Advocates, families seek more measures to prevent jail suicides
"Assessment is not a one-time event, but a process that should be ongoing throughout the at-risk patient's incarceration."
By Adele Uphaus
The Free Lance-Star
FREDERICKSBURG, Va. — Hugh Hall's phone rang about 11 p.m. Oct. 10. The call was from an inmate at Rappahannock Regional Jail.
He answered it, expecting it to be his son, Michael, but it was a voice he didn't recognize, that of another inmate, Markus Todd.
"Your son in here, is his name Michael Hall?" Todd asked. "Your son hung himself tonight."
Hall hung up the phone. He didn't understand what he had just heard.
He started frantically making phone calls. Finally, a detective from the Stafford County Sheriff's Office called and confirmed that Michael Hall had hung himself and that he was dead.
Jail Superintendent Kevin Hudson confirmed the incident in an email to The Free Lance — Star.
"We did have a suicide by hanging on October 10, 2022," Hudson wrote on Oct. 28. "There is an internal investigation being conducted as well as an investigation by the Stafford Sheriff's Office. They are both routine investigations as part of any death in custody at our facility. All policies and procedures were followed leading up to and during this incident."
But Hugh Hall said he feels there is more the jail could have done to prevent his son's death.
"We would talk two or three times a week and he would tell me, 'Dad, I'm asking for help and nothing's happening,'" Hall said. "He was not of his right mind. They could have prevented this, had they paid attention."
Michael Hall had been in the jail for four months when he died, serving time for violating probation that resulted from a 2021 conviction on drug possession charges.
Hugh Hall said his son did not struggle with his mental health before entering the jail this summer.
"He had life struggles like the rest of us do, but he did not have suicidal thoughts or any kind of mental thing," Hall said. "That jail broke him."
Records show that Michael asked to see a mental health provider at least twice in the month before he died.
Also, on Sept. 20 and Sept. 22, jail officers postponed a scheduled disciplinary hearing for him "until [he could be] seen by mental health," according to paperwork.
But Hugh Hall said his son never mentioned speaking with a mental health care provider.
Hall said that at first, it seemed that Michael was adjusting to being in the jail as well as he could.
"We could hear from the background that there was camaraderie between him and other inmates," Hugh Hall said.
About two months in, that started to change.
"It seemed like he was in a daze," Hall recalled.
According to notes that Michael scribbled, he worried that people were watching him and wondered if he was "under investigation" for something.
"Everyone in every pod is whispering and [correctional officers] are allowing this," he wrote.
Another note pleads, "Don't call me hall no more back here please. No one need to know my name."
Markus Todd, the inmate who called Michael's family to tell them about his death, said he noticed a change in Michael.
"I was in a pod with him a year and a half ago, and he used to talk to me about the Bible and stuff," Todd said.
When Michael got out of jail last year, he left Todd a letter with his information so they could keep in touch. But this year, Todd said, Michael claimed not to know him.
"He wouldn't say anything," Todd said. "He would just stare at me. You could tell something was going on with him. He wasn't the same at all."
Allen Weathers, another inmate who knew Michael last year, also noticed a change in him this year.
"He wasn't like he normally was," Weathers said. "You could tell he was struggling. You could tell he was off."
About two months into his incarceration, Michael started to resist complying with orders from jail correctional officers.
Over the next seven weeks, he was charged with refusing to go into a cell that had two other inmates in it, buying ibuprofen from another inmate, fighting, refusing to go into lockdown and refusing to participate in morning clean-up.
His disciplinary records show he was placed in "disciplinary detention," or isolation, on at least two occasions, once for 10 days. On each occasion, he lost privileges to telephone calls, commissary, visitation, the recreational library, television, programs and tablets.
At some point, Michael filled out an application form for New Life for Youth, a faith-based residential recovery home in Richmond. On the form, he marked that he was suffering from anxiety disorder, depression, hallucinations, paranoia, PTSD and suicidal thoughts.
"I need [to be] checked," he wrote.
On Aug. 25, another inmate filled out a jail request form for Michael, asking for an appointment with a mental health services provider. The inmate wrote that Michael said he was hearing voices and having trouble remembering things.
On Sept. 20 and 22, his disciplinary hearings were postponed until he could see a mental health provider, and on Sept. 26, Michael filled out another request for himself.
"I need to speak to [someone] from [mental health and substance abuse] for an evaluation," he wrote.
On the day he died, Michael Hall had been out of isolation and housed in a cell by himself in general population for a week and a half. He wouldn't talk to anyone, fellow inmates said.
"Something was really wrong with him," inmate Floyd Hill said.
Hill and Weathers said the last time they saw Michael on the evening of Oct. 10 was about 8 p.m., when he went up to his cell after recreation.
About 9 p.m., officers brought new inmates into the pod and assigned one of them to Michael's cell. The man went into the cell and came out saying, "I'm not going in there, there's somebody hanging."
Hill said he ran to help Michael, but officers told him not to touch anything.
According to his death certificate, Michael Hall was declared dead at Stafford Hospital Center at 10:05 that night.
Hall's is the second suicide to occur in Rappahannock Regional Jail in less than a year. Samantha De Mars said her brother, Jacob Dean, hung himself in the jail Nov. 22, 2021, and died four days later in Stafford Hospital after being on life support.
"He was suicidal going in there," De Mars said in an interview. "He told my mom on the phone, 'You know you're going to lose your son, right?'"
Another inmate lived through a suicide attempt at the jail last year, his mother said.
Suicides in correctional facilities on the increase
Rappahannock Regional Jail contracts with the Rappahannock Area Community Services Board to provide mental health and substance abuse services to inmates.
The team of providers includes a jail and detention supervisor, one mental health therapist, two substance abuse therapists, one diversion therapist, one diversion case manager, one mental health case manager and one psychiatric nurse practitioner to provide medication management services.
A second mental health therapist position is vacant, as is a peer specialist position, according to Jacque Kobuchi, RACSB's director of clinical services.
Kobuchi said the number of requests for mental health services at the jail varies.
"Individuals in crisis cells are seen daily. General population can put in a request for services and are prioritized by need," she said in an email. "Individuals with a known history of mental health treatment or an urgent need are seen first."
According to the jail's most recent annual report, there were an average of about 65 emergency mental health consultations and about 48 non-emergency consultations each month between July 1, 2021, and June 30, 2022.
Suicides in federal, state and local correctional facilities increased between 2001 and 2019, according to a 2021 report by the U.S. Department of Justice's Bureau of Justice Statistics.
In local jails, suicides accounted for between 24% and 35% of all deaths and the number of suicides increased 13% between 2001 and 2019, the report found.
Most jail inmates who died by suicide were male, white, non-Hispanic and between the ages of 25 and 44—all of which describe Michael Hall.
Jails with large populations were most likely to report inmate suicides, the BJS report found.
"Deaths by suicide in 2019 were concentrated in the largest jails," the report states. "More than half of local jails housing 1,000 or more inmates on June 30, 2019, reported at least one inmate suicide."
The Rappahannock Regional Jail has capacity for 1,836 inmates, according to its annual report, and had a population of over 1,000 in July, August, September, October, November 2021 and February 2022.
The population in December 2021 was 991. In January and March 2022, the population was 997 and 999, respectively.
Suicide prevention practices
In 2019, the National Commission on Correctional Health Care, a nonprofit working to improve the quality of care in the nation's jails, prisons and juvenile detention facilities, released a suicide prevention resource guide as part of Project 2025, an initiative developed by the American Foundation for Suicide Prevention with the goal of reducing the annual suicide rate in the U.S. by 20% percent by 2025.
"Incarcerated people are particularly vulnerable to suicide for a variety of complex reasons," the guide states. "Three areas have been identified as crucial for suicide prevention in a correctional setting—assessment, intervention, and training."
The guide distinguishes between a suicide risk screening and a risk assessment. It defines a screening as a one-time event that occurs at intake.
RRJ uses a "brief" mental health screen during intake to identify people with mental health needs, Kobuchi said.
However, individuals who are involved in the justice system often have a history of trauma or impulsive behavior that a one-time risk screening may not identify or take into account, according to the guide.
In addition, a report published this year in the American Journal of Preventative Medicine found that most men who died by suicide had no prior known mental health conditions—meaning there would be nothing to report on a one-time screening.
An assessment, which the guide defines as an "in-depth process involving a comprehensive examination by a qualified mental health professional" can gather more information about the individual's risk.
"Assessment is not a one-time event, but a process that should be ongoing throughout the at-risk patient's incarceration," the prevention guide states.
The guide notes that interventions for suicidal patients often occur after the person has been placed on suicide watch, which often is not a therapeutic environment, or in a location that doesn't offer privacy.
Portia Bennett, RACSB coordinator of jail and juvenile detention services, said providers primarily see clients at Rappahannock Regional Jail in the pod classrooms or "possibly the pod library."
"However, on occasion when deemed necessary for extra privacy, we sometimes have them brought to Medical or the [administrative segregation] classification office," she said.
Training is one of the most important components of a correctional suicide prevention program. The NCCHS guide recommends that all staff who work with inmates be trained in suicide prevention, both initially and at least on an annual basis.
"Everyone should be provided at least a basic knowledge about risk factors, warning signs, what to do if they think someone may be at risk, and the overall suicide prevention plan," it states.
Training for custody staff—which the guide calls the "eyes, ears, and leaders" of every correctional facility—should ensure the staff member can recognize and respond to warning signs; intervene to interrupt a suicidal act in progress and "recognize when an individual needs to be referred for mental health care and ensure the referral is made in a timely and effective manner."
Hudson said jail officers and mental and medical health staff are required to complete annual in-service training on mental health and suicide prevention.
But the jail continues to have difficulty filling all of its jail officer positions. According to the most recent financial report, 23% of jail officer positions were unfilled last fiscal year. In December 2021, there were 101 vacant jail officer positions.
Some jail officers are part of the Rappahannock Area Crisis Intervention Team, which began in 2009 and trains law enforcement to respond to someone experiencing a mental health crisis.
Out of 191 correctional officers, 36 are trained in crisis intervention, Hudson said.
The NCCHS guide also notes that correctional facilities can reduce suicide risk by promoting "protective factors" such as ensuring connectedness.
Facilities should "ensure that each incarcerated person, especially those housed alone, can maintain regular contact with family and other sources of support, regardless of administrative status or financial resources" and should "reduce isolation of offenders," it states.
Records show Michael Hall was denied these protective factors in the weeks before he died.
"Michael was a good person"
Michael Hall's death continues to affect the inmates who witnessed it. They said they don't trust staff's ability to prevent a similar incident.
"After this happened, it was like this place is not safe," said Todd, the inmate who notified Hall's family of his death.
Hill said he can't shake the image of Michael's face as he was being taken away.
"We see that face all the time," he said. "We've asked for mental health to give us something to help us sleep."
Kobuchi said a mental health therapist provided crisis therapy to "several inmates who were directly affected by this incident," but Weathers said he has asked for more help.
"To see something like that—it kind of plays back in your mind," he said. "It's not a good thing."
Hugh Hall said that losing his son in the jail has made him rethink his faith in the criminal justice system.
"We need to have these places because people do bad stuff," he said. "But Michael was a good person. He got around the wrong people and he picked up some bad habits.
It seems like once you're in the system, you're doomed. I still feel that if you do the crime, you do the time, but to treat people inhumanely is not good with me."
NEXT: 4 innovative approaches to inmate suicide prevention
(c)2022 The Free Lance-Star (Fredericksburg, Va.)
Distributed by Tribune Content Agency, LLC.