Castro suicide was ‘perhaps inevitable,’ report says

Recommendations for preventing prisoner suicides

— Increase mental health staff involvement with high profile inmates

— Require better accountability of officers and supervisors who do security rounds

— Bring back rigorous staff training on inmate suicide and end online courses

— Examine the use of mental health observations and suicide watch policies

— Push staff to perform as though all suicides can be prevented

Source: Lindsay Hayes and Fred Cohen, contractors to the Ohio Department of Rehabilitation and Correction

Ohio inmate Ariel Castro’s suicide in September was not predictable but “not surprising and perhaps inevitable” given how Castro perceived that he was being harassed and threatened by guards and prisoners, according to a report released Tuesday from two national experts on prisoner suicide and mental health.

Castro, 53, hanged himself at the Correctional Reception Center in September, just a month into his life sentence for multiple counts of aggravated murder, rape, kidnapping, child endangerment and other charges. Castro kidnapped three young women and held them captive in his Cleveland home for a decade.

The state Department of Rehabilitation and Correction hired experts Lindsay Hayes and Fred Cohen to review suicide prevention efforts as well as the high-profile suicides of Castro and death row inmate Billy Slagle. Slagle, 44, committed suicide in August just three days before his scheduled execution date.

“The two suicides here had high profile status, for different reasons obviously, but neither can be attributed to failure of the DRC staff,” the report concluded. Hayes is a nationally recognized expert in suicide prevention within jails and prisons and Cohen is a leading expert on correctional mental health law.

Over the past five years, Ohio DRC’s suicide rate among inmates has fallen below the national average of 14 per 100,000 inmates in state prison systems. But this year Ohio DRC has seen 10 inmate suicides, spiking its rate to 19.8 deaths per 100,000 prisoners.

Between January 2008 and November 2013, Ohio DRC had 38 suicides, state data show. Ohio has on average 50,419 inmates with 20,000 annual admissions to the system’s 28 prisons.

Hayes and Cohen examined 16 cases of suicide in Ohio prisons over the past two years and found that most had long sentences left to serve, most had been convicted of violent crimes, on average they had already served five years, and most had a history of suicidal or self-injurious behavior. They also found that staff lacked specialized mental health training or had not had it in many years in most cases and in six cases there were problems with timely cell checks, including falsified documentation.

DRC Director Gary Mohr will work with Hayes and Cohen to implement recommendations, said DRC spokeswoman JoEllen Smith.

Hayes and Cohen concluded that the state does not have legal liability in either Slagle or Castro’s death because officials were not deliberately indifferent to a high risk of suicide. Case law on liability for custodial suicide make it “extremely difficult for plaintiffs to prevail in such cases,” the report said.

In Slagle’s case, “there was no indication he was displaying any obvious signs of suicidal behavior,” the report said. Slagle was on death row for fatally stabbing a neighbor.

In Castro’s case, DRC took elaborate steps to protect him from other inmates and administered a battery of mental health assessments. Castro denied that he had thoughts of suicide, claimed he was a happy person and seemed oblivious to his future situation, other than his concerns about his own safety.

Hayes and Cohen rejected the theory that Castro accidentally hanged himself during auto-erotic asphyxiation. Castro carefully arranged a Bible and family photos that gave it a shrine-like appearance and “all seemingly assembled in preparation for death,” the report said.

While inmates reported that guards harassed Castro, the consultants said it was unclear whether that happened. Nonetheless, DRC should make it clear to staff that their job does not include inflicting additional punishment on “even the most loathsome inmate,” the report said.

In his handwritten journal, Castro complained about the quality of the food, cleanliness of his cell and treatment by guards. “I feel as though I’m being pushed over the edge, one day at a time,” Castro wrote.

Castro kidnapped his victims — Michelle Knight, Gina DeJesus and Amanda Berry — from 2002 to 2004, kept them confined to his Cleveland house, repeatedly raped them, fathered a girl with one victim, and savagely beat Knight so that she would miscarry her pregnancy. The women escaped in May when Berry forced open a door and called for help from neighbors.