State agency faulted in death

Girl, 15, hanged herself in Md. juvenile jail lacking suicide-prevention effort

April 13, 2002|By Todd Richissin | Todd Richissin,SUN STAFF

A 15-year-old girl locked in a Maryland juvenile jail had threatened to kill herself hours before she was found hanging lifeless from a bunk bed, but a guard failed to report the threat and no precautionary measures were taken, according to a report by an independent oversight office.

In their report released yesterday, the investigators fault the juvenile justice agency, which runs the facility where the girl committed suicide, for serious lapses that might have contributed to her death.

The findings contradict earlier statements by state officials that the girl had given no indication she might hurt herself.

Most serious, the report said, is the department's failure to implement even a basic suicide prevention program despite attempts by dozens of jailed teens to kill themselves.

The investigators had warned the juvenile justice agency more than a year ago that the lack of a suicide prevention program was a dangerous omission. More than half the teens committed to the department suffer from mental illness or drug and alcohol problems.

"There is a tremendous gap between what the department is able to do and what needs to be done," said Stacey Gurion-Sherman, an attorney and child advocate. "How many kids will we have to see suffer and even die before there's a real change?"

The investigators declined to comment, but their findings are in a six-page report by the Office of the Independent Monitor, which was created in September 2000 to oversee the Juvenile Justice Department because guards were assaulting teens at the agency's boot camps.

The report was obtained by The Sun under state public records law.

The girl committed suicide March 14 at the Waxter Center, an all-girls facility in Laurel. Juvenile justice officials denied as recently as last week that she had threatened to kill herself.

Bishop L. Robinson, the agency's secretary, said yesterday that investigators did not know about the suicide threat until a few days after the girl's death. He said he did not know why a spokesman said last week that the girl had made no threats.

Officials from his department are trying to determine why suicide prevention training is moving so slowly, Robinson said.

The investigators from the oversight office found that the girl - while being medicated for depression - threatened to commit suicide the same day she was found dead.

The report cites the guard for not properly reacting to the girl's threat. Under the existing policies of the juvenile justice agency, the threat should have been reported to supervisors and the girl monitored closely.

On the day of her suicide, the girl was "disrespectful to staff" during her morning bathroom time, the report said, and she was misbehaving later during school classes held at Waxter. As a result, she was ordered to stay in her room.

It appears "the suicidal threat was made by the youth while she was being escorted to her room immediately after school and that this comment was entered into the log book shortly thereafter," the report said.

Investigators said there is no evidence that other Waxter staff members were told.

No precautions were taken to protect the girl from harm, the investigators found. Instead, guards disciplined her by confining her to her room.

Up to an hour elapsed before staff members checked on her. When they did, they found shoelaces looped around her neck and tied to the bunk bed above.

Her roommate was in the room reading. The investigators said they have no explanation why the roommate did not come to the girl's aid, but they ruled out foul play.

Waxter was understaffed at the time of the suicide, with only two adults watching a unit of 26 troubled girls, the investigators found. One of the two adults was working a double shift.

"The level of staffing," the report said, "is insufficient."

The report does not include the girl's name. She was from Montgomery County and arrived at Waxter on Dec. 28 after spending two months at the Noyes detention facility in Rockville.

Her case file, according to the investigators, said she had been sexually abused and was locked up for "minor delinquent offenses." She had been taking the antidepressant Prozac.

The juvenile justice agency secretary said that despite early confusion about the threats, it is now clear that there were warnings.

"She did threaten to kill herself," Robinson said. "There's no question. It's in the report."

In December, he had ordered that suicide prevention training begin for all juvenile justice employees who work directly with teens, he said. Robinson said he had no explanation for why his orders have not been carried out: "That will be part of the investigation."

Vincent Schiraldi, director of the nonprofit Center on Juvenile and Criminal Justice in Washington, said the need for suicide prevention training in juvenile jails is obvious. The lack of training, despite Robinson's directive, he said, is another indication of how the agency is failing:

"It's so obvious. It's a very traumatic thing to be placed in a detention facility, and it's triply so for kids with mental health problems. The risk for suicide is very real."

The report issued by the independent monitor asks that the juvenile justice agency implement its suicide prevention plan and report its progress within 45 days.

The investigators did have one bit of praise for the agency. Their report concludes with a note that grief counseling was prompt.

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