Teen's jail suicide highlights complexity of screening inmates for mental illness
Experts caution that mental health screening in correctional settings needs to be a thorough and ongoing process
By Hannah Leone
The Beacon-News, Aurora, Ill.
AURORA, Ill. — Less than 24 hours after booking officers determined he was not a suicide risk, 19-year-old Devin Jaros was found hanging from a sheet in his LaSalle County jail room.
Tied around a TV mount affixed to a wall, Jaros was out of view of the motion-activated surveillance camera.
His two cellmates said they were sleeping and didn't notice. When a corrections deputy conducting cell checks discovered the body, the commotion woke them up, they said.
The cellmates held Jaros while the officer cut him down.
Months later, public records and interviews detail the last day of Jaros' life, from his arrest in Marseilles to his Sept. 17 hanging at the jail in Ottawa, showing how the troubled teen was able to slip though the cracks among staff trained to prevent suicide.
Experts caution that mental health screening in correctional settings needs to be a thorough and ongoing process. LaSalle jail officials said they followed protocol, state and national standards and could not have anticipated the suicide based on the information they had.
One deputy called to Jaros' cell that night told investigators in a recorded interview, "How he accomplished that without those other two inmates seeing it, hearing it, reporting it, that's the biggest thing that shocks me."
In a phone call the week after Jaros' death, his parents wondered whether authorities handled the situation properly.
"We are concerned," Jason Jaros said. "It doesn't seem to me like something that should happen in a jail, as not only are they charged to protect the public, but they are also charged with their (inmates') safety."
Citing pending litigation, Jason Jaros declined further interviews for this story but said he hoped for more awareness of tragedies such as his son's.
Born in Aurora, Devin Jaros had a history that wasn't reflected in intake documents, which stated he was not mentally ill or on suicide watch.
On a suicide prevention screening sheet, a corrections deputy drew a line down the "no" column to answer all 16 questions.
"They ask them every single question in a row and if there's not a yes to any of them, they will just do one line," said jail superintendent Jason Edgcomb.
Was Jaros very worried about major problems other than his legal situation, such as fear of losing his job?
Did he express feelings of helplessness or hopelessness?
Did he have a psychiatric history?
Not according to the screening sheet, which also indicated no history of drug or alcohol abuse, though a postmortem toxicology report revealed marijuana and fentanyl in Jaros' urine; his prior convictions included marijuana possession; and, hours before, he had told a Marseilles police detective that his smoking habit made him a bad drug dealer.
It was just Jaros and the detective, sitting on opposite sides of a wooden table in a bleak room with gray walls. Blond-haired and blue-eyed, wearing a gray T-shirt and black sweatpants, Jaros slouched in his chair. It was just past midnight.
"I made a mistake," Jaros told the detective during a videotaped interview at the police station. "After a while of being good I made a bad decision. It really (screwed) me over, and now I got to deal with the consequences."
Taking his grandmother's car without her permission had been one thing. When Marseilles police tried to stop Jaros for driving without lights on, he sped away and crashed. Police found a loaded 12-gauge semiautomatic shotgun in the trunk, and it wasn't his grandma's.
Considering his record, Jaros said, he had hoped he could get away.
"I didn't want to go to jail," he said, later adding: "I can't stand it there."
But police secured felony charges, including aggravated fleeing and eluding and unlawful use of a weapon. Driven from the police station, Jaros was booked in the jail about 2 a.m. Saturday, Sept. 17.
Pre-trial detainees attempt suicide at a rate about 7.5 times greater than the general male population, according to a 2007 World Health Organization report.
While a federal report documented a dramatic decline in jail suicide between 1983 and 2002, when the rate per 100,000 inmates dropped from 129 to 47, more recent data show that trend has not continued.
Suicide, the leading cause of death in local jails nationwide, increased 13 percent between 2013 and 2014, according to a Bureau of Justice Statistics report published in December. In 2014, the most recent year covered in the report, the Bureau recorded 372 jail suicides -- the most in any year since the Deaths in Custody Reporting Program began in 2000.
While levels have fluctuated over the years, Bureau data show the suicide rate is consistently highest in local jails, where the 2014 rate was 50 per 100,000 inmates, compared with 20 in state prisons, 14 in federal prisons and 13 among the general population.
Improved screening helped jail suicide rates plummet in the late 1980s, but it's hard to say why those rates started increasing again, said Judith Cox, a former prison psychologist. Smaller jails typically have higher suicide rates because of staffing, Cox said.
At the LaSalle County jail, where the average daily population is 175, staff for years have been noticing more inmates struggling with mental illness, Edgcomb said.
The World Health Organization calls jails and prisons "repositories" for vulnerable groups with high suicide risks, including young males; people with mental disorders; socially disenfranchised or isolated people; and substance abusers. Further, according to the organization, the psychological impact of arrest and incarceration may exceed the average prisoner's coping skills, as may drug withdrawal, and some jails may lack formal policies or procedures to identify and manage suicidal inmates.
Questions on LaSalle County screening guidelines, which Edgcomb said they've been using since at least 2002, appear most similar to a suicide prevention model Cox helped develop for New York prisons in the 1980s. Cox described four essential components: identify, refer, keep safe, provide treatment.
In a 2007 report, researchers funded by the National Institute of Justice said two mental health screening tools they created and tested were likely to work in correctional settings.
Robert L. Trestman, who worked on one of the screens, said both focus on recognizing mental illnesses and there is no universal screen specifically for suicide risk in jails, though the New York model is frequently used.
But screening often relies on what inmates choose to self-report, and they commonly keep suicidal ideations secret. Staff will sometimes catch someone who has previously received mental health treatment at the jail lying during screening, Edgcomb said.
"Most are going to try very hard to hide that," he said.
Though Jaros had been to the jail before, no one involved in his booking on Sept. 17 had prior knowledge of his mental health history, Edgcomb said.
Identification of suicide risk should start when a person enters and stop only when that person leaves the jail, Cox said. It should incorporate information from officers involved in the arrest and transport of the inmate along with lawyers or family who might see the inmate in jail or know of drug use, Cox and Trestman said.
Anyone screening inmates should be trained to notice panic, anxiety, loss of interest and other suicidal or strange behaviors, Cox said.
At one point, when Jaros was alone in the interview room, video shows him picking at his fingernails and putting something he'd picked off into his mouth.
Cox said that type of behavior demonstrates anxiety and, if observed, should lead to a referral for health care.
Professionals said Jaros had anger issues and hinted at depression, his dad said. He described past efforts to help his son "from a psychological standpoint," including a residential behavioral health facility, family counseling and court-ordered rehab facilities. At some point, Jaros was prescribed a mood stabilizer, his father said.
During his interview at the police station, Jaros reminded the detective of his "history with the Marseilles Police Department."
Besides traffic citations, between 2012 and 2015, LaSalle County records show Jaros' prior convictions included possession of smoking materials, violating curfew, driving without a license, leaving the scene of a crash, fleeing police and marijuana possession.
The detective asked Jaros if Marseilles police had always treated him decently, and he said they had, but he was still afraid.
"I was scared that I was already going to jail," Jaros said, "especially since I had the gun in the back for protection and I obviously don't have a FOID card."
Jaros said he'd been stashing the shotgun in his grandmother's backyard in the weeks since he bought it for $160 from a stranger in Boulder Hill. He'd been robbed of money and marijuana during recent visits to Marseilles and didn't want to take his chances, he said.
"I do carry a lot of weed," Jaros said. "But I don't sell it because I end up smoking before I'm able to sell it so ... my selling business isn't going that well."
He said he did have an actual job, tiling floors.
"Had an actual job," he amended.
"Man, for a while there, I thought you were doing pretty good," the detective said.
Jaros was, he said. But on Sept. 16, a friend of a friend needed a ride from Oswego to Marseilles.
When the cop came up behind him, lights activated, Jaros got scared and sped off. As he turned a corner, he tried to brake but struck a white Chevy, he said. He jumped out of the car, panicking and anxious, ran down an alleyway and hid by some stairs until an officer saw him.
"You screwed up your grandma's car," the detective said. "Pretty badly."
"I know, I know," Jaros said.
Both people in the Chevy were National Guard members, in the area for weekend drills, the detective said.
"Serving our country," he said, "and they get T-boned."
Again, Jaros said, he knew he messed up.
But was he already feeling suicidal?
The reasons people might lie about their mental health aren't much different in jail, Trestman said. They could be embarrassed, worried about incriminating themselves on substance abuse questions or fearful about how suicidal inmates are handled. Inmates may be uncomfortable sharing with someone who's not a health care professional, he said.
If it's a busy night, if other people are around or if the officer asking the question is antagonistic or clearly uninterested, they are less likely to get truthful answers, Trestman said.
"If people feel they are in a safe environment and someone is genuinely concerned about their safety, they're more likely to give an honest answer," Trestman said.
Getting at the truth can be difficult, and picking up on more subtle cues requires "a culture of being concerned," Trestman said.
As an expert witness in suicide prevention cases, Cox said she has noticed poor assessments, done too quickly or in noisy areas.
"You can't rush a suicide assessment," Cox said.
Brought in on a slow night, Jaros was the only inmate in the booking room with two officers during his screening, Edgcomb said.
Experts, including Trestman and Cox, stress the importance of communication and collaboration in suicide prevention.
When someone is repeatedly incarcerated, a correctional facility should know about previous mental health treatment in the community, Trestman said.
The goal in health care is to minimize the chance of mistakes -- including in jails, which are often underfunded and understaffed, he said.
"It's a difficult job, but we have a constitutional obligation to do it," he said.
In these settings, an appropriate standard of care is rarely taken, Trestman said. "Occasionally it happens, and almost always in response to a tragic event," he said.
Best practices have medical, nursing or other specialized staff conducting initial screenings and involve heavy training when corrections officers are responsible, Trestman said. But without practice, supervision and ongoing feedback, training has been shown to do virtually nothing to reduce risk, he said.
Suicide prevention training should incorporate supervision by a mental health professional, Cox said. Ideally, resources permitting, at least the initial training would be done in a group environment, she said.
In LaSalle County, Edgcomb said all corrections officers rotate booking duties and complete annual training for managing inmates' mental health, using a video-based program with no classroom instruction. Two lessons specifically relate to suicide prevention, according to materials provided to the Beacon-News.
Each new officer goes through eight weeks of field training during which training officers observe them performing mental health screens, Edgcomb said.
Jail policy outlines a collaborative, all-staff approach to suicide prevention using medical screening, suicide precaution protocol and "additional indicators."
An initial medical screening conducted by the booking officer is followed with an appraisal by qualified health care personnel within 14 days of intake. Jaros had only the initial screening, which includes questions along with observations of behavior, mental state and appearance. The first 12 hours of incarceration have the highest potential for suicidal acts, according to jail policy, which details several strong indicators of potential suicide and a long list of secondary indicators.
Classification records for each inmate are supposed to contain all available information about current offenses, past convictions and institutional records, including any history of medical or mental health conditions requiring special housing considerations. Ongoing therapy from community providers "will be disclosed and taken under advisement" when creating treatment plans for mentally ill inmates, jail policy states.
Jaros was in a pre-classification area, awaiting a morning bond hearing.
Throughout efforts to revive him before medics arrived, a nurse never detected a pulse.
From a local hospital, Jaros was airlifted to St. Francis Medical Center in Peoria, where he was pronounced dead at 3:41 p.m. Sept. 19 from lack of oxygen to the brain due to hanging. The Peoria County coroner ruled it a suicide and determined he was not intoxicated by any drugs in his system.
The suicide affected everyone involved, Edgcomb said.
But he said he doesn't think it means the jail needs to change its policy, procedures or layout. Since 2010, one other inmate has died by suicide, he said.
In 2014, a 38-year-old man from Streator charged with dealing heroin hanged himself 11 days after he was booked. Two days before the hanging, Jason Watson was released from the jail's mental health care to its general population, a decision typically made by a psychiatrist or mental health nurse, Edgcomb said. No longer considered a suicide risk, Watson got a regular jail uniform and a cell to himself.
Though both Watson and Jaros were discovered hanging from bedsheets during cell checks and later pronounced dead at the same hospital, Edgcomb characterized their cases as "opposite," with one under the care of the medical department for more than a week and the other in custody less than a day.
Reflecting on Jaros, Edgcomb said he didn't know if anyone, even an experienced mental health specialist, would have guessed he was having suicidal thoughts.
"It weighs on me anytime something like that happens," Edgcomb said. "Our job is to keep everyone safe, but our officers couldn't, and I don't think there is anything anyone else could have done to prevent that situation."
The wall mount from which Jaros was hanging has not been moved, he said.
(c)2017 The Beacon-News (Aurora, Ill.)