Guidelines on Suicide Watch Are Tightened

The night before he was found hanging unconscious in his cell, a 16-year-old youth at the California Youth Authority facility in Norwalk was identified as a possible suicide risk after carving his grandmother’s initials into his arm, according to an internal state report obtained Wednesday.

But the teenager, who died one week ago today, was not placed on suicide watch because a psychiatrist concluded that he was not in crisis, according to a report to state officials based on information from the CYA and other agencies.

The disclosure came as CYA officials confirmed Wednesday that two more juveniles attempted suicide during the last week at other facilities run by the agency. Neither of those youths was on suicide watch. One of them, a 17-year-old, came out of a coma Wednesday.

The incidents prompted the agency’s acting director, Jerry Harper, to implement new suicide prevention procedures.

They include security checks at 15-minute intervals instead of 30-minute intervals for all youths in isolation cells. Previously, the 15-minute checks were made only for juvenile offenders under suicide watch.

Additionally, Harper said he has instructed the superintendents and top staff at each of the CYA’s 15 facilities to personally inspect the living quarters for juveniles and the clothing they are issued to assure that all safety precautions are being followed.

“It is just a very intense look at the whole process,” Harper said.

But even as the CYA and the state inspector general’s office continue their investigations into last week’s suicide, state Sen. President Pro Tem John Burton (D-San Francisco) said he was so disturbed by the events that he will probably press for the Legislature to make its own inquiries.

Burton, who has long taken an interest in criminal justice matters, said he was particularly troubled by the suicide at the Norwalk facility, the Southern Youth Correctional Reception Center and Clinic.

“It looks as if they really screwed up,” Burton said in an interview.

An investigation by the Los Angeles County Sheriff’s Department has found that the teenager, who was in custody for auto theft, committed suicide about 7:30 p.m. on Feb. 22.

Five minutes before he was found hanging from a bedsheet in his cell, the youth was sitting on his bed eating a sandwich, said Sheriff’s Homicide Sgt. Tom Harris.

But the internal state report on the incident raises questions about events well before the final minutes of the teenager’s life.

The youth, according to the report, had been held at the Norwalk facility since Dec. 12 and had indicated that he had previously attempted suicide at Juvenile Hall.

The night before he hanged himself, the youth had been placed in a single-person cell after flooding a room he shared with other youths by plugging a toilet.

It was in his single-person cell that authorities discovered the youth carving into his skin and contacted a psychiatrist.

The psychiatrist, according to the state report, instructed the CYA staff to place the teenager in a room monitored by a camera but did not tell them to put him on suicide watch because he was not in crisis.

Therefore, the bedding was not taken from the teenager’s room.

The next day, according to the report, the psychiatrist visited the ward twice, once with a psychologist and a social work specialist, and all believed the teenager was not in danger. The youth also was visited by the superintendent of the facility.

That night, during room checks, CYA staff members found the youth hanging by a sheet attached to the camera’s steel cable line.

Staff members had been monitoring another cell, authorities said.

“Because there was some activity in another cell, they were concentrating on a person who was on suicide watch,” Harris said.

The suicide came four months after a state task force recommended a series of safety measures for the CYA.

Among the recommendations: that staff not rely solely on video cameras to monitor juveniles who may be suicidal. The task force said cameras should be used to supplement visual checks.