Durham County officials knew about suicide hazards in jail cells for two decades, but failed to fully fix window bars and ventilation grates that 12 people used to hang themselves from 1998 to 2017, public records show.
The most recent death was 17-year-old Uniece “Niecey” Fennell, who used a sheet to hang herself on a type of window bar the county later fixed for about $205 per cell, according to documents.
About two weeks after Fennell’s death, the Sheriff’s Office received a bid to modify 432 of the jails’ 576 windows for $88,900. The work was completed in October 2017.
The first 144 windows were modified in 1999, after Gregory Gibson, 20, used a window bar to hang himself in August 1998, but the work to modify the additional 432 windows wasn't completed until 2017, after five others hanged themselves from the window bars.
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It's not clear why it took the county so long to address the window hazards when interviews with county commissioners, who approve the Sheriff's Office budget, indicate the board supported addressing the hazards at the jail as quickly as possible.
A June 2002 internal Sheriff’s Office memorandum from Lt. Col. G.R. Naylor, then director of the jail, to then Chief Deputy C.W. Crabtree outlines concerns about the window bars and heating and air conditioning vents at the jail, which opened in 1996.
The long metal, window bars stretch across the rectangular windows high on the wall in jail cells. There is a small space between the bar and window, which six inmates have died hanging from.
In 2001, the death of 34-year-old Dwayne Davis led to jail officials identifying two rectangular vents in each cell with small wire grids that inmates have slipped items through.
By the end of June 2002, two people had died from hanging from the vents and two others had died from the window bars, the memo stated.
“As we are clearly meeting and exceeding the requirements of the state standards on suicide precautions, we can only go so far with policy and procedure,” the memo states. “There clearly comes a time when design changes becomes necessary to aid in the prevention of suicide.”
The work on the windows stopped after the first 144 were replaced because funding wasn’t included in the next fiscal year's budget, the 2002 memo stated. County documents indicated that it would have cost about $33,048 to do the rest of the windows in 2002.
Then Sheriff Worth Hill sent a memorandum to then County Manager Mike Ruffin in 2003 stating that an American Jail Association report had recommended suicide-prevention measures, including addressing the window and vent hazards "as soon as possible."
Sheriff's Office documents indicate the county didn't make any substantial progress until years later due to funding.
After recent public comments about the deaths, Durham County Commissioner Wendy Jacobs asked staff to research capital improvement plan requests to see what had been requested from the sheriff, Jacobs said, reading a statement Monday night on behalf of commissioners.
“Let me assure this community that your Board of County Commissioners believes that all inmates housed in the detention center should always be kept safe from the time they enter until the time they exit the facility,” Jacobs said.
Proposed detention center projects for the plan that extended from 2004 to 2013 included a project of $40,000 for window modifications for the rest of the windows and a $1.2 million proposal to address the vents, Jacobs said. The first project was to be done in the 2004-05 time frame, and the other in 2005-06.
Formal approval for individual projects that are in the [capital improvement plan] must still be brought before commissioners, Jacobs said.
“We could not find the actual capital project amendments for those referenced projects, so it appears they were not placed before our board,” Jacobs said.
Meanwhile, people continued to hang themselves on the window bars in 2003, 2008, 2013 and 2017.
Others, a total of six, died after hanging themselves from the vents two months after the June 2002 memo and again in 2010, 2011 and 2012.
Efforts to reach Hill, who was sheriff from 1994 to 2012, for comment were unsuccessful.
'I wish I was a mind reader'
In 2012, Hill appointed Mike Andrews, who finished Hill's term and won a full term that will conclude in December. When Andrews was appointed in 2012, staff said the vents should be the priority, Andrews said in an interview last week.
The vent work, which requires welding, can only be done during two short periods in the fall and spring when the jail’s temperature can remain comfortable with the heating and air-conditioning system turned off, Andrews and others said. Otherwise, the system would circulate fumes and smoke throughout the building, Andrews said.
So, the strategy was to do the work over time, Andrews said. So far, 164 vents in 82 cells have been modified. An additional, 988 vents in 494 cells remain.
In the meantime, the jail and related agencies have worked to improve screening for people at risk for mental health issues and provide crisis intervention training to deputies.
Individuals identified as at risk are put in cells where vents and the windows have been modified. The jail also opened a mental health pod for the most vulnerable male inmates in November 2017.
Critical state report
State reports after deaths at the jail in 2013 and 2017 found deficiencies in identifying and monitoring people who might harm themselves.
A 2013 report noted failures after the death of Terry D. Lee, 21.
Lee didn’t answer yes to any of the mental health questions when he was booked on March 13, 2013, according to a state report.
The next day, an outside agency alerted medical staff that Lee had recently been treated for mental illness. When that staffer went to check on the inmate, she found a towel blocking the cell window and discovered Lee hanging from a sheet on the window bar.
The report states that the county failed to take into account Lee’s previous record of mental illness associated with six previous arrests.
“In 2007 and 2008, the inmate had been transferred to John Umstead Hospital because he was found to be incapable of proceeding with the charges against him,” the letter states.
The 2013 state report also said the county should address the window bars.
“While it would be a large undertaking, the facility should explore the alteration of more windows with the goal of correcting all windows,” the June 26, 2013 N.C. Department of Health and Human Services letter said.
When asked why the windows weren't done at that time, Sheriff's Office Chief Deputy Donald Ladd said he doesn't know. The priority was the heating and air-conditioning grates, he said.
Another investigation after Fennell's death found a detention officer responsible for checking on Fennell learned roughly two hours before her body was found that another inmate had reported she was talking about harming herself.
Andrews said in an interview last week that Fennell signed a piece of paper that said she wasn’t going to hurt herself.
The Sheriff's Office completed alterations on all the window bars within sevens months of Fennell's death, according the Sheriff’s Office.
Moving hundreds of inmates
Another potential option for addressing the remaining vents sooner, said Andrews, would be to temporarily move the jail's roughly 500 inmates to another location.
County officials didn’t appear to be considering that option until Graves and her attorneys spoke about the jail hazards at a June 11 budget hearing, along with requesting that 16- and 17-year-olds are separated from the adult population.
“For fifteen years prior to Niecey’s death, the county was aware of a hanging risk that existed in the facility,” said attorney Ian Mance, pointing to the 2002 memo circulated by Hill. “Following those warnings, this commission took no action and chose not to spend the modest sum of money, less than $100,000, that it would have taken to address the issue.”
Ladd said the county hasn't turned down any funding requests related to the suicide hazards.
Andrews said the jail is a county building and the funds to maintain it come from a specific source.
“I don’t want to point fingers at anybody, but we can’t do anything without funding,” Andrews said.
'We need facts'
Jacobs, who has been on the board since 2012, said she isn’t aware of a time when Andrews has asked for funding to address the hazards and the commissioners said no.
“Every time we have talked to him, we have said please get it done as soon as possible; it has never been a matter of funding,” Jacobs said. “Any request that we have gotten safety related we have always said absolutely.”
“It is very disturbing and very concerning, and we want to do all that we can to make sure that this doesn’t’ happen again,” she said.
After the budget hearing, Jacobs asked the staff to put together a report.
“We need the facts,” Jacobs said. “What has been requested over time, what has been funded and what has been done.”
In addition, a group of county officials has started meeting to explore how much it might cost to speed up fixing the ventilation grates and possibly move the inmates.
Since the 2013-14 fiscal year, the county has budgeted from $19,500 to $25,000 in the sheriff’s budget for incremental vent repairs, said county budget director Keith Lane. The proposed 2018-19 budget includes $25,000 to continue that work.
An initial estimate for addressing all the remaining old vents ranged from $600,000 to $800,000. Moving inmates would push that significantly higher, county officials said, if it is even possible.
Timeline for vent, window bar suicides
March 2017: Uniece “Niecey” Fennell, 17, was found hanging on a bed sheet attached to a bar in the cell window.
March 2013 Terry D. Lee, 21, was found hanging from a sheet tied around the window bars.
March 2012: Michael Thomas Rascoe,55, tied a sheet to pants then to air vent.
January 2011: Mandi Tosca-Smith, 37, tied a sheet to an air vent five days after she was arrested.
October 2010: Christopher Kelly, 37, died after he tied a sheet to air vent four days after he was arrested.
February 2008: Brian Rollins, 28, died after tying a sheet to a window bar four days after he was arrested.
September 2003: Cornelius Omar Freeman, 19, of Durham was found sitting next to his cell wall, his neck tied to a sheet that was suspended from a bar on the window. He had been booked into the jail about 3 ½ hours.
August 2002: Christian Hassell, 26, of New York, hanged himself by attaching his shoelaces to an air-conditioning vent.
June 2002: Charlie Lamont Jones, 35, of Durham, used a jail issued shirt to hang himself from a window bar.
Sept. 2001: Bobby Caldwell,31, hanged himself on an air-conditioning vent with an Ace bandage two days after he was booked into the jail, his father said in an interview in 2002.
March 2000: Darrin Dewayne Davis, 33, of Durham used a sheet to hang from a vent cover a few hours after he was arrested.
November 1998: Gregory Devon Gibson, about 20, was found dead in his cell. He tied a sheet around a bar on a window.
Staff writer Dan Kane contributed to this story.