Failure to Report: How did the D.C. Jail let two troubled inmates kill themselves in their cells? Don’t ask the D.C. Jail
By Brendan Smith, Washington City Paper
No one noticed when Thomas Alemayehu killed himself in Cell 43 of the D.C. Jail by twisting a torn piece of a bed sheet around his neck and tying it to the top bunk.
By the time someone checked on him, his body already was cold and stiffening; rigor mortis doesn’t occur until approximately two hours after death.
Alemayehu, a 28-year-old Ethiopian cab driver with a history of mental illness, died two days before Christmas in 2006, but he might have survived if corrections officers had done their job. Two corporals claim they completed mandatory inmate counts every 30 minutes, but surveillance cameras show no one had set foot on the cell block tier for more than two hours, according to a recently released internal-affairs investigation by the D.C. Department of Corrections.
Thomas Alemayehu
“There is a strong possibility that Mr. Alemayehu was hanging in a position between his bunk and toilet during the times that security checks and official counts were supposed to have been conducted,” the DOC report states.
During his initial health screening at the jail four days before his suicide, Alemayehu told medical staff he had tried to kill himself before, which should have triggered a mental-health assessment by a psychiatrist from jail medical-services contractor Unity Health Care.
However, Alemayehu never received the mental-health assessment, and he wasn’t placed on suicide watch. Instead, he was forgotten and died alone in a single cell. The internal-affairs investigation found that Unity Health Care’s policy for referring inmates for mental-health assessments was “considered nonexistent.”
Unity had never worked in a jail before winning a three-year contract in 2006 from the DOC, which didn’t seek any other bidders. Under the $83 million contract, Unity provides medical services for inmates and ongoing treatment for former inmates at its local network of community health clinics.
Three months after Alemayehu’s suicide, Alicia Edwards, 32, also hanged herself with a bed sheet in a single cell. During her health screening two days earlier, she told Unity medical staff she had attempted suicide before. She said she needed a prescribed psychotropic medication for bipolar disorder to stop the dangerous swings from major depression to mania that haunted her mind.
Like Alemayehu, Edwards never received a mental-health assessment, and she wasn’t placed on suicide watch. She also didn’t get the medication that could have prevented a relapse of her mental illness.
On March 31, 2007, after cutting her body down from the makeshift noose, corrections officers found a piece of paper lying near Edwards’ body. It was a medical request form. Edwards was asking again for the medication she needed, the internal-affairs report states.
D.C. Jail’s Central Detention Facility (Darrow Montgomery)
Alemayehu and Edwards weren’t hardened criminals. They faced relatively minor charges when they killed themselves. Their suicides exposed major problems with the diagnosis, treatment, and supervision of mentally ill inmates in the D.C. Jail, which holds, on average, more than 3,200 inmates per day.
The Department of Corrections, headed by Director Devon Brown, fought for 10 months to prevent the release of its internal-affairs reports on the suicides. The reports were recently released after several appeals to Mayor Adrian Fenty’s office through the D.C. Freedom of Information Act.
Brown has good reason to want to keep the reports secret. The investigations reveal widespread misconduct by corrections officers and medical staff from Unity Health Care that directly contributed to the deaths of Edwards and Alemayehu. Fenty’s office allowed the redactions of the names of all of the employees from the reports, although some names slipped past the black pens of the censors… Continued on next page >>