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A death sentence? Suicide deaths at Utah County Jail set off alarms

Published: Sunday, Sept. 4 2005 12:00 a.m. MDT

Handcuffs hang from a bench in the pre-booking area of the Utah County Jail, where suicides are increasing.

Stuart Johnson, Deseret Morning News

SPANISH FORK — Blake Ludlow worked during the day at his grandpa's Ford dealership in Santaquin, changing oil, snacking on circus peanuts and making customers laugh.

After eight-hour shifts, he would head to Spanish Fork where he spent his nights — in jail. Ludlow phoned home from the work-release program to tell his mom he was safe.

He never forgot.

On the weekends, when he wasn't allowed to leave, the clean-cut kid passed the time reading or playing cards with the other Utah County Jail inmates, talking about his family.

On Saturday, Jan. 15, he didn't call home.

Ludlow's mother, Karen Montague, received a phone call early Sunday morning from her parents. They told her the jail had called with bad news: Blake had attempted suicide by wrapping a sheet around his neck so tight that he stopped breathing.

By the time they arrived at Utah Valley Regional Medical Center, Blake Christian Ludlow had died.

Ludlow's death was the first of four suicides in the Utah County Jail this year — already a record number for a single year. In the previous seven years, seven inmates committed suicide.

The four suicide deaths set off alarms. As a result, jail staff formed a new committee to re-evaluate jail protocol and training. They also added a step to the screening procedures for every inmate who enters the jail.

"Hopefully, this is just a statistical anomaly, as far as numbers," said Utah County Sheriff James Tracy. "We certainly are doing everything in our power to prevent all (suicides). That is our institutional objective — to have no suicides. That is drilled into everybody all the time."

But the families who lost sons, brothers and husbands still have questions about protocols followed by staff at the Utah County Jail.

Were they monitored enough? Did they take note of the inmates' mental states?

What went wrong? And what could have been prevented?

"You never think you're going to lose one of your kids like that," Montague said. "I'm not really bitter towards the jail. I'm just concerned about . . . what they can do to prevent this."

Behind bars

The hallways at the jail are sterile, lined with unbreakable, bulletproof windows. Inmates look out from one of 12 living areas — or pods — named after Utah ski resorts. There's Aspen, Alta, Snowbird, Brighton.

In each pod's common room there's a TV and a small bookshelf with worn-out copies of popular novels. Collect-call telephones line the wall. Court numbers and attorney names are posted on the bulletin board.

There are two floors of cells, a staircase in the middle. When the inmates aren't playing checkers, writing letters or watching TV in the common room they stay in their cells, waiting for meal time or visiting hours. They get three meals a day, two visits a week.

The pods are direct-supervision areas. A control desk — marked off by thick, red lines on the floor that inmates cannot cross — is for the housing officer who pulls 12-hour shifts.

The officer is the regulating force, keeping the peace and the remote control.

They monitor inside-the-jail activity as closely as they can, but it's a 1-to-64 ratio.

Utah County is one of only a handful of jails in the nation that functions under the "direct supervision" philosophy.

Other jails use a linear, cell-block philosophy with security cameras. Tracy said he thinks a housing officer is more effective than a camera, as his or her presence sets the tone for the inmates and helps prevent inmate-on-inmate violence.

But the number of inmates the guard must supervise continues to grow, in large part because of a countywide population explosion that impacts the jail as well.

Now, many inmates are housed two to a room to accommodate the influx.

Currently, there are 651 inmates. When the Spanish Fork-based facility first opened in 1997, the average number of those incarcerated at any one time was a little more than 200.

The county is in the process of approving funds and starting to work on building six additional pods that can hold 64 inmates each. But even with the new buildings, Tracy said the extra beds won't stay empty for long.

Preventing the problem

A jail officer heads door-to-door, tapping a round metal button on each cell's door frame with what looks like a fat blue marker. That markerlike object — called "The Pipe" — is used by the jail staffer, first as he touches a dime-size object on the cell door, then on one of nine similar metal buttons in an electronic notebook.

Each of the nine buttons corresponds to a certain behavior, such as standing, sleeping, eating, yelling or bizarre actions.

With each tap of the electronic pipe, the officer makes a downloadable record of his 15-minute-interval visit to each inmate in the medical unit. This procedure is used throughout the jail, though not with the specific descriptions of the medical area.

The Pipe is one element of the jail's monitoring process, but the full screening starts much earlier — right at the beginning of the path from patrol car to pod. Each inmate is carefully screened because jail personnel know the first 72 hours of incarceration are the most crucial. Mental-health screening and the suicide-prevention process starts immediately upon arrival.

All new inmates are asked a standard list of questions about their mental health, whether they've had any emotional issues or troubles in their life or if they have a history of depression. Mental-health professionals use suicide prevention screening guidelines to ascertain if the inmate has suicidal thoughts, has attempted suicide before and to note whether he or she appears overly anxious, angry or afraid.

Those who answer yes to suicide-related questions or raise other red flags are put on "suicide watch," then interviewed by mental-health personnel and placed in a special area where a jail staffer can check them every 15 minutes with a specific monitoring procedure.

This constant supervision is effective because it creates a check on inmates that have been identified as having mental-health or physical-health issues. However, the problem arises when inmates don't notify personnel that they are entertaining suicidal thoughts or perhaps suffer from depression.

If the staff doesn't know about a problem and the warning signs are muted, they can't do much, Tracy said.

Often, instead of speaking up and getting the necessary help, the inmate remains silent and heads to a pod. And the suicide-screening process only happens once unless sudden warning signs emerge. It's now the housing guard's responsibility to monitor the emotional status of his inmates, watching for those warning signs. But with only 109 full-time deputies and 18 part-timers, maintaining constant communication with each individual inmate is a daunting challenge.

"It takes only 3 to 5 minutes to kill yourself," said Tracy. "We have (almost) 700 inmates. To check every one of them 24 hours a day, no more than 3 to 5 minutes apart? I'd need triple the staff to guarantee never a suicide. But our operational goal is to prevent as many suicides as we can . . . if somebody attempts it, we do everything we can to eliminate the problem and then treat the inmate."

Comparing the facilities

The Salt Lake Metro Jail uses screening procedures similar to the Utah County Jail, placing those with questionable stability in individual cells with nothing but a blanket. That's to prevent inmates from using an article of clothing to harm themselves.

In 2004, Salt Lake jail personnel stopped 67 suicide attempts with no successful suicides.

The facilities are similar in size. Last year, the metro jail booked some 16,000 people. The Utah County Jail booked 12,000.

"We do everything possible to prevent (suicides)," said Salt Lake Sheriff Sgt. Paul Jaroscak. "Aside from literally strapping someone down, it would be impossible to prevent every single possibility, but we do our best to eliminate as many as possible."

But no jail can ever be "suicide-proof," says Anthony Callisto Jr., chief deputy of the Onondaga County Sheriff's Office in Syracuse, N.Y., and past president of the American Jail Association. "It's impossible to design it that way."

Callisto said his facility generally sees 30 attempted suicides a year, most of which are unsuccessful thanks to astute and trained staff. Yet even with careful monitoring, competent staff and bare surroundings, inmates can still find ways to kill themselves.

Death by asphyxiation — hanging — is the most common method, Callisto said.

Unlike the typical image of a noose, inmates can cut off the air supply by wrapping a towel, a sheet or even socks around their necks. In less than 3 minutes, a person will pass out, then become oxygen deprived, which eventually causes death. Ten of the 11 Utah County Jail suicides since 1998 were by asphyxiation, Tracy said.

The other happened when an inmate jumped from a higher level of the jail.

The third person to commit suicide at the Utah County Jail this year, Aaron William Colby, 36, hanged himself April 24 in the bathroom of the booking area.

The jail staff started CPR but stopped once they realized Colby was completely unresponsive, and the ambulance team's defibrillator indicated that his heart was not responding to the resuscitation efforts.

The questions left behind

For five years, Blake Ludlow had struggled with a heroin addiction. Although he had graduated from a substance abuse program, the sway of getting high was too strong — and he couldn't stay clean for very long.

Because Ludlow was older than 18, his mother couldn't force him to attend other drug-treatment programs. She said other people told her jail would be the best place for her son, to help him get clean and turn his life around.

So Montague turned her son in for stealing, hoping he could get the help he needed.

"It was hard for me, because, I hate to say this as a parent, but when he got put back in work release, I was relieved — (because) I know where he was at every night," Montague said. "I felt he was safe there. When you've had a kid on drugs and tried so many things, when they're in (jail) somewhere, you hate it, too, but you know where they are, that they're not out (on the street)."

But when Ludlow learned he would be going back to jail, he got scared about being found with heroin in his system, his mother said. So he quit cold turkey.

That was Jan. 11. He was picked up by police the next day — and died four days later.

"Blake just didn't seem like the suicidal type," Montague said. "I personally think the withdrawals were more than he could handle. I ask myself over and over and blame myself sometimes. It's been really hard."

Ludlow's mom said she wonders about the screening process. Maybe there should be a new drug-test policy for inmates before they start the work-release program so jail staffers know how to deal with those who are going through dangerous and painful withdrawals.

But for Ludlow, the precaution still might not have been enough. The drug cycles through the body in 72 to 80 hours. Had he been tested right away, they would have seen the heroin in his system.

But five days later, on his toxicology report, Montague said he was clean.

A drug test might also have made a difference for Ronald Forbush, 42, who died at the jail in April.

Ronald Forbush loved working on cars and spent time with his dad, farming family land in Springville. Although Maurice Forbush worked with his son frequently, he never thought substance abuse was an issue.

"We never knew about it," he said. "It was kind of hard for me to tell if he was on drugs because I wasn't looking for it to start with."

But the signs started getting worse, especially when Ronald Forbush's habits moved from alcohol to drugs.

Then, he started stealing to support his heroin habit. He was arrested. And after he missed a court appearance in April, the police started looking for him.

His mother, Sharon Forbush, said he called her one night, vowing he wasn't going back to jail.

Sharon Forbush, worried her son would get in worse trouble if he continued to run and hide, told his parole officer where he was staying, and her son went back to jail.

He checked in Thursday, April 7. He died the next Monday, April 11.

"They told me, 'Well, we interviewed him. We checked him really good. We didn't think he was on drugs. We had no indication that he was on drugs,' " Sharon Forbush said of her conversation with jail officials.

However, her two other sons saw Ronald Forbush the night he was picked up, and they told her he was obviously under the influence.

"Part of the reason he was picked up was for possession (of drugs)," Sharon Forbush said. "They should have known that he was on drugs — or a drug user."

The jail also never labeled Forbush as a suicide risk, something that worried his mother. She said jail personnel told her there had been no indication he was suicidal.

"Why aren't they interviewing them better?" she said. "Just because somebody says, 'No I'm not suicidal,' do you leave it at that? I've never been suicidal, but I don't think I'm going to run tell somebody if I am."

Prisoner pressure

Jeremy John Wilkins, 30, had a lot to think about when he went to jail.

The Pleasant Grove man was booked into the jail in May after police arrested him for allegedly attempting to burn down his mother's home.

Accompanying charges included drug possession, domestic violence and possession of a dangerous weapon.

Wilkins, a devoted father who loved computers and technology, had struggled with drug problems, stemming from an addiction to painkillers, and was under the influence when he ignited his mother's basement, said his brother Brandon Wilkins.

"He was definitely on something that night . . . my mom could tell he was in a state when all that happened," Brandon Wilkins said.

Once at the jail, Jeremy Wilkins requested a quiet place to stay and recover and was placed in the frequently monitored medical unit. However, as he started to come off the drugs, his family said the consequences of his actions became real.

"The possibility of jail for that long; I don't think he could handle that," Brandon Wilkins said. "I'm sure it was drugs, mixed somewhat (with) coming-off effects, withdrawal. That would be tough on me — to do something, then all of a sudden realize what I had done."

Although Jeremy Wilkins was being carefully watched in the medical unit, he used a bed sheet to hang himself.

There is pressure inherent in incarceration, enough to be a factor in some suicides. However, consequences of drug use also play a major role, especially because the possession of any drug other than marijuana is a felony.

"The way that we have labeled people with felony convictions makes it more difficult for them than it used to be," said Richard Gale, a defense attorney known for his work with the Utah County Public Defender's Association. "Now there's so many things that are felonies — (they have a) real hard time living a normal life."

And if drugs have been a part of that "normal life," he said, it becomes even more difficult to find a sense of balance, especially behind bars.

"I think sometimes they're euphoric out of custody, when on the drugs," Gale said. "Then, they get put into jail, and when they get put into jail, they start sobering up and then everything — reality — comes crashing down and it just seems overwhelming to them."

And watching for those warning signs of depression — even if the inmate didn't raise red flags during initial screenings — is the housing officer's job, Tracy said.

Inmates who talk about traumatic life experiences such as the loss of a job, removal from a position of power or the shocking nature of their alleged crimes are flashing bright warning signs. But other hidden issues might be harder to detect without thorough screening and continued monitoring.

"If they're prominent (in the community), sure logic would tell you that you have to be especially careful — but there's not a hard or fast rule at all, except to do a good screening," said forensic psychologist Stephen L. Golding.

Golding, who teaches at the University of Utah, said it's difficult to pinpoint a single factor that would lead someone to take their own life.

"The only thing that makes any sense is to say that the emotional reaction of individuals, especially the large proportion of people who are mentally ill, is always a cause for concern, both in entering the system and thereafter," he said. "It depends upon there being adequate screening and monitoring. (That's) where the interventions need to take place."

Stopping the suicides

Improved screening is the focus at the Utah County Jail now.

Jail personnel will soon implement a new screening form to be filled out by the officer who brings someone to the booking area, said Lt. Scott Carter, jail programs supervisor.

The officer will record his or her experience with the person before he arrived at the jail. Was there a fight? Was the individual emotionally distressed? Were there drugs involved? These first-hand observations will help jail personnel know more about the new inmate and any circumstances that might not have come out through the previous screening procedures alone.

This was one of the ideas that came out of a new suicide prevention committee.

"Some people think we're not doing anything, that if some guy wants to commit suicide and tries, he's successful," Tracy said. "That's not the case at all."

The committee meets each Thursday to share ideas and develop new policies that might be more effective in suicide prevention. The jail nurse, housing sergeant, a member of the public defender's office, as well as a representative from the Utah County Attorney's Office were invited to participate with jail staff on this committee.

"Our goal is to evaluate policies and make recommendations for changes in policies, to look at procedures and identify things that can be changed, improved," Carter said.

Jail personnel are deeply affected by each death, he added, and they want to do everything they can to prevent it.

The jail's policies are based on national standards, but adopted and modified to fit the specifics of the Spanish Fork location. Yet even with the best planning, some tragedies do occur.

However, it's not as easy as simply changing one policy to eliminate inmate suicide, said Utah County Commissioner Jerry Grover.

"If it was that easy," Grover said, "we would have done it."

Not only will the jail be starting a review process, but new computer software will now make tracking both suicides and attempted suicides easier. Often, the few suicides overshadow all the prevented tragedies, especially because in the past, attempted suicides were not recorded as dutifully as were the completed suicides.

The same night of the last successful suicide in May, two other attempts were foiled.

June 22 would have been Blake Ludlow's 21st birthday. His mom threw a party for friends and family, and they talked about the man they loved. Montague and her family are still going to counselors, sharing their story with others and trying to come to terms with their loss.

The harsh reality of drug use and suicide are issues the Montagues know about on a personal level. They've learned important lessons — but at a steep price.

"He talked about (drug use)," Montague said. "He hated it. He felt the drugs were controlling him, not him controlling the drugs. He wanted to do what was right . . . I think with Blake it had been a big fight. And he lost."


E-mail: sisraelsen@desnews.com

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