Report: Nebraska inmates' suicide deaths may have been avoided by policy change (2024)

The deaths of at least two inmates who died by suicide at Nebraska prisons in recent years may have been avoided if the Department of Correctional Services had followed through on recommended policy changes years ago,a new report from the Legislature's prison watchdog suggests.

Nebraska's Inspector General of the state's troubled prison system reviewed the deaths of three incarcerated men who died by suicide in state prisons from December 2021 to June 2023, detailing findings in a 28-page report made public Wednesday.

All three of the men whose deaths were reviewed byInspector General Doug Koebernick's office died after hanging themselves with bed sheets tied either to the top bunks of their beds or, in one case, to a locker in the man's cell, according to the report.

Corrections staff had long ago recommended that administratorsremove the second bunk and cabinets from special management cells atthe Tec*mseh prison after an internal review of a prior suicide there in 2016 in which the inmate also hanged himselfby tying a bed sheet to a wall cabinet.

But the department never followed through on the recommendation, according to Koebernick's report, which calls for the prison system to "revisit" its own 2016 report and review four other policies surrounding suicide response and prevention within the state's prisons.

A spokeswoman for Nebraska's prison system did not respond to an email seeking comment Thursday.

Sixteen days before his suicide,Schroeder had used a razor blade to cut his wrist but survived the injury, telling medical staff he was not suicidal but had harmed himself due to the effects of using K2, a form of synthetic marijuana often smuggled into prisons.

That claim was undercut by an apparent suicide note prison staff found inSchroeder's death row cell— among the type of cells considered a "special management unit" cell —following the cutting.

After a hospital stay, Schroeder was placed on suicide watch at the Tec*mseh prison for a period of time before his status was downgraded to "Plan B status," a step down from suicide watch. Three days later, he was returned to his cell on death row.

Schroeder hanged himself there, with a bed sheettied to the top bunk of the bed,in the early morning hours of Aug. 29, 2022. He hadn't met with the prison's behavioral health team for around 10 days, according to Koebernick's report.

An internal department review ofSchroeder's death determined "nothing was discovered to suggest (his) death could have been prevented at the time of occurrence" sinceSchroeder did not disclose his suicidal thoughts to prison staff. A grand juryfound no criminal wrongdoing inSchroeder's death.

Internal investigators who came to that conclusiondid not review Schroeder's prior self harm, interview nearby inmates nor make any inquiries into why Schroeder was removed from suicide watch,according to Koebernick's report.

A similar internal probe in 2016 had yielded the recommendation that Nebraska's prison system remove the top bunks of beds in special management units at the Tec*mseh prison, including death row.

Prison policies require the department to complete a "psychological autopsy" for all suicides and some suicide attempts in Nebraska prisons. The reports are supposed to include background information, circ*mstances or events that preceded the incident, clues of suicide, conclusions, recommendations and a list of documents examined.

Koebernick's office asked the Department of Correctional Services for a copy ofSchroeder'spsychological autopsy, but "it was not provided," the inspector general wrote.

Nebraska's prison system in 2018established a work group to look at suicides, which have typically been a leading — and rising— cause of death in American prisons, where the number of suicides increased 85% in state prisons and 61% in federal prisonsfrom 2001 to 2019.

The working group, led by the department's medical director at the time, recommended the department create a brochure on suicide to be distributed to inmates and family, make changes to the staff training manual, stream a suicide prevention video in all facilities, use an additional screening tool at transfer times and intake, and advertise a phone number that people could call when they are concerned about a loved one who is incarcerated in Nebraska to prompt a welfare check.

"It eventually ceased to exist," Koebernick wrote.

In his latest report, the inspector general encouraged prison administrators to review the 2018 working group's findings and "determine whether a special team should be established to focus on deaths by suicide" and attempts.

Koebernick also recommended the prison system review itsrequirement regarding psychological autopsies and revisit the prior recommendation regarding the removal of top bunks and cabinets in restrictive housing cells.

His office also suggested Nebraska's prison system examine its own internal investigation process to determine whether interviews with individuals other than prison staff should be included in the probes, which are meant to be “comprehensive and meticulous," according to department policies.

In a June emailed response to a draft ofKoebernick's office's report, Rob Jeffreys, the director of Nebraska's prison system, said he had "received the report and will consider the recommendations.”

A day later, Jeffreys issued a policy directive requiring psychological autopsies for all suicides and, when appropriate, for suicide attempts, according to the report.

The directive closely resembles what was already the department's written policy.

In the U.S., the national suicide and crisis lifeline is available by calling or texting 988. There is also an online chat at 988lifeline.org