Las Vegas Sun

December 8, 2023

Suicide raises questions about mental health care at jail

Click to enlarge photo

Dr. Keith Courtney, chief psychiatrist at Clark County Detention Center, talks to an inmate in this June 2009 file photo.

A suicide at the Clark County Detention Center in 2009 is kindling accusations that the downtown facility run by Metro Police is doing a poor job addressing mental health needs, an issue that prompted a Justice Department investigation of the facility a decade ago.

In a federal lawsuit, Las Vegas attorney Cal Potter III alleged on behalf of plaintiff Amanda Lou Cavalieri that the suicide of her husband, Michael Anthony Cavalieri, could have been prevented had the jail better screened and observed him.

Defendants include Metro and NaphCare, an Alabama company contracted by the jail to provide detainees with psychiatric and medical care. Metro spokesman officer Marcus Martin declined to comment on the lawsuit, filed in March, and a Las Vegas lawyer who represents NaphCare didn’t return calls seeking comment.

Cavalieri, 55, was an electrician booked in February 2009 on assault and weapons charges and was a pretrial detainee. According to the lawsuit, he suffered from bipolar disorder and was withdrawing from drug addiction.

He was initially placed in an observation cell and was to be housed in a unit with authorized suicide watch by jail staff at 15-minute intervals. But the lawsuit alleges that staff erroneously concluded he did not have suicidal thoughts and placed him in a cell within the general population.

On March 6, 2009, a correctional officer allegedly failed to perform a required twice hourly walk-through, and Cavalieri was discovered hanging from an air-conditioning vent. He was pronounced dead at University Medical Center.

Dr. Simone Russo of Las Vegas, retained by Potter, stated in an affidavit that Cavalieri “should have been admitted to a psychiatric ward for further observation and treatment.”

“Based upon my review of the record there does not appear to be any suicidal precautions taken after the decedent was placed in the general population, which is below the standard of care,” Russo said. He said that resulted in Cavalieri taking his life.

The lawsuit also stated that problems concerning suicide prevention and mental health care have been long-standing at the jail and it “has continued to be plagued by suicides.” According to Martin, one suicide occurred at the jail in 2008, but none in 2010 or so far this year.

After inspecting the jail in early 1998, the Justice Department issued a scathing report identifying numerous issues that it said violated the inmates’ constitutional rights. Among those issues were “inadequate mental health care and suicide prevention.” Investigators found inadequate suicide screening when individuals were first processed into jail, and poor supervision once they were placed in temporary holding areas, a combination they said posed “an especially dangerous inmate suicide risk.”

“In many cases, inmates who are mentally ill go unrecognized and untreated in general population units, as well, despite obvious signs of mental health problems,” investigators said. “The officers in general population units are not adequately trained to recognize and refer mentally ill inmates to the mental health professionals at the detention center.”

The Justice Department said its investigation was prompted in part by two suicides that occurred in 1997 in the holding area, where detainees are taken after they are booked. A third inmate attempted suicide in a holding cell that year, but a cell mate summoned officers to intervene.

Investigators noted suicide response was inadequate because of the absence of readily available instruments to cut down hanging victims. They looked into a 1996 suicide in which it took staff several minutes to locate scissors to cut the bed sheet an inmate used to hang himself.

The investigation was concluded in 2002 after the Justice Department expressed satisfaction with upgrades. But Potter said he thinks the department should reopen its investigation to demand better mental health screening at intake, closer supervision of inmates with suicidal tendencies and removal from all cells of air vents and other design features that can be used by detainees to hang themselves.

“They replaced some of the air vents after the investigation but obviously didn’t replace all of them,” Potter said. “There was also a failure of supervision.”

Amanda Cavalieri said her husband had been bipolar for several years and had been taking prescription Lexapro, which is used to treat depression and anxiety disorders. But she said he was denied his prescription in jail and had been falsely led to believe that he was to be housed in the detention center’s psychiatric unit.

“They need to get doctors there to help the inmates who are mentally ill,” she said. “I wasn’t even notified of his death until six hours later, even though they had my cell number.”

One complaint the American Civil Liberties Union of Nevada hears often about the jail is detainees’ inability to get their prescriptions quickly, said Maggie McLetchie, its legal director.

“Once you get arrested, there seems to be a significant delay in getting prescriptions,” she said.

In a national study of jail suicide last year by the Justice Department, author and project director Lindsay Hayes of the National Center on Institutions and Alternatives in Baltimore recommended that all cells designated to house suicidal inmates be as suicide resistant as possible. He recommended that jail staff closely observe actively suicidal inmates at least every five minutes and detainees who express suicidal ideation at least every 10 minutes.

But in response to questions via email, Hayes said most jails haven’t taken such stringent measures. In the case of a lack of suicide-resistant housing, part of it has to do with lack of money, he said.

“Jail systems do not take corrective action and renovate enough cells until following suicide,” he said.

Hayes cited staffing costs for the reason many jails don’t offer the level of observation he recommends.

“Most suicides occur when inmates are not on suicide precautions,” he said. “Therefore, the question becomes, following a comprehensive review, should they have been on suicide precautions and, if so, what was broken in the identification process?”

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