On a cold, gray February morning, Cheryl Miller sat on a bus cradling the gym bag that held the box with her son's ashes.
For five months, the ashes had sat in the embalming room of a Chicago Heights funeral home because Miller could not pay off the bill for the funeral of her 16-year-old son Jamal, who had committed suicide at the Illinois Youth Center in St. Charles. As soon as she received an income tax refund, she got a cashier's check for $2,500 and took the bus from Springfield, where she lives, to bring him home.Finally, she had her son's remains. But she still didn't have answers.
"He's at peace now," said Miller, 42, as the city bus lumbered south on Halsted Street toward her mother's home. "I won't be at peace until I get some conclusion to this. Some justice."
For Cheryl Miller, as for the families of six other young men who committed suicide in the state's juvenile facilities in the past decade, information about her son's death has been scant and elusive. State officials tell families little. Miller didn't even know her son had left suicide notes, including a letter saying goodbye to his family, until the Tribune showed her copies.
Laura Westerfield, whose 15-year-old son Timothy hanged himself at the juvenile facility at Kewanee in September 2008, said she, too, tried unsuccessfully to get answers about how and why her son committed suicide.
Then, a week after Timothy killed himself, she got a letter from the center's superintendent. It detailed how she could request the $57.91 that remained in her son's account. It felt, Westerfield said, like a final insult.
"I still don't understand my son's death," she said in the living room of her Decatur home. "They never explained to me what happened. They never told me how I could find out."
No fault found
State officials decline to disclose much information about the suicides; in many cases, the Tribune learned, they simply don't try to uncover it.
Investigations into the seven suicides conducted by the Illinois Department of Corrections failed to answer key questions or resolve inconsistencies in accounts of the deaths, the Tribune found. None of the investigations found fault with procedures or staff, records and interviews show.
"If he would have done that here at home, they would have locked me up for child neglect," said Miller, who moved to Springfield from Park Forest, where Jamal had grown up. "But when it happens in the system, who is responsible? Who is punished?"
Miller knows that her son, who died Sept. 1, was troubled. Jamal Miller had a history of mental illness and suicide attempts and had bounced around from treatment centers to juvenile detention. He had been sent to the correctional system for attempted robbery and aggravated battery. But his death, she said, deserves greater scrutiny.
"They're just looking at what these kids are doing," she said. "They're not finding out where it's coming from and why it's happening. ... All they're looking at is what they see. Lock them up and throw away the key."
Contradictions mark the record of the last hours of Miller's life, yet the investigation of his death made little attempt to sort out the truth.
The afternoon before he committed suicide, Miller argued with a guard, the investigation found. That evening, Miller attempted to apologize. Three inmates in his housing unit told the investigator handling the suicide inquiry that the guard rejected Miller's overture. In her interview with the investigator, the guard said that she had accepted the apology, telling Miller, "Tomorrow is a new day."
The report by the investigator, Arnold Kinard, shows that he did not return to the guard for further questioning despite the witnesses' statements and even though the incident appeared to be a factor in Miller's suicide. One of the notes Miller tacked to his wall was addressed to the guard and read, in part: "I want you to know your what pushed me off the edge and thank you for your help."
The account of another guard, the one on duty the night Miller died, also went unchallenged in spite of inconsistencies, raising questions about the thoroughness of the investigation.
Department of Juvenile Justice procedures required the guard to walk the hall every 15 minutes that night, looking into each room with a flashlight to check each inmate's well-being. Guards need to "see skin," a phrase they use for making sure some part of the inmate's body is visible. They then return to their post to fill out a form documenting the checks on each inmate.
In her statement, the guard wrote that when she looked into Miller's room during rounds at 3:09 a.m., he appeared to be squatting, using the toilet. When she looked again, she said, she noticed a "long piece of rope" attached to the top bunk. She called for help, and when she and another guard entered the room, they found Miller hanging from his bed.
Police photographs of the scene show that the toilet is several feet from where the remains of the noose were hanging, making it unlikely that Miller was using the toilet. The guard's statement also did not mention the sheet of notepaper attached to the door window, on which he had written: "RIP Jamal Damerco Miller." She told the investigator that she did not recall seeing the paper, although photographs show it covered more than a third of the window.
Most puzzling, her tracking form for that night shows a check mark for Miller at 3:09 a.m. If she had followed procedure, that would mean she discovered Miller hanging from his bunk, called for help, cut down his body and attempted CPR -- then returned to her station and checked him off on the form.
Kinard did not make note of that inconsistency, nor did he follow up on an inmate's statement that the guard did not do all her checks that night. Three investigators told the Tribune that they try to get the tracking forms as quickly as possible in any death investigation because of concerns that guards don't always make the required checks even when they say they do.
A former St. Charles inmate, Matthew Sirtoff, now 21, told the Tribune that guards often did not make all their checks. Sirtoff, who occupied a room near Miller's, said he had stayed awake for some time on the night of Miller's death and never saw the guard on duty shine her flashlight through the window of his door. Sirtoff was not interviewed by the investigator.
Kinard's interview with the guard summarizes some gaps in her account, but there is no evidence of follow-up. It concludes: "She don't recall what Miller was doing during the 2:54 check. She don't remember seeing a note attached to the door that read 'RIP Jamal Damerco Miller,' on the glass window during the check at 2:54 or when she discovered him hanging. The last time she recall seeing Miller walking around and talking in his cell was approximately 10 p.m., the beginning of her shift."
Department of Juvenile Justice Director Kurt Friedenauer and other officials said they did not think Miller's argument with the guard, or whether she had accepted his apology, was relevant to the investigation.
But the confrontation was significant to Miller, and understanding the circumstances could help the department better train employees in how to deal with the youths.
Friedenauer also said he has no reason to doubt that the second guard did her checks as required. While he said he could not reconcile the position of the noose with her statement that she thought Miller was using the toilet, he said he had no doubt "that's what she thought she saw." He said he was satisfied with the investigation.
The two guards declined to speak with the Tribune. Kinard said he was willing to discuss his investigation with reporters, but Department of Corrections officials would not allow him to be interviewed.
In December 2002, Zachary Schwartz, incarcerated for burglary, was found hanging from an air vent cover in his room at the Kewanee facility. Records show the 17-year-old removed the mattress from his bed, rolled it into a cylinder and tied it up with torn strips of bedsheet. He used other strips of sheets to make a noose he tied around his neck.
Schwartz fastened the other end to the air vent cover on the wall, presumably by standing on the rolled-up mattress. Still other knotted strips of sheet were found in a hole he apparently had made in the mattress.
Investigative records say he was found dead seven minutes after the guard's last check.
But the investigator, Anita Emrich, raised no questions in her report about Schwartz doing so much in such a short time or, if Schwartz had torn the sheets earlier, about how he had done so without being detected.
Luke Hartigan, the chief of investigations for IDOC, stands behind his officers' investigations, saying they "look at all of the aspects" of an inmate's suicide. "We want to make sure staff have done all that they're supposed to do," he said.
Friedenauer, who reviews all investigations, said he, too, is confident in the work. Although IDOC ran the state's juvenile facilities until July 2006 and continues to provide support staff, he said he considers it an "outside agency" and says its investigators are not reluctant to hold employees accountable.
"My experience has been that they tend to be very thorough," he said.
Despite his public support of the investigations, Friedenauer sought to set up a review panel for inmate deaths less than two weeks after Miller's suicide. That process was enacted in legislation passed earlier this month to establish a mortality review team -- with members to be named by the director -- that will suggest improvements in policies. After Miller's mother requested his files following his death, Department of Juvenile Justice officials also determined that, in the future, families will be allowed to get the investigative reports.
In May, eight months after Jamal Miller's death, his mother learned that he had left her a message.
She had gotten very little information about the suicide except what she could glean from friends and family. A young relative who had also been at St. Charles told her that her son had killed himself after arguing with a guard. A member of her church had heard he put a note on the window of his door.
But, according to Miller, officials did not tell her about the note until she asked about it. Even then, she wasn't told her son had left three other suicide notes.
They had been stuck to the wall with toothpaste. On one, he drew a face with a thought bubble reading "HELP!!!" and labeled "The Real Jamal ... Scare of the Real World." He also left the note to the guard.
And to his family, he wrote: "I love you, I hope you all got my last picture I sent you guys just know I loved you all. Bye."
The first time Cheryl Miller saw that note, she was sitting in her living room in Springfield, next to the sideboard displaying the "Praying Hands" urn containing her son's ashes and a collection of photos of him, almost all taken in one institution or another.
She took the copy of the note and clutched it to her chest, crying.
"I knew he would tell me bye," she said. "He never would leave me without saying something."
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About this report
The Tribune reported these stories by reviewing thousands of pages of court papers, prison records, medical and psychiatric records, and other documents, as well as conducting dozens of interviews. The newspaper obtained many documents through the state's Freedom of Information Act. Other documents, including confidential prison and mental health records, were obtained with the cooperation of inmates' family members, who shared documents they had obtained and made open records requests to the Department of Juvenile Justice. The reporters petitioned Cook County Juvenile Court for records involving Jamal Miller.
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