NEW BEDFORD — Brandon St. Pierre signed his name on the “New Commitment Housing Classification” form at the Ash Street jail on April 24, 2000.

Above his signature appears three classifications. A check mark was inked beside “General Population: No problems expected.”

The document appears as part of 526 pages associated with the Fall River native’s institutional records at Bristol County Jail and House of Corrections. The documents, obtained by the Standard-Times through a public records request, reveal the 15 years that followed St. Pierre signing the document were mired with constant problems, ending when correctional officers found him hanging from a window on May 6, 2015 in Cell M-03. He was 32.

St. Pierre’s suicide represents one of 14 in the last decade at Bristol County correctional facilities, according to Sheriff Thomas Hodgson’s office.

Eleven suicides have occurred under Hodgson’s watch in the last five years. In a 15-year period, from 1998 through 2012, the Bristol County Sheriff’s Office reported 10 suicides.

The spike follows a statewide trend where Massachusetts ranks fourth in the country with 32 suicides per 100,000 state and federal prisoners. The national average is 16 suicides per 100,000 inmates.

“I’ve been here 20 years. We had less suicides back then,” Hodgson said. “We didn’t get worse at building our systems in our health care and everything else. (Dr. Jorge Velize) has been here and the work that we’ve done with (Correction Psychiatric Services) We’ve gotten better.”

In interviews with The Standard-Times, attorneys, suicide prevention experts, Hodgson, and medical and prison personnel debated prevention but described no surefire method.

The newspaper requested public institutional records for six suicide victims at the correctional facilities. At this time, Bristol County has provided records for St. Pierre, as well for Aaron DeBrito, Jose Santiago and Michael Ray.

Interviews and public records show Hodgson has instituted improvements in suicide prevention policies, but also that the office has sometimes been unable to keep track of all of an inmate's history prior to suicide attempts.

“If we say we’ll take the whole money of the world and put it here. We take 100 clinicians and we put it here. We take better psychiatrist(s) and we’ll put it here. Will that solve the issue? I don’t think so,”  said Velize, the CEO and owner of Correction Psychiatric Services, the medical company contracted by the sheriff's office. 

“What we’re working with is the unpredictably of a condition, a human condition, that is close to impossible to detect. And to that end, we have taken so many measures. We are not denying the problem.”

“Maybe the next 10 years we have five (suicides) or none,” Hodgson said. “If you came back and said ‘Geez, how’d you do that so well?’ We may not be able to give you those answers. We probably won’t be able to do, but as the doctor said, it’s cyclical.”

Lindsay Hayes, the project director of the National Center on Institutions and Alternatives, and one of the leading experts in the country on suicide prevention in prison, travels around the country helping facilities improve their prevention policies. 

He said Hodgson has never invited him to Bristol County to offer his expertise. Bonnie Tenneriello, of Prison Legal Services, said Hodgson tries to cut corners. 

Hayes said he doesn't link the number of prison suicides to a cycle and said he believes good policies can help limit inmates from harming themselves. 

"The best systems I’ve seen operate, and unfortunately none of them are in Massachusetts, are those that they individualize the decisions on a case-by-case basis," he said. 

"Our last national accreditation, across the board 100 percent," Hodgson said. "Top 10 percentile in correctional facilities in the nation, but we had suicides. They inspect all of that."

When presented with criticisms of his facility, the sheriff shook his head and dismissed outsiders who he said have never stepped foot in any of his facilities. 

"I love these people who have never called us or asked a question about it and decide how it is," he said. "Who aren’t even professionals, who don’t have enough (knowledge) to put in a thimble of the education and specialty that (Dr. Velize) has, telling us why those people are committing suicide."

The Standard-Times reached out to three families that were affected by suicides in Bristol County. Each declined comment, including St. Pierre's mother, Barbara Kice. Each said they were looking into a lawsuit against Bristol County as well. 

In the past, Colleen Lewis has talked to the media about her brother, Kevin Leonardo, who took his life in February 2016. Bristol County didn't provide the Dighton native's records. 

While differing opinions emerged regarding solutions, those interviewed agreed on the causes: that substance abuse and mental health issues within correctional facilities have increased in recent years. 

"Since the 1980s when you had mental hospitals were widely closed. What happened in the subsequent decades was the lack of adequate care in the community meant that a lot of people ended up in prison," said Tenneriello, of Prison Legal Services. "You see it kind of an inverse line. As mental health care declines, the prison population increases. And it’s not an coincidence."

According to a 2011 Legal Action Center study of 2.4 million American prisoners, an estimated 65 percent were clinically addicted to drugs or alcohol, with only 11 percent receiving professional treatment. Those numbers have likely increased, specifically in Massachusetts, due to the opioid epidemic.

From 2013 to 2015, according to the Centers for Disease Control, overdose deaths as a result of synthetic opioids other than methadone have increased by 72.2 percent. No state saw more of a spike from 2013 to 2014 in terms of fentanyl cases than Massachusetts.

In the last six years, in which 12 suicides occurred at the Dartmouth and New Bedford (Ash Street Jail) facilities, inmates that reported substance abuse has increased 76 percent within Bristol County.

According to the sheriff’s office, Bristol County facilities have inmates detoxing at a rate two-thirds higher than any other lockup in the state.

“The amount of drugs they have been using. I have never seen that high of a dosage that a person is taking,” Velize said. “We know that the number of problems with the drugs, alcohol, they’re highly correlated to suicide.”

More than 800 pages of Bristol institutional records show difficulty in tracking an inmate's history of mental health and substance abuse.

The files of St. Pierre, Ray and DeBrito note that each used heroin and alcohol. Santiago’s file notes that he used heroin.

However, information on St. Pierre's final "initial classification review" didn't include important facts about his history. The review form states, “frequent use of most drugs” in April, 2015.

It doesn’t mention that his father died of abusing heroin and alcohol, which is stated in earlier reports. It also doesn't show that other review forms stated St. Pierre began using marijuana and alcohol at 13 (some reports state he started using at 14).

"Suicide Risk" appears as a stamp in block lettering on several pages in Michael Ray's records. He and St. Pierre were marked as suicide risks when they entered the facilities. All four men were flagged with mental health issues.

“We have come to the conclusion that (it's) not even possible to mark all of them,” Velize said. “There’s not one specific set of symptoms that one would say this person will make it definitely as a suicide. We can not even make a guess estimate as the potential of being suicidal.”

In the investigation of St. Pierre’s suicide, his cell neighbor said that he “talked about suicide a lot to him and other inmates, but no one thought he was serious.” He also said St. Pierre told him he would be "outta here one way or the other" and he was going to "hang it up on second shift."

St. Pierre's institutional records show he attempted suicide on August 24, 2001 — that information appears on a number of pages, but not on some of the most recent initial classification reviews. On an initial classification review of St. Pierre on Oct. 5, 2001, it states that he attempted to hang himself on Sep. 12, 2001. The incident is never mentioned again in any of the 526 pages.

In May 2007, a third suicide attempt is listed. It says on “Aug. 1 inmate allegedly attempted to hang himself.” 

Two days prior to killing himself, St. Pierre was punished for an altercation with another inmate. In 2001, he tied a sheet around his neck and jumped off a bed two days after he was placed in segregation for a fight with another inmate.

In the case of Michael Ray, he spoke to his fiancee the day before he hanged himself. He told her, “he couldn’t go on living like a homeless person,” “he was tired” and he “couldn’t do this anymore.”

In the case of Jose Santiago, who hanged himself on Aug. 3, 2013, the New Bedford native met with with Sean Stubbert of Stepping Stone. Stubbert wrote in an incident report form, "I learned they were going to charge him with being a habitual offender which could give him considerable time in jail... He seemed to be in relatively good spirits throughout the meeting and seemed more upset with the fact that they would going to make is girlfriend testify with why he did."

Hayes wrote in an article for the National Center on Institutions and Alternative that "many suicides occur in close proximity to a court hearing," specifically when a decision results in a negative scenario. 

Even if those items appeared on St. Pierre’s latest classification review, Velize said he doesn’t believe that a suicide can be predicted with any patient.

“Nobody in the world has been able to detect it. There is nobody who has the answer to it,” he said. “There is no consultant who has been able to provide that. We don’t have any institution of level zero forever in suicide. Having said that we’ve done a lot of different things.”

At Bristol County, any inmate flagged as potentially suicidal receives an exam by a clinician. A possible recommendation as a result is a mental health watch. In a transition from mental health watch back to general population, an inmate could undergo three phases to assure they are mentally healthy.

Each phase ends with the inmate being rewarded with points. The points can pay for items like, to name a few, crayons and a coloring book (two points), a puzzle (three points), two hours with a radio (four points) or an extra phone call during the week (five points).

The documents show that St. Pierre was on 15 minute mental health watch two weeks before he hanged himself. The most intense mental health watch involves 24 hour watch, where an officer sits and watches the inmate around the clock. Michael Ray was on “eye ball watch” for 48 hours two years prior to his hanging in June.

Inmates on a mental health watch are stripped of their clothing and forced to wear a suicide smock, which is intended to prevent the inmate from having any materials to harm themselves. They receive finger food because they are not allowed utensils.

“I’ve had so many clients in and out of mental health watch and (they) just described it as a horrifying experience for them. It’s humiliating too,” Tenneriello said. “You’re sitting there under constant observation while all there is to sit on is this blanket. It’s humiliating. It’s traumatizing.”

Velize said he has been studying technological advances that would allow for inmates to have more freedom under mental health watch. He’s hoping to find a device that would detect an inmate’s vital signs.

Inmates should be “given a little bit more flexibility as a human being” on mental health watch, he said.

“Oftentimes in our desire to keep inmates safe while they threaten suicide or engage in self dangerous behavior, we go too far,” Hayes said.

“It should not be one sized fits all,” Hayes said. “It should be individualized based on the needs and the severity of the suicidal behavior of the inmate.”

Judith A. Borges, the director of Medical Services for the Bristol County Sheriff’s Office, said clinicians follow those guidelines.

“You read their policies and you think 'Oh wow this is a pretty decent policy,'” Hayes said. “They have all these components of the suicide program in place. So what’s going on? Then, of course, you peel the onion a little bit and you realize the practices do not match the policies.”

In the investigation of St. Pierre’s suicide, it stated that protocol for rounds “required an irregular schedule approximately every thirty minutes.”

On the day St. Pierre committed suicide, the log book showed rounds were completed within 35 minutes. However, in the nine hours prior to St. Pierre taking his life, the log showed 23 rounds. Fourteen were completed within two minutes of the top of the hour or exactly midway through. Nineteen fell within five minutes of the top of the hour or midway through. 

Bristol County has taken the responsibility of rounds out of its officer’s hands. Rounds are now completed digitally. An alarm counts down randomly between 8 and 14 minutes to alert the officer on mental health watch to make the rounds.

On April 21, 2000, a camera captured St. Pierre’s first criminal mug shot. He stared directly into the camera with a look of nervous confusion on his young face. Short dark hair covered his head. The outlines of three tattoos appeared on his neck, forearm and wrist. He faced charges of assault and battery with a dangerous weapon.

Fifteen years later, through at least three suicide attempts and 26 discipline reports within the department of corrections, St. Pierre’s final mugshot showed him staring slightly up at the camera with a hardened look on his face. His hair was gone, replaced by tattoos. In all, 44 pictures documented the ink scrawled across his body. He faced charges of armed assault to murder.

Between the bookended mugshots, the first reference of suicide on St. Pierre’s record appeared Aug. 24, 2001, two days after he was accused of fighting with another inmate.

St. Pierre told a correctional officer that he was going to “rip out, because he should not be in (segregation).”

Soon after, officers noticed that it looked “like inmate St. Pierre was trying to tie his bed sheet to the screen in his cell.” As officers entered the cell, St. Pierre jumped off his bed, tightening the sheet around his neck.

Officers managed to save St. Pierre’s life, but the standards of 2001 placed the 18-year-old on a 30-day discipline sentence.

In studying suicide prevention for more than three decades, Velize drafted a chart of factors that could contribute to suicidal thoughts entering a person’s mind.

“There are so many ways that a human being can think about this thing and the unpredictability of doing it,” Velize said. “Short of saying that everyone is watched 24 hours a day by an officer and even then, still I don’t even know if it’s possible, not possible to do it.”

Every person who interacts with inmates at Bristol County receives mental health training, which is done to spot those with suicidal thoughts. Every inmate who enters any Bristol County facility receives a mental health screening. 

“One effective prevention strategy is to create more interaction between inmates and correctional, medical and mental health personnel,” he wrote in an article for the National Center on Institutions and Alternative.

Velize also focused on the communication between staff at Bristol County when asked about interactions between inmates and correctional officers.

“There’s a lot of interaction and communication with inmates and our staff. We know that,” Superintendent Steven Souza said. “If we see someone that doesn’t seem right come to the kitchen to eat in the chow hall, and they're very quiet today and they’re usually very jovial, they’ll usually make a note of that.”

“Speaking to an individual by itself doesn’t correlate directly," Velize said. "It’s the quality of communication. That there’s no interference between corrections and mental health health.”

St. Pierre’s institutional records show conversation between he and correctional officers were difficult. Many led to notices of discipline for foul language and disrespect.

“There isn’t anything that our officers feel more badly about and the medical staff as well than to have somebody commit suicide,” he said. “Professionally it’s hard to accept that. And wondering if there was something more I could’ve done because you’re left without the answers.”

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