Suicides by prisoners in Nebraska could possibly have been prevented

The inspector general of Nebraska's troubled prison system investigated the deaths of three incarcerated men who died by suicide in state prisons between December 2021 and June 2023, laying out his findings in a 28-page report released Wednesday.

All three men whose deaths were reviewed by Inspector General Doug Koebernick's office died after hanging themselves with bedsheets attached either to the upper bunks of their beds or, in one case, to a locker in the man's cell, the report said.

Two of the three men – 45-year-old death row inmate Patrick Schroeder, who died in August 2022, and Michael Becker, a 25-year-old who died in December 2021 at Tecumseh State Correctional Institution – hanged themselves while locked in cells in a “special management unit,” according to the report, which does not name any of the three inmates.

Correctional staff had long ago recommended that the administration remove the second cot and lockers from Tecumseh Prison's special administration cells after an internal review revealed a previous suicide in 2016 in which the inmate also hanged himself by tying a bedsheet to a closet.

But the agency never implemented that recommendation, according to Koebernick's report, which calls on the prison system to “revise” its own 2016 report and review four other policies on responding to and preventing suicide in the state's prisons.

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

The report takes a particularly close look at the death of Schroeder, who was on death row after strangling his cellmate in 2017. At the time, Schroeder had already served 11 years of a life sentence for the killing of a 75-year-old Pawnee City farmer.

Sixteen days before his suicide, Schroeder had slit his wrists with a razor blade but survived the injury. He told medical personnel that 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 undermined by an apparent suicide note that prison officials found after the circumcision in Schroeder's death row – a cell considered a “special administration cell.”

After a hospital stay, Schroeder was placed on suicide watch at Tecumseh Prison for a time before his status was downgraded to “Plan B” status, one step below suicide watch. He was returned to his death row three days later.

There, Schroeder hanged himself by tying a bedsheet to the top bunk of the bed in the early morning hours of August 29, 2022. According to Koebernick's report, he had not met with the prison's mental health team in about ten days.

An internal investigation into Schroeder's death found that “nothing was discovered to indicate that his death could have been prevented at the time it occurred” because Schroeder had not disclosed his suicidal thoughts to prison staff. A grand jury found that Schroeder's death did not constitute criminal misconduct.

The internal investigators who reached that conclusion did not investigate Schroeder's past self-harm, did not interview nearby inmates, or asked questions about why Schroeder was no longer monitored for suicide risk, Koebernick's report said.

A similar internal investigation in 2016 recommended that the Nebraska prison system remove upper bunk beds from special units at Tecumseh Prison, including death row.

Prison policy requires the department to conduct a “psychological autopsy” on all suicides and some suicide attempts in Nebraska prisons. The reports are supposed to include background information, circumstances or events preceding the incident, indications of suicide, conclusions, recommendations and a list of documents examined.

Koebernick's office had asked the Department of Corrections for a copy of Schroeder's psychological autopsy, but “it was not provided,” the inspector general wrote.

Nebraska's prison system established a task force to study suicides in 2018. Suicides tend to be one of the leading—and rising—causes of death in American prisons. From 2001 to 2019, suicides increased 85% in state prisons and 61% in federal prisons.

The task force, led by the department's then-medical director, recommended that the department create and distribute a brochure on suicide to inmates and their families, modify the staff training manual, broadcast a suicide prevention video in all facilities, implement an additional screening tool during transfers and admissions, and provide a phone number that people can call if they are concerned about a loved one incarcerated in Nebraska to request a well-being check.

Koebernick's office found in 2019 that the prison system had implemented only one of the group's recommendations: the phone line. But the inspector general's office “called them several times (and) it didn't work.”

“At some point it ceased to exist,” Koebernick wrote.

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

Koebernick also recommended that the prison system review its requirements for psychological autopsies and reconsider the previous recommendation regarding the removal of upper beds and cabinets in inmates' cells.

His office also suggested that the Nebraska prison system review its own internal investigation procedures to determine whether the investigations, which are supposed to be “comprehensive and rigorous” under agency policy, should include interviews with people who are not prison employees.

In an emailed response in June to a draft of the report from Koebernick's office, Rob Jeffreys, the director of the Nebraska prison system, said he had “received the report and will review the recommendations.”

A day later, Jeffreys issued a policy directive requiring a psychological autopsy for all suicides and, where appropriate, suicide attempts, the report said.

The instruction is very similar to the department's already written policy.

In the US, the National Suicide and Crisis Hotline can be reached by calling 988 or texting. There is also an online chat at 988lifeline.org