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Nearly 35% of the people incarcerated at the El Paso County jail were identified as having a mental illness, including 34 on suicide watch, according to an April jail population report.

After a 33-year-old man took his life last week while incarcerated at the El Paso County jail, the number of suicides in the facility since 2019 rose to five, after nearly a decade when none were reported.

Their deaths come as suicides remain as the No. 1 cause of death in jails nationwide and as the El Paso County jail juggled mental health providers after a report found "critical shortfalls" in the jail's former health care contractor. After making the switch to a new contractor, three more suicide have been reported.

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Meanwhile, Sheriff Bill Elder's long-time vision of having a network of local healthcare professionals and mental health experts providing at the jail, rather than one of the big national for-profit companies like its current provider, has seemingly stalled.

The climb in suicides calls attention to not only the state's unremitting mental health crisis, but the urgent need for community-based care, experts told The Gazette.

“Jails and prisons have become the largest in-patient mental health facilities in our country, which is unfortunate,” said Boulder County Sheriff Joe Pelle, a vocal critic of a criminal justice system that has become a last resort for people with mental illness. “It is failed policy.”

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The mental health care “crisis” is not new, though, Pelle said, and not one that Colorado faces alone.

Because there is no national tracking system for deaths inside jails, the public and policymakers are often left in the dark about facilities with high rates of death. But according to data collected by Reuters, at least 65 people died while incarcerated in Colorado between 2009 and 2019.

Colorado ranks eighth among states with the highest number of jail suicides in the last decade, falling behind California, Florida, Pennsylvania, Texas, Maryland, Massachusetts and Georgia, data shows. Nationwide, suicide accounts of about a third of all jail deaths, according to U.S. Department of Justice report published last month.

Nearly 35% of the people incarcerated at the El Paso County jail were identified as having a mental illness, including 34 on suicide watch, according to an April 2 jail population report.

For years, the sheriff has reportedly been working to overhaul the jail's medical model that would put the care of inmates in the hands of local providers, instead of corporate correctional giants. Discussions regarding the program began several years ago when the tumultuous relationship between Armor Correctional Health Services at the Sheriff's Office ended at the end of 2019, after the company's CEO told Elder the multimillion-dollar deal had soured beyond repair.

But his vision remains unclear, still, and details of a newly approved agreement between the Sheriff's Office and county health department to create a direct medical care program within the jail remain thin.

According to a resolution signed in March, the county's Board of Commissioners unanimously approved a $57,000 one-year agreement between the agencies to "establish a program for medical services at the El Paso County jail," including care for people after they are released. The agreement can be renewed in one-year increments, up to a total of four additional years, according to the resolution.

El Paso County Public Health will work with the Sheriff's Office to develop the program in the jail, communicate with external vendors to provide direct care inside the jail, and help implement the Sheriff's BHCON Unit, which pairs a deputy with a licensed behavioral health clinician to respond to emergency mental-health related calls within the community, according to a Sheriff's Office spokeswoman. The public health department will also create a system that creates a continuity of care to inmates released from the jail, including behavioral health treatment and substance use disorder treatment.

Spokespeople from both agencies could not comment further, explaining the infancy of the program.

'Lack of community-based mental health solutions'

While the Sheriff’s Office said it could not explain the increase in suicides among inmates in the past two years, the increase comes as no surprise to Vincent Atchity, president of Mental Health Colorado, a nonprofit that promotes equitable access to mental health resources for people across the state.

“The overall percentage and need in the population for mental health care has risen, especially in the context of the pandemic,” Atchity said. “I think that jail is the catchall place for all kinds of other failings in our system."

What's needed? A community-based health care system that meets the needs of people with serious mental health needs, he said.

“We can’t have our health care system just shrugging and saying we can provide all the chemotherapy you need, but we just don't have the capacity to manage mental health. That’s really got to change within the community."

When Pelle became Boulder's Sheriff in 2003, about 15% of the people inside the county jail had a diagnosed mental illness, he said. Today, that number is between 60 and 70%, sometimes more.

"The lack of community-based mental health solutions, the lack of civil beds, the lack of walk-in centers and crises centers — all of that has resulted in the last resort: the emergency department or the jail for people who are in crisis," Pelle said.

He and his staff have worked to find solutions to address mental health care needs inside the jail, including transforming part of the facility into a competency restoration unit where psychologists can determine if they are fit for trial. Due to a severe backlog at the Colorado Mental Health Institute in Pueblo, dozens of inmates' jailed with serious mental illnesses were forced to wait in jail for "months and months" before receiving their court-mandated evaluation.

While the new unit has helped alleviate the backlog, Pelle likened the steps by jails to address mental health as "putting Band-Aids" on the myriad problems.

“Jail staff are more attuned to security and safety,” Pelle said, while adding that a lot of his staff are trained to recognize symptoms of mental illness. "All that said, jails aren't mental health hospitals."

"When I began my career in policing, we had a secure psychiatric hospital in Boulder where we could take people who are actively trying to harm themselves or others, and we could drop them off, and they would be secure and wouldn’t be able to leave and they would get treatment and evaluation," he said. "That doesn’t exist anymore."

'Maybe a little careless'

Since the El Paso County jail switched to Nashville-based provider WellPath in January 2020, three inmates have died by suicide. It's unclear what treatment they were receiving inside the jail or if the jail's medical staff was aware of their mental illnesses. WellPath did not return The Gazette's several requests for an interview.

After each death, the agency’s detention investigators interview each staff member that responds to a suicide; reviews jail logs and behavioral logs; and revisits policies to discuss if there are required updates, a sheriff's spokeswoman said.

It is not in the agency’s purview to investigate WellPath’s medical practices or procedures, she said.

A jail deputy resigned in December 2019, after 18 years with the El Paso County Sheriff’s Office, after investigators found he likely passed an inmate hanging inside his cell five times while conducting his routine checks at the county jail.

When another deputy found the 32-year-old man, his body was “completely stone cold,” according to the report recently obtained by The Gazette. As two nurses tried to save the man, they struggled to open his airway — his body had become rigid.

The deputy’s apparent negligence or misconduct and the man’s death came amid a 13-month span in which four inmates died in the El Paso County jail — none of the inmates had been convicted of a crime at the time of their death. The Sheriff's Office said misconduct was not found in the three remaining deaths, and an investigation is underway for a March 29 suicide.

Colorado Springs-based attorney Josh Tolini said the news of the deputy’s checks were initially “alarming” — his first thought was that the misconduct was connected to the death of Holly Peck, a 36-year-old mother of five who took her life in the jail in the summer of 2019.

Peck's estate threatened the county with a $10 million lawsuit. It claimed her death was caused by the “deliberate indifference” of the Sheriff’s Office and the “negligence” of its former health care contractor, Armor Correctional Health Services, Tolini wrote to a letter to the county.

Jail staff previously told The Gazette that the Sheriff's Office conducted a thorough review of Peck's death and had "absolutely no concerns" with how jail staff handled the incident. Armor said her death was "not the result of any action of inaction" by its staff and that its employees followed "all medically prescribed protocols."

But Tolini wrote in the letter that jail security and medical staff were to blame for the “willful and wanton wrongful death for this pretrial detainee” and that there was no evidence from the Sheriff’s Office “to determine why this happened and how we can prevent this from happening again.”

Since Peck’s death in June 2019, four inmates have died in the El Paso County jail.

Tolini is still working to track down the people who were in nearby cells to Peck before she died, to see if she made any signs that should have alerted jail staff that she was suicidal and if staff were doing the required checks, he told The Gazette last week. COVID-19 has slowed the process, he said.

About six months after Peck's death, former Deputy Salvador Sarmiento resigned in lieu of termination after an internal affairs investigation found that he failed to see the 32-year-old man who had died by suicide in his cell while conducting his routine checks during an overnight shift in November 2019.

Surveillance video from the jail showed Sarmiento conducted his checks on time but in a cursory manner, by “merely walking by and glancing through the cell door window as opposed to making a concentrated effort to look inside the cell,” the report stated. As he conducted his checks, he didn’t break stride and didn’t use his flashlight.

Investigators found his amount of detail in the jail log to be “remarkable and potentially exaggerated.” His last check, performed at 1:32 a.m. before he switched assignments, he wrote that the inmate “appeared” to be sleeping.

Thirteen minutes later, a deputy that took over Sarmiento's shift found the man hanging in his cell, the report stated. He had no pulse and his body was cool to the touch.

“‘There’s no way he died 15 minutes before (discovery),’” employees of the El Paso County Coroner’s Office reportedly told the Sheriff’s Office, the report stated. The inmate had signs of post-mortem lividity, which typically occurs about 30 minutes after death as blood starts to pool in hands and feet, the report stated.

Investigators were unable to determine the man's exact time of death, according to the report, citing the "inexact science" and lack of reliable methods to do so.

In an interview with an investigator, Sarmiento reportedly said if he were to stop at each cell and peer through the window, he would not be able to stay on time for his subsequent checks.

Sarmiento called his actions "maybe a little careless," but not malicious or reckless, the report stated. In a note to the investigator, he wrote that he apologized for the inmate's death and said that he had been more thorough in his checks since that death.

In 2020, two more suicides were reported by the Sheriff's Office. Attempts to reach the individuals’ families were unsuccessful.

  • May 12, 2020: A 45-year-old man died by suicide after spending six days in jail, court records show. Police issued him an arrest warrant after he violated his probation and missed two court days. His autopsy reported that he had a history of personal stressors, suicidal and homicidal threats, and a previous suicide attempt.
  • July 3, 2020: A 47-year-old man took his life after he was booked less than two months prior on charges related to burglary and theft between $300 and $750, court records show. He was held on $1,000 bond. His next court date was scheduled 10 days after his death.

On Monday, jail deputies found a man hanging in his cell. He had no pulse and was not breathing, the Sheriff's Office said. When he was previously incarcerated at the El Paso County jail, staff was alerted for his mental health, according to the El Paso County Coroner's Office.

He was booked into jail in January on suspicion of possession of controlled substances and other drug-related charges. Further details on his death were not immediately available.

The Gazette's Breeanna Jent contributed to this story.

Reach Olivia at olivia.prentzel@gazette.com.

Twitter: @oliviaprentzel

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