A Marine with PTSD, a schizophrenic father, a granddad struggling with depression: They are just some of the many who've taken their lives in U.S. jails — a problem experts say is preventable with more training and safeguards. Here are their stories:
DEVIN LYNCH - COOK COUNTY JAIL
The inmate, unsupervised, empties out an unlocked utility closet. He stands there for a moment, looking at a surveillance camera, before stepping inside and closing the closet door. About an hour later, a guard appears — and finds that Devin Lynch, a 26-year-old Marine, has taken his life.
"I didn't know he was a risk," the guard would later say in a lawsuit deposition.
Just before he died, Lynch called his mother from Chicago's Cook County Jail.
"He was crying by the time our one-minute warning came on," Charlene Bigelow recalls. "I said, 'Hang up and call me right back,' and he didn't."
Six weeks before, in February 2016, Lynch had gotten drunk and attempted suicide. He was arrested the same day on charges alleging he sexually assaulted his girlfriend and was jailed awaiting trial.
Lynch suffered from depression and anxiety and had post-traumatic stress disorder after serving with the Marines for almost eight years, including deployments to Afghanistan and Japan on a mission to collect human remains after the 2011 tsunami, according to Bigelow and court records.
At the jail, home to one of the largest populations of mentally ill inmates in the nation, intake staff noted Lynch's history and assigned him to a special mental health unit where guards were supposed to closely watch inmates and check cells, bathrooms and closets at least every 30 minutes. The unit was created in 2013 after a federal investigation found inmates at the jail were at risk from poor mental health care. A federal court order required Cook County to step up staff suicide-prevention training and monitoring.
The video of Lynch's last moments surfaced in a lawsuit filed against the county by Bigelow that settled this April for $1.7 million. Another video, described in the guard's deposition, showed the officer sitting at a desk and talking on the phone over the 90 minutes during which Lynch killed himself.
In an email, Cara Smith, chief policy officer for the Cook County sheriff's office, said jail employees receive "extensive" mental health training and that, "unfortunately, Mr. Lynch made a terrible and unforeseeable decision to take his life. There were no warnings prior to his action."
Bigelow, however, believes her son's death was preventable and hopes her lawsuit helps ensure suicide-prevention policies are carried out. Her son, she says, "would want to hope that his story would make a difference in somebody else's life."
— By ELLIOTT DAVIS, of the Capital News Service.
ANTHONY WEAVER - ROGER D. WILSON DETENTION FACILITY
Anthony Weaver was awaiting the birth of his grandchild at the hospital in October 2016 when police served him with an outstanding arrest warrant for failing to appear at a hearing on a vehicle burglary charge. The 55-year-old had been in and out of jail as he struggled with drug addiction and depression.
He was taken to the Roger D. Wilson Detention Facility in Knox County, Tennessee, where just six months earlier he'd used a razor to slit his wrists in a suicide attempt, according to court records. This time, jail staff assured his public defender that Weaver would be seen by mental health professionals, court records say.
County policy requires that inmates be placed in a housing cell within 48 hours of booking. Yet six days later, Weaver was still in an intake cell, in clothes soiled from his own urine and feces. He could not walk and had to use a wheelchair to meet his attorney. He had not been assessed for suicide risk, given his prescription drugs or provided with medication for drug withdrawal, court records say. He didn't even have access to a working lavatory. He told an attorney he wanted to kill himself, which records say was relayed to jail staff.
Wright Surgenor, Weaver's social worker, was told Weaver was unavailable when she tried to visit him and stressed her concern to a jail official. "I got it, it's taken care of," Surgenor was told, according to court records and a recent interview.
Ten days after his arrest, Weaver learned that his grandchild had been born with a genetic defect and died. Inexplicably, he was again given a razor by one of the jail guards and left unattended. The next day, he slit his throat and died, never having been moved out of intake.
His wife, Linda, filed a wrongful death lawsuit against Knox County in 2017 but died before the case was resolved. Wayne Kline, an attorney for the jail's mental health provider, Helen Ross McNabb Center, says the company settled for an undisclosed sum. The case against the county is still pending. The sheriff's office, Weaver's public defender and Linda Weaver's attorney did not respond to questions.
Weaver was at least the second inmate to commit suicide that year at the jail. Another hanged himself two days after intake.
— By SAMANTHA HAWKINS, Capital News Service.
JOHN ORLANDO - ALLEGHENY COUNTY JAIL
A fight led to the arrest of John Orlando in 2016 on charges of public drunkenness and assault.
The 41-year-old, who suffered from schizophrenia, was suicidal when he arrived at Allegheny County Jail in Pennsylvania, court records say. At intake, he declared he was high on recreational drugs and said, "I hope I die in here."
The facility should have been primed to handle someone like him. Six years earlier, following 47 suicides in 30 years, the jail had issued new procedures for dealing with mentally ill inmates.
But Orlando was strapped down in a chair for nearly eight hours, records show. He was eventually assigned to a mental health unit, where guards were supposed to visit his cell every 15 minutes. Three days later, Orlando was left unsupervised long enough to construct a noose out of materials in his cell. He hanged himself from his bunk and died in the hospital.
His mother, Jean Lawniczak, sued the county, alleging her son's constitutional rights were violated because staff was inadequately trained to prevent him from harming himself. A judge ruled in favor of the county, saying the family needed to show that jail staff acted with "deliberate indifference." Lawniczak is appealing.
When asked about suicide prevention in a deposition for Orlando's case, a jail nurse who was present when Orlando arrived said she did not recall being trained in suicide prevention, nor was she aware that the jail had a written suicide prevention policy.
In an email, Allegheny County spokeswoman Amie Downs detailed steps the jail is taking to prevent suicide, including the use of suicide prevention gowns. Intake screenings are performed by multiple staff members, she said, adding: "There is a mental health specialist in the jail 24 hours a day, 7 days a week."
Orlando left behind a daughter, Elena, who is 10 now. "He worshipped the ground she walked on," Lawniczak says. "He did everything with her."
Lawniczak and her granddaughter used to visit Orlando's grave together, until the girl told her that it "hurt her heart too much."
"It feels like it happened a week ago," the mother says through tears. "It doesn't go away."
— By HANNAH GASKILL, of the Capital News Service.
IGOR KARLUKOV - LAKE COUNTY JAIL
Igor Karlukov was convinced an evil spirit had taken control of his ex-girlfriend in 2014 and that he needed to eradicate it before his soul was stolen.
The troubled 35-year-old was arrested for forcing his way into her apartment and brought to Lake County Jail, just north of Chicago. His family warned that he had talked about killing himself to prevent bad spirits from harming him.
He was placed on suicide watch in a special pod, where jailers were supposed to check on him every 15 minutes, according to the sheriff's office. Yet Karlukov had time to fashion a makeshift noose out of a mesh laundry bag and hang himself to death from a heating vent.
"It doesn't make sense," says Matt Popp, an attorney in the firm that represented the estate of Karlukov in a lawsuit. "You're supposed to keep an eye on them every 15 minutes. How is the guy able to make a noose out of his laundry bag and tie it and hang himself?"
The civil rights complaint alleged his death was caused by negligence on the part of the county and Wexford Health Sources, a private contractor that provided the jail's mental health care at the time of Karlukov's death. Wexford denied responsibility, and Lake County claimed there was no basis for the allegations, but in 2017 both reached an undisclosed settlement. Karlukov's loved ones were unavailable because they live in Ukraine with limited access to contact, according to Popp. In 2015, Lake County Jail switched health care providers.
Since 2010, there have been two suicides at the jail, according to the sheriff's office. Recently, Sheriff John Idleburg, who took office in December 2018, established a change in procedure that would allow correctional officers to call an ambulance even if the contractual health care provider doesn't agree.
Since its introduction, the policy has been used at least twice and has allowed staff to get care for inmates facing medical emergencies "in a much more expedient manner," according to sheriff's Sgt. Christopher Covelli.
— By JESS FELDMAN, of the Capital News Service.
DAVID MICHAEL ERNST - CREEK COUNTY JAIL
David Michael Ernst was on a mix of antidepressants and painkillers in August 2013 when he lost control of his truck outside Tulsa, Oklahoma, killing three adults and a child in a passing car. That landed the 52-year-old in the Creek County Jail on manslaughter charges.
He was suicidal from the start, court records say, and was allowed to continue some of his medications. Yet five months into his incarceration, the private company hired to provide mental health services at the jail told him the drugs he needed either were not available or allowed to be dispensed, court records say. He asked for individual counseling, the records say, but was told it was not offered at the jail.
After his conviction in June 2014, Ernst's mental state worsened. Returning to jail on the day of his sentencing, he told a deputy that he should "just hit him with the car." The deputy, records say, told jail staff that Ernst needed to be placed on suicide watch or seen by medical staff, but the nurse who evaluated him later said she wasn't told he might be suicidal. Ernst never was placed on suicide watch, and five days later, he used a blanket to hang himself in a shower stall.
An inmate who helped cut Ernst down hanged himself two months later, despite warnings to staff about the man's mental state. That inmate, also, was never placed on suicide watch, court records say.
In June 2015, the county terminated its contract with the private mental health contractor, Advanced Correctional Healthcare or ACH, for "failure to provide inmates appropriate medications," according to court records. The company settled a lawsuit with Ernst's wife for an undisclosed amount. She lost a case against the county; a judge found that while the nurse's failure to place Ernst on suicide watch was "a serious error" and that "better communication would likely have prevented this tragic result," law protects municipalities unless "deliberate indifference" is demonstrated.
Jessica Young, president of ACH, says it would be "completely false to suggest that ACH denies medication and/or care to patients in an effort to reduce expenses" but declined further comment on why the county terminated the contract.
The second inmate who hanged himself was Ransom Andrew Moss, 49. His sister, Betty Moss, still wonders how it could have happened.
"The anger's still there," she says. "And it could've been prevented."
Creek County Sheriff's Office and the jail did not respond to multiple requests for comment.
— By THERESA DIFFENDAL