AP investigation: Utah jail inmate’s suicide not an isolated case
Tanna Jo Fillmore one of hundreds in the U.S. who took their lives while incarcerated during 2015 and 2017
(Rick Bowmer | AP) Melany Zoumadakis stands in her home Wednesday, April 24, 2019, in Salt Lake City, talking about the grief she has endured since the 2016 death of her daughter, Tanna Jo Fillmore. Fillmore, who had a history of mental problems, killed herself in 2016 at the Duchesne County Jail in Utah. Her mother, who has filed a lawsuit, says her daughter was denied her prescription medications and had threatened to harm herself.
(Rick Bowmer | AP) Melany Zoumadakis holds a crucifix while talking about her daughter, Tanna Jo Fillmore, at her home on Wednesday, April 24, 2019, in Salt Lake City. Fillmore, who had a history of mental problems, killed herself in 2016 at the Duchesne County Jail in Utah. Her mother, who has filed a lawsuit, says her daughter was denied her prescription medications and had threatened to harm herself when they spoke the day before her death.
(Rick Bowmer | AP) An arrangement of photos, flowers and Easter eggs surrounds the grave of Tanna Jo Fillmore on Friday, April 26, 2019, in Salt Lake City. Fillmore, who had a history of mental problems, killed herself in Duchesne County jail in 2016 while locked up on a probation violation. She told her mother she was being denied her prescription medicines that had stabilized her.
(Courtesy of Melany Zoumadakis via AP) This undated photo provided by the family in 2019 shows Tanna Jo Fillmore as a girl. Jo-Jo or TJ, as her family called her, competed in rodeo barrel races while growing up in Utah. Fillmore, who had a history of mental problems, killed herself in 2016 at the Duchesne County Jail. Her mother, who has filed suit, says her daughter was denied her prescription medications and had threatened to harm herself when they spoke the day before her death.
(Rick Bowmer | AP) Melany Zoumadakis wipes a tear while visiting the grave of her daughter, Tanna Jo Fillmore, on Friday, April 26, 2019, in Salt Lake City. More than two years after her daughter's suicide, her mother says she still grieves and thinks about her constantly. Fillmore told her mother she desperately needed her prescription medicines, but a jail nurse wouldn't provide them. Her mother has filed sued.
(Rick Bowmer | AP) Melany Zoumadakis clutches a photo of her daughter, Tanna Jo Fillmore, on Friday, April 26, 2019, in Salt Lake City. Fillmore killed herself in the Duchesne County Jail in 2016, after repeatedly calling her mother, saying she was being denied her prescription medicines that had stabilized her. Her mother has filed suit.
Melany Zoumadakis arranges photos and flowers that she brought to the grave of her daughter, Tanna Jo Fillmore, on April 26, 2019, in Salt Lake City. Fillmore killed herself in 2016 while being held on a probation violation. She had threatened to harm herself after she told her mother she was being denied her prescription medicines. Her mother has filed suit. (AP Photo/Rick Bowmer)
(Eric Risberg | AP) A clock at top counts down intervals between checks on inmates in the booking area holding cells at the Lake County Jail in Lakeport, Calif., on Tuesday, April 16, 2019. Major reforms were put in place at the jail following the 2015 suicide of a woman with a history of mental health problems who had repeatedly begged for help. Her son’s lawsuit resulted in $2 million wrongful death settlement.
(Morry Gash |AP) Dane County, Wis., Sheriff David Mahoney looks through a small window in a solitary confinement cell at the county jail in Madison. Mahoney says he has no separate housing for inmates with certain behavioral, medical or mental health problems, so he has to put them in these cells even though he says it's "inhumane. But we're forced into a situation to keep these people alive."
(Morry Gash | AP) Dane County, Wis., Sheriff David Mahoney stands in a solitary confinement cell at the county jail. An advocate for the mentally ill, Mahoney says he sometimes has to lock certain inmates in these cells even though he calls the conditions "inhumane." Mahoney hopes to secure funding to replace the jail with one that will have a hospital-like wing.
(Brett Coomer/Houston Chronicle via AP) In this Sunday, July 26, 2015 file photo, Margaret Hilaire bows her head in prayer during a demonstration calling for the firing and indictment of Texas State Trooper Brian Encinia in Katy, Texas. Sandra Bland was found dead in her cell on July 13 in the Waller County Jail, just days after being arrested by Encinia during a traffic stop. Authorities determined through an autopsy that Bland hanged herself with a plastic bag.
(Pat Sullivan | AP file photo) This July 22, 2015 file photo shows the Waller County jail cell in Hempstead, Texas, where Sandra Bland was found dead. In Texas, the Sandra Bland Act became law in 2017, mandating mental health training for law enforcement and making it easier for those arrested to receive a personal bond if they have a mental illness or substance abuse problem. Bland killed herself after being jailed for a minor traffic violation.
(Eric Risberg | AP) Dane Shikman holds a photograph showing him with his mother, Elizabeth Gaunt, at his home in San Francisco on Friday, April 19, 2019. Gaunt, a former social worker with a history of mental health and substance abuse problems, killed herself in 2015 in the Lake County Jail in northern California. Her son's wrongful death lawsuit resulted in a $2 million settlement. Changes also were made at the jail.
(Eric Risberg | AP) Dane Shikman holds a rock from the beach where the ashes of his mother, Elizabeth Gaunt, were scattered in Ireland along with a pair of cufflinks she had made for him as he sits at his home in San Francisco on Friday, April 19, 2019. His mother, who had a history of mental health and substance abuse problems, killed herself at the Lake County, Calif, jail in 2015, after she repeatedly cried for help. Her son's wrongful death lawsuit resulted in a $2 million settlement.
(Eric Risberg | AP) In this Tuesday, April 16, 2019, photo, Emma Elwood, a nurse at the Lake County Jail in Lakeport, Calif., checks the vitals of a woman in the booking area. A series of changes, including adding a registered nurse, were made at the jail following the 2015 suicide of Elizabeth Gaunt, a former social worker who had repeatedly cried for help while locked in a cell. A wrongful death lawsuit resulted in a $2 million settlement.
(Eric Risberg | AP) This Tuesday, April 16, 2019 photo shows an exterior view of the Lake County Jail in Lakeport, Calif. After a 2015 suicide at the jail resulted in a $2 million settlement in a wrongful death lawsuit, several changes were made, including adding a larger surveillance monitor, to prevent further tragedies.
(Eric Risberg | AP) An inmate is shown covered in a tear-resistant blanket sleeps at the Lake County Jail in Lakeport, Calif., on Tuesday, April 16, 2019. These blankets were one of the many changes and reforms made at the norther California jail after a 2015 suicide there resulted in a $2 million wrongful death settlement.
(Eric Risberg | AP) Sheriff Brian Martin looks at a video monitor in a control area of the Lake County Jail in Lakeport, Calif., on Tuesday, April 16, 2019. The sheriff instituted many reforms and changes, including a larger video surveillance monitor, following the 2015 suicide of a woman who had repeatedly cried for help. Her son's wrongful death suit resulted in a $2 million settlement.
The last time Tanna Jo Fillmore talked with her mother, she was in a Utah jail, angry and desperate. She’d called every day that week, begging for help.
I need my medicine, she demanded.
At 25, Fillmore had long struggled with mental illness, but Xanax and hyperactivity medication had stabilized her. Now, she was locked up on a probation violation, and she told her mother the jail nurse was refusing to provide her pills. In their final conversation, Fillmore threatened to kill herself.
Melany Zoumadakis was so alarmed she immediately called her daughter’s probation officer, who assured her Fillmore was being closely monitored. But on Thanksgiving 2016, a day after that threat, Fillmore hanged herself in the Duchesne County Jail.
Her case is not isolated. Increasingly, troubling questions are being raised about the treatment of mentally ill inmates in the nation's 3,100 local jails, possible patterns of neglect — and whether better care could have saved lives.
(Courtesy of Calley Clark) Tanna Jo Fillmore is one ore than 300 suicides in local jails from 2015 to 2017 — in just nine states. A woman who says she was Fillmore's cellmate says she didn't receive her anti-anxiety medication before her death in November 2016.
A joint investigation by The Associated Press and the University of Maryland's Capital News Service finds many jails have been sued or investigated in recent years for allegedly refusing inmates medication to help manage mental illness, ignoring cries for help, failing to properly monitor them, or imposing excessively harsh conditions.
A review of 165 lawsuits that specifically involved suicides or attempts in local jails found:
In about a third of the cases, staff allegedly failed to provide prescription medicines.
Many inmates weren’t checked regularly — usually every 15-30 minutes — because of staffing shortages or inadequate training.
More than half the suicides or attempts occurred during the first week, a stressful time for those coping with sudden confinement, and about 80 percent of the inmates were awaiting trial.
Clothing, bedsheets or shower curtains were frequently used; some inmates were given razors, despite warnings to staff that they might harm themselves.
These lawsuits represent a tiny fraction of the problem. Suicide, long the leading cause of death in U.S. jails, hit a high of 50 deaths for every 100,000 inmates in 2014, the latest government data available. That’s 2½ times the rate of suicides in state prisons and about 3½ times that of the general population.
The total number of suicides in 2014 was 372, according to federal statistics.
An exclusive 50-state reporting effort to collect recent statistics found more than 300 suicides in local jails from 2015 to 2017 — in just nine states. The others did not provide numbers or offered incomplete data, an issue prompting some legislatures to consider bills that would require jails to provide better information about those dying behind bars.
It's a problem commonly blamed on the fact more mentally ill people are being jailed, a trend that started after state psychiatric hospitals began closing in the 1970s. More recently, jails have been overwhelmed with opioid or meth users, many of whom also wrestle with depression.
Lori Rifkin, a California prisoners' rights attorney, argues the vast majority of these suicides "are foreseeable and preventable."
"I think there is a cultural dismissiveness toward both the signs that help us predict suicide — and toward the steps necessary to prevent them," she adds.
Jonathan Thompson, head of the National Sheriffs' Association, calls that absurd and says while jail officials must safeguard inmates, "we're not the nation's psychologists. We have decided that as a society let's just warehouse the mentally ill in a jail ... which is neither equipped for, trained to handle or able to be most efficient and effective at solving the problem."
Some cases have resulted in substantial settlements over faulty policies or neglect.
In Lake County, Calif., Elizabeth Gaunt, a 56-year-old former social worker with a psychiatric history, was jailed after acting erratically but never charged. Over 25 hours, she begged for a doctor, repeatedly screamed “help me,” tore a blanket into strips and then killed herself. A guard didn’t enter her cell during a check but noted in an observation log all was OK. The county settled a wrongful death lawsuit for $2 million.
Dane Shikman, Gaunt’s son, says his mother belonged in a mental health center, not jail, and believes guards were negligent. “When they see someone who looks like they’re struggling,” he says, “they don’t say, ‘Let me step in. This is someone’s mom.’ ... They think this is a woman on drugs doing whatever she’s going to do, she’ll shut up.”
Sheriff Brian Martin implemented reforms that included installing a larger surveillance monitor, replacing blankets with tear-resistant ones and giving staff more suicide-prevention training.
In Fillmore's case, a lawsuit is pending against Duchesne County, the former sheriff and others, including the jail nurse.
Fillmore had been diagnosed years earlier with post-traumatic stress, anxiety, panic disorder and depression. She also had a history of drug use, but attorney Tyler Ayres says she wasn't suicidal and just needed her medication. "They have an obligation to provide adequate medical care," he says.
Fillmore was jailed, Ayres adds, for failing to provide a change of address to a probation officer.
Sheriff Travis Tucker, who took office in January, declined comment on the case but noted a jail wing is being built to serve mentally ill and addicted inmates.
When she died, Fillmore was waiting to enter a residential drug program. Five days later, on what would have been check-in day, her mother got a call asking why Fillmore hadn't shown up.
She relayed the news. Then she prepared to bury her daughter.
Cohen, an AP national writer, reported from Chicago. Eckert is a reporter with the University of Maryland’s Capital News Service. Also contributing to the data analysis were Capital News Service reporters Riin Aljas, James Crabtree-Hannigan, Elliott Davis, Theresa Diffendal, Jessica Feldman, Hannah Gaskill, Samantha Hawkins and Roxanne Ready.
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