Report: Pitkin County inmate who died by suicide went unchecked for 50 minutes; no discipline handed down, sheriff says
A Woody Creek woman who died by suicide in the Pitkin County Jail last month was in her cell for 50 minutes before jail deputies found her, according to a sheriff’s office report released Friday.
During that time, a newly trained jail deputy checked on Jillian White, 64, twice and didn’t see her but didn’t investigate further because he thought she might be using the bathroom or taking a shower, the report states.
However, the breakdown in procedures — which also includes not removing the electrical cord that was left over from a previous inmate’s medical equipment and which White used to hang herself — has not led to any disciplinary measures at the jail, Pitkin County Sheriff Joe DiSalvo told The Aspen Times on Friday.
“I’m not going to call it a mistake,” DiSalvo said. “We’re dealing with a new deputy who was doing the best he could with the training he had. Just like you would, he feels pretty bad.
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“Obviously, we could have done things better.”
Still, the sheriff said he didn’t think that White would have lived even if she’d have been found during the first scheduled cell check after she hanged herself.
“I don’t know if it would have made a difference based on the video (of her death),” DiSalvo said.
White, who was awaiting a bed at the state psychiatric hospital in Pueblo to be restored to competency, was found dead in her cell the evening of Nov. 3. At the time, DiSalvo took responsibility for the electrical cord being left in her cell.
“We did something wrong,” the sheriff said Nov. 4. “This cord shouldn’t have been there. I got no defense.”
At the time, White’s lawyer sharply criticized Colorado’s treatment of the mentally ill and said state officials in Pueblo had been warned about White’s mental deterioration. White died “due to the lack of supervision and care, which is required for those suffering from mental illness, care that no jail is equipped to provide,” Jennifer Longtin said at the time.
Longtin did not return a phone message Friday seeking further comment.
White had been arrested multiple times for theft, drunken driving and other charges during the past decade.
In the report on his investigation into White’s death, Pitkin County Sheriff’s Detective Brad Gibson said White not only threatened suicide during several recorded phone conversations prior to Nov. 3, she also can be seen in videos from her cell in the days leading up to Nov. 3 testing out her method of suicide.
White also appeared to place a yoga mat at the end of her bed, possibly to block the view into her cell, according to the report. Video shows she died in about 90 seconds.
White made 51 phone calls Nov. 3, the report states. The final one was to her mother, when she told her she was “leaving tonight,” would be “leaving my soul” and that she’d changed her will, the report states.
At the time of White’s suicide, the newly trained jail deputy was being supervised by a veteran jail supervisor in the facility’s common room because the deputy appeared to be nervous around inmates and needed to spend more time with them the supervisor told Gibson, according to the report.
The deputy told Gibson he remembered White coming out of her cell for dinner that night just before 5 p.m. He then checked on her at 5:44 p.m. and 6 p.m., and he didn’t see her and didn’t investigate further.
“(White) had the curtains drawn by the toilet and the shower,” according to Gibson’s report. “(The deputy) said he thought maybe White was showering or on the toilet or on the phone, areas where he could not see her looking through the cell door.”
In the report, Gibson quoted the deputy as saying: “So … I made the decision not to go in at that time. Twenty-twenty hindsight, I wish I had.”
The deputy said he’d dealt with White that morning and in the past and didn’t pick up on any signs that she was suicidal.
By the time the third cell check rolled around Nov. 3 about 6:15 p.m., the deputy told the supervisor he had not seen White “in a while,” which prompted the supervisor to immediately check her cell. That was when they found her body, according to the report.
They attempted to revive her using CPR. They also tried to use a defibrillator, but it wouldn’t provide an electrical shock, the report states.
The supervisor later said that while it can be difficult to see inside all of the cells from the door because of their varied layouts, a deputy is supposed to locate an inmate if he or she can’t be seen from the door.
“(The supervisor) told me if he does not see the inmate, he opens the door to check on the person,” according to Gibson’s report. “But … you’re supposed to eyeball the person.”
Video from White’s jail cell showed that 10 minutes after speaking with her mother, she went back into her cell and killed herself, the report states.
Despite having video of White’s testing of the electrical cord and her suicide, it was not caught by deputies because the jail primarily relies on direct supervision of inmates, said Ron Ryan, Pitkin County undersheriff. The jail’s 40-plus cameras are not monitored all the time and not intended to be, he said.
“Cameras are not a replacement for supervising inmates,” Ryan said.
Gibson also noticed during his investigation that the camera views are “jumbled” and “discombobulated” with “too many camera views on too few monitors,” according to his report.
DiSalvo said he’s been in contact with Longtin since White’s death, though he doesn’t know if White’s family plans to file a lawsuit against the county.
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