to the merger that formed WellPath, has been sued 1,395 times in federal court since 2003.
“Lawsuits are not a direct indicator of the quality of care provided to patients,” says Lilley. “WellPath’s patients are often a vulnerable and forgotten population. We usually meet our patients when they are angry or at a very low point in their lives, and there is no mechanism in the United States judicial system to prevent the filing of meritless lawsuits. Anyone can file a lawsuit, and anyone can be forced to become a defendant even when there was no wrongdoing. Therefore, a statistic that may be more relevant is the percentage of lawsuits dismissed without any findings by the court or payment by the defendant. For WellPath, more than 90 percent of the claims filed against it are dismissed without any findings or payment by WellPath.”
The lawsuits against WellPath stem from concerns over the quality of care provided by private health care providers. Reporting from Reuters found that, “from 2016 to 2018, those relying on one of the five leading jail healthcare contractors had higher death rates than facilities where medical services are run by government agencies.” Privately run health care providers had death rates that were 18 to 58 percent higher than those of public providers, according to Reuters. However, Colorado’s statewide data shows that El Paso County, which uses private health care providers, actually has a lower death rate than both Boulder and Denver counties, which use a public provider.
“The Reuters report is an apples to oranges comparison of distinct facilities and relies on comparison of death statistics to draw conclusions about the efficacy of public versus private health care providers,” says Lilley. “This comparison fails to account for all of the external factors which also impact patient mortality in correctional facilities. WellPath is always working to improve its services and is committed to delivering high quality healthcare to all of its patients.”
El Paso County had considered a public option before choosing WellPath. “That was something we explored and continue to explore,” says Kirby. “We did not have enough time to put the pieces together for the public model before the contract with our former provider, Armor, expired.”
Correctional facilities have to weigh a number of factors when considering health care providers. “More importantly than price,” says Kirby, “it will be what the provider, whether private or public, can offer to meet the needs of our incarcerated population.”
Health care providers aren’t the only piece of the jail suicide puzzle; the correctional officers tasked with ensuring inmate safety can also play a role. Lilley says WellPath works with law enforcement agencies, noting, “WellPath offers and provides training to its law enforcement partners on a variety of topics, including suicide prevention.”
Even the most rigorous training can’t contend with human error. On Dec. 11, Deputy Russell Smith, who was assigned to the El Paso County Jail, lost his POST certification, preventing him from working as a law enforcement officer in the state of Colorado, following an investigation that revealed he fabricated duty logs and claimed to have done checks he didn’t actually do (see tinyurl.com/Smith-POST). Smith’s actions were uncovered after another deputy discovered an inmate who had been injured during a fight on Smith’s Nov. 28, 2019 shift, which Smith did not report. In July 2019, an inmate was hospitalized after being assaulted and stuffed under a bunk (see tinyurl.com/Jail-Checks), which led Detentions Bureau Chief Clif Northam to issue explicit instructions to all deputies at the jail regarding inmate checks.
On Nov. 12, 2019, Johnathan Cowans died by suicide. Cowans was booked into El Paso County on Sept. 8, 2019, on charges stemming from a domestic violence incident, which was a violation of Cowans’ parole. While in custody, Cowans faced additional charges, including human trafficking of a minor, intimidation of a witness and violation of a restraining order.
Like the injuries suffered by the inmate on Smith’s shift, Cowans’ suicide was discovered after a shift change. According to the incident report obtained through the Colorado Open Records Act, Deputy Scott Jones noted, “At approximately 0142 hours, I started to walk a check in Ward [redacted]. I walked a check in the lower right quadrant first and then entered the lower left quadrant. I looked [through] the window of Cell 4 first and then looked into the window of Cell 3. I observed Inmate Cowans sitting on the floor between the foot of the bunk and the toilet with his back against the wall. I took two steps away from the door and then stepped back because it just did not look right. When I looked closer, through the window, I could see something white, which appeared to be part of a sheet tied around the corner of the bunk and Inmate Cowans’ neck. I called a [redacted], medical emergency, over my Tait Radio, and advised we needed the cutdown knife. I unlocked the cell door and stepped inside the cell. I did not see Inmate Cowans moving. I called his name and did not get a response. I attempted to lift Inmate Cowans and noticed his skin was cold to the touch.”
Deputy Juanito Cuellar, who was the first to respond to Jones’ radio call, also noted, “Upon grabbing Inmate Cowans’ arm I noticed his skin was cold.”
Jones found Cowans after taking over for Deputy Salvador Sarmiento. Sarmiento wrote in the incident report, “At approximately 0132 hours, I walked a check in my ward. Inmate Cowans appeared to be sleeping on the bottom bunk with his head facing the south wall. At approximately 0135 hours, I took over Ward [redacted].”
Within 10 minutes, according to Sarmiento, Cowans was sleeping on the bottom bunk, and then got up, rigged a sheet on his bunk frame, hanged himself, and was found by Jones “cold to the touch.” Those details raised concerns at the jail.
“This event was investigated by our Detentions Investigations Team and included reviewing camera footage and reports,” says Kirby. “It was then referred to Internal Affairs for further investigation.”
Sarmiento is no longer an employee of the El Paso County Sheriff’s Office.
Suicides can be difficult to prevent in correctional environments. Six months after Cowans’ suicide, Michael Roach, who was booked into the El Paso County Jail for menacing, possession of a weapon by a previous offender, and violation of a restraining order, died by suicide on the afternoon of May 12, 2020.
“At approximately 1317 hours, [redacted], knocked on the ward door of [redacted]. I opened the door to ask him why he was knocking when Inmate Foster interrupted me and stated, ‘Dude in 13 just hung himself,’” read the report from Deputy Joel Watkins. “I immediately responded to cell 13 and observed an unknown inmate between the toilet and bunk, with his back towards the bunk. ... It was evident all of his body weight was being supported by the sheet around his neck.”
Despite the immediate response from deputies and medical staff, Roach died. Watkins documented his most recent check on Roach, noting, “On a previous check within the last hour between lunch and the 1315 check, I did observe Inmate Roach standing by the toilet with his arm resting against the wall behind the toilet. At that point Inmate Roach had his face turned away from me and he appeared to be looking down at the Floor. Inmate Roach did respond to my morning hands and face check.”
Deputy Justin Tafoya also corroborates Watkins check: “On the previous check, I do recall Inmate Roach was standing up without his shirt on between the bunk and the toilet facing the wall with his back turned away from the door.”
A 2016 report from the U.S. Department of Justice titled, “Mortality in Local Jails, 2000-2016” notes that “Almost half of suicides among jail inmates from 2000 to 2016 occurred in general housing (47%).”
The Vera Institute points out that, “Best practices for suicide prevention and response for correctional systems do exist ... These include initial and annual staff trainings, intake and on-going assessment, communication procedures, and housing that includes architectural and environmental safeguards—for example, buildings free of protrusions and designed to ensure the incarcerated person is maximally visible in any location, procedures for emergency response, appropriate mental health care, and multidisciplinary mortality reviews.”
Lilley notes that WellPath is working on the problem. “Unfortunately, suicide is a leading cause of death in both the jail and prison systems in the United States and is now a leading cause of death in the United States as a whole. According to the [Centers for Disease Control and Prevention], approximately 123 Americans die by suicide each day. Wellpath is committed to reducing that number in Colorado jails, and is working closely with law enforcement partners to achieve this goal.”