Why is the suicide rate so high at this Maryland jail?

Behind security gates and heavy metal doors at the Harford County Detention Center, messages of despair are scrawled on the cell walls.

“Although the darkness is tempting, do not lose yourself in it.”

“Remember who you are.”

In this corner of the sprawling, 762-bed jail are the roughly two dozen cells of “R-dorm” — each about the size of a parking space — consisting of a bunk bed, a sink, a toilet, and a small window overlooking a barbed-wire fence. It’s where many newly booked detainees, the majority of whom had not been convicted of a crime, have spent nearly all their time in isolation.

During one four-year span, four people hanged themselves in R-dorm in a similar fashion, using bed sheets secured to the top bunk in their cells. In that same four-year-span, another detainee managed to hang himself while on suicide watch, using a pair of pants.

A Baltimore Banner investigation into the suicides revealed a suicide rate five times the average rate of local jails across the country, flawed practices, lapses in supervision and failures by the Harford County Sheriff’s Office to critically question its own staff or share information with the public, including the loved ones of those who died.

The Banner combed through reams of police reports and court records, located and interviewed independent witnesses and shared its reporting with experts, finding that:

• The eerily similar nature of the suicides should have made them preventable. Those who killed themselves in R-dorm have done so for years in a nearly identical manner, using bunk beds and bedsheets. Their cases shared many similarities, including the common risk factors of alcohol and substance use issues.
• The jail routinely placed newly booked detainees in what’s known as “23-1 lockdown” — all but one hour per day in isolation — a practice that experts said would exacerbate any existing mental health issues.
• People who were known to be struggling with their mental health or substance issues were returned to isolation after just a few days of special observation, another practice experts said would heighten the risk of suicide.
• The Harford County Sheriff’s Office has been all but shielded from scrutiny on how it runs its jail. Deaths in county jails are investigated entirely by local law enforcement, not by the state attorney general’s office, which investigates police-custody deaths. Unredacted portions of police reports show that the sheriff’s internal investigations rarely leveled critical questions at jail staff, who were uniformly cleared of wrongdoing.

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The bunk beds in the jail’s R-dorm cells, combined with the routine placement of at-risk people in isolation, amounted to “incompetence” by the staff of the Harford County Detention Center, said Terence Keel, a UCLA professor of human biology and society who co-authored a study on jail deaths in Maryland.

“They’re creating the conditions for people to kill themselves,” Keel said.

The latest person to die by suicide in the jail was Nathaniel Maurice Powell Jr., a 26-year-old new father. Powell was booked into the detention center on Jan. 18, 2023, on charges of domestic assault.

The Harford County Sheriff’s Office says Powell was discovered hanging during a routine wellness check. But several people who were incarcerated with him gave The Banner a markedly different version of events.

On the evening of Jan. 21, 2023, Powell had been repeatedly calling for medical attention from the confines of his cell, they said. When those in cells near him feared he hanged himself, they called for deputies, who did not respond for at least 15 minutes, the witnesses said.

“They could have saved that man,” said one witness, who asked not to be named due to concerns over his safety and potential retaliation.

For the Powell family, every attempt to get information about Nate Jr.’s death was met with roadblocks. Over the course of several months, the sheriff’s office repeatedly denied the family access to Powell’s suicide note and provided only heavily redacted documents relating to his case.

After the sheriff was presented with The Banner’s findings and questions about the jail suicides, his agency released complete documents — including the suicide note, 911 call audio and video footage — to the family through legal representatives at the ACLU of Maryland, which took on Powell Jr.’s case in the course of The Banner’s reporting.

While largely declining to discuss specific cases, citing the potential for litigation, the sheriff’s office defended its past practices.

The sheriff’s office invited reporters to tour the jail and emphasized that a recent change in medical providers revamped suicide prevention protocols and allocated new resources to mental health services in the jail.

Under his watch, Sheriff Jeffrey Gahler said, the detention center has invested heavily in upgrades, including a new camera system, additional “suicide blankets,” tear-proof heavy garments used instead of clothes to shroud individuals who might be at risk for self-harm, and a new “rubber room,” used to house people who are actively trying to harm themselves.

The sheriff’s office claimed that its jail has a lower suicide rate than other Maryland facilities. Gahler also suggested that some jurisdictions do not accurately report jail deaths and get around the reporting requirements by releasing people from custody before they are pronounced deceased.

“One is too many, we don’t want any,” Gahler said. “We’re not opposed to doing things within our ability and the taxpayers’ willingness to pay the taxes for it, the expenses for it. But I just don’t believe that these other facilities aren’t having the same [suicide rate] or more.”

Gahler also noted that there was a five-year stretch after he took office in 2014 when there were no suicides at the detention center.

A Banner data analysis contradicted Gahler’s assertion that their rate was in line with or lower than other local jails. From 2018 to 2023, the suicide rate at Harford County Detention Center was about 270 per 100,000 incarcerated people — more than five times the average rate of local jails across the country in 2019, the latest year for which data was available from the federal Bureau of Justice Statistics.

Gahler’s defense of his jail comes amid a growing movement among criminal justice reformers to mandate better reporting standards and even require independent investigations for in-custody deaths in Maryland. The practice would be modeled after the way police shootings and fatal vehicle pursuits are now reviewed by the Maryland Attorney General’s Office since a 2021 package of police reforms mandated that change.

A Republican, Gahler has been a fierce critic of those reforms — opposition so staunch that, in April 2022, the former attorney general sued the sheriff’s office over an evidence-sharing dispute following a fatal police shooting.

Gahler rejected the notion that the state attorney general’s office, or anyone else, would be better equipped to conduct investigations into jail deaths than his own detectives.

“The citizens have put their trust in me as the elected sheriff,” Gahler said. “Many places in the state, they don’t have that … and that’s unfortunate.”

What happened to Nathaniel Powell Jr.?

In the months following Powell’s death, rumors swirled on social media alleging that it was not a suicide at all — simply made to look like one.

Nathaniel Powell Sr., who had in recent years reconnected with his son and developed a strong bond with him, knew that his family was depending on him to get to the bottom of it.

“No matter what happens, nothing is going to bring him back,” Powell Sr. said in August. “But I need somebody to answer for that. Me and my family need somebody to answer for that.”

Answers, however, have been hard to come by. A toxicology report showed a mix of sedatives in his son’s system, including one typically used for treating withdrawal.

But the family says they weren’t aware of Powell Jr. having any substance use issues. According to Powell Sr., the sheriff’s office never informed him of any detox protocol Nate Jr. might have been on.

The unredacted portions of the incident report on Powell’s death state that medical staff “gave Nathaniel his medications” at 9 p.m. on the evening that he died, but don’t specify what those medications were, or whether it was jail medical staff who administered the sedatives later found in his system.

Powell Jr. made his last call to his family around 6:35 a.m. on Jan. 21, less than 24 hours before he died. During the call, he asked his grandmother to put money in his commissary account. For his father, that indicated that he didn’t have any intention to harm himself — Powell Jr. knew his grandmother did not have much money.

When Powell Sr. met with a Banner reporter in August, he knew nothing about a suicide note his son had left behind in his cell.

After that meeting, Powell Sr. requested the incident report from the sheriff’s office that referenced the note and received a copy with 74 of the 99 pages completely blacked out. He made repeated attempts to access the suicide note, but was denied.

Over the fall and winter, The Banner located several people who were incarcerated in the Harford County jail at the same time as Powell Jr. and said that they were housed near him when he died.

One witness, who asked not to be named due to fears of retaliation, said Powell was banging on his cell door for hours leading up to his death, asking for medical attention. The witness said he recalled Powell requesting a specific medication, though he could not remember what it was.

Powell, the witness said, had “seemed fine when he got there [to the dorm],” just a couple of days prior, then began “talking crazy.” In the hours leading up to his death, “It was definitely implied” that Powell was threatening to harm himself.

The witness recalled that on the night Powell died, he had stopped responding to a repeated question from those in the cells near him: “You good?”

“We tried calling the COs for 15 minutes before they came in,” the witness said. “By the time they came in, he was dead.”

Another person in the jail when Powell died, who also asked to remain anonymous due to fears of retaliation, said he remembered Powell “hollering and asking for help,” even kicking the cell door at points, for what felt like “all damn day.”

“It was a drawn-out thing,” the witness said. “He would stop, go back, and try to get them to come. … People were talking about how he really needed help.”

There is no mention of Powell’s being in any distress in the unredacted portions of the police reports on his death, and no indication that deputies interviewed any detainee who might have had information about what happened in the hours preceding his death.

The incident report states only that, at 11:47 p.m. on the night of his death, a deputy from the sheriff’s office “conducted a count of the inmates and during that time observed Nathaniel standing at the cell door alive and apparently normal.”

About a half-hour later, the report said, the deputy “conducted another check of all cells and finds Nathaniel hanging from a bed sheet inside his cell.”

The Harford County Sheriff’s Office declined to comment on the witness accounts of Powell’s death, or other aspects of the case, because of a potential lawsuit by his family.

The agonizing toll of isolation

For the family, Powell Jr.’s death was a shock that no one saw coming.

Experts in suicide prevention, however, say that Powell Jr. posed a risk of self-harm that exceeded that of a typical detainee, which should have been taken into account by correctional and medical staff.

Powell Jr. would have fallen under multiple risk categories, they said: He was charged over a domestic-related incident, indicating relationship problems, and he had just been booked into the jail — the first seven to 10 days of incarceration are known as the riskiest period of time for self-harm.

On top of all of this, Powell Jr. was placed in isolation for 23 hours per day, a practice that took some experts by surprise. They said the extensive use of isolation in the Harford County Detention Center would likely exacerbate any underlying mental health issues.

Dr. Terry Kupers, a forensic psychiatrist who advises jails and other detention centers on suicide prevention practices, reviewed The Banner’s findings and said that, while not commenting on any specific case, it was apparent to him that the medical and mental health coverage at the Harford County Detention Center was “very thin.”

People with “any risk at all of suicide” should not be placed alone in a cell, Kupers said, and detention centers need thorough, comprehensive mental health screening to determine that risk.

“That is the number one warning we give jails,” Kupers said.

The sheriff’s office said that everyone who is booked into the jail has a medical screening before going to housing, but did not further specify what steps are taken to evaluate mental health.

The suicides examined by The Banner shared many similarities: All of them occurred in isolation, and the four that occurred in R-dorm were done in exactly the same manner.

In the summer of 2021, Jack Lazar, 51, who was awaiting extradition to Pennsylvania for a burglary charge, hanged himself in Cell R-22. The incident report for his death is heavily redacted, but notes that he was placed on 15-minute watches for “detox purposes” after he was booked on July 3.

Three days later, he was taken to the hospital for undisclosed reasons, but returned to jail the next day. Two days after that, on July 9, he was again seen by medical staff.

“Inmate Lazar advised that this was the first time he had been incarcerated and that he had been unable to make contact with his family,” the sheriff’s office incident report states. “Inmate Lazar was able to make a phone call and after speaking with his family, calmed down and was returned to his cell.”

He was discovered hanging the next day. Like others in R-Dorm, Lazar had torn his white bedsheet and used it to hang himself from the top post of the bunk bed. Deputies observed blood on the bed post as well as a small cut on his face, near his right eye. Those discoveries were not explained in the unredacted portions of the incident report on Lazar’s death.

The sheriff’s report concludes: “There were no notes or any indicators/evidence that would have explained why Inmate Lazar would have wanted to harm himself.”

Attempts to reach the Lazar family were not successful.

Lazar’s death came less than a year and a half after the death of Randy Gisiner. Similarly to Lazar, Gisiner was placed on 15-minute watches, with the listed reasons both as detox protocol and suicide watch, after he was booked on April 16, 2020.

Five days after booking, on April 21, Gisiner’s was taken off “Level 2″ observations and put on “Level 3,” which entailed 30-minute checks. He was placed back on 23-1 lockdown in quarantine.

The following day, a mental health specialist discontinued the “Level 3″ watches. Gisiner hanged himself two days later.

Kupers, the forensic psychiatrist, said that incarcerated people deemed to be at risk of self-harm “should from then on, not be in a cell by themselves and should have some kind of treatment plan that indicates what monitoring is necessary to keep them safe.”

That plan, Kupers said, “should go on for days or weeks after observation.”

“Suicidal crises do not go away in a day or two,” he said. “They can be removed from observation when the mental health staff feel they’re safe enough, but they should not be put in solitary confinement. They should not be put in a cell by themselves.”

The R-dorm was temporarily shuttered for renovation during a January tour by Banner reporters. The sheriff’s office said it has traditionally been used for intake, classification, and quarantine during the Covid pandemic.

The sheriff’s office declined to address questions and experts’ concerns about its use of isolation in the first few days of incarceration, but noted that the agency followed CDC guidelines and input from its private medical providers during the pandemic. All of its housing policies fall “well within the state standards for adult detention center housing,” the sheriff’s office said in its initial response to The Banner’s findings.

Marc Bullaro, a retired assistant deputy warden at Rikers Island who is now an adjunct professor at John Jay College of Criminal Justice, reviewed The Banner’s findings and pointed out that each of the suicides occurred within seven days of admission, known to be the riskiest period for self-harm, except Gisiner’s, which occurred eight days after admission.

Bullaro also noted that four of the five cases involved some kind of drug or alcohol use, which he considered “high-risk” factors. He questioned why people who were booked on minor charges such as domestic disputes or probation violations related to DUIs were housed in isolation.

“To me, those charges aren’t really appropriate for a cell environment,” he said, adding that the vast majority of suicides in jails and prisons occur in cells, rather than dormitory-style housing.

Daniel J. Galbraith, the warden of the Harford County Detention Center, said that it would not be feasible to remove the bunk beds from those cells for many reasons: The sheriff’s office said that it “often” puts more than one detainee in R-dorm cells, but cites only the examples of “protective custody and disciplinary issues,” which are not typically instances in which more than one person would share a cell.

Galbraith also said he needs the extra space.

“If I was to take off the top bunk, you’d be eliminating half the bedding space that I have in my jail,” he contended.

The Harford County Detention Center was last expanded in 2011, an addition of 288 beds.

During the January tour of the facility, the majority of the detainees were being held in older portions of the jail, which the warden attributed to staffing shortages and ongoing renovations. The warden said they were getting ready to reopen newer additions to the jail, including an upgraded medical unit.

Galbraith also contended that “there are other ways” people can kill themselves other than hanging. But he cited only a case from several years ago when someone unsuccessfully tried to kill themselves by flinging themselves head-first off a single tiered bed. Galbraith said the man was able to strike the wall head-first “about two or three more times” before deputies intervened and stopped any further attempts.

“They have access to plastic bags, they have access to clothing,” Galbraith said. “If somebody wants to kill themselves, they’re determined and they’ve made their mind up, they’re going to find a way.”

Not everyone shares that point of view.

Kupers, the forensic psychiatrist, said people sometimes kill themselves accidentally “because they can’t get the attention they need from staff.”

“If staff would come and talk to them, they would settle down, and they probably would avoid harming themselves,” Kupers said. “Something is wrong in this jail.”

A new push for independent investigations

For those who have lost a loved one in jail, it can be incredibly difficult to obtain detailed information about what happened.

The family of Nathaniel Powell Jr. fought for nearly half a year to obtain basic records, which they received only after they acquired legal representation from the ACLU of Maryland and after the Harford County Sheriff’s Office was presented with detailed findings of The Banner’s investigation

Sonia Kumar, a senior staff attorney at the ACLU of Maryland, said that Powell “should not have died at the Harford jail” and that “families deserve independent, substantive investigations to prevent tragedies from recurring.”

“How can families trust investigations conducted by the same sheriff who runs the very facility where their loved ones died?” Kumar asked.

When the police reform package passed in 2021 created the Independent Investigation Division, a wing of Maryland’s Office of the Attorney General tasked with probing police custody deaths, the idea was that local law enforcement couldn’t be trusted to impartially investigate cases that would implicate their own officers.

Kumar added that, for the same reasons the group demanded independent investigations into police custody deaths in 2021, “we need them in jails and prisons.”

Dr. Roger Mitchell Jr., former chief medical examiner of Washington, D.C., who now serves as a chief medical officer and trauma and violence prevention center director at Howard University, said every state should have a multi-disciplinary committee that independently reviews in-custody deaths and reports their findings to the U.S. Centers for Disease Control and Prevention.

In Maryland, deaths in local jails are largely investigated and adjudicated by the jail authorities themselves, with assistance from the medical examiner’s office. Mitchell said that there is a need for more independence as well as transparency and uniformity among jail death investigations “to ensure justice.”

More immediately, he added, medical examiners should denote on death certificates whether a death occurred in custody so that academics and researchers can study it from a public-health lens.

“Right now, we don’t have an infrastructure to even record and to review death in custody,” Mitchell said. “We don’t know how many people, and under what circumstances people are dying in our jails and prisons today.”

Carmen Johnson, a criminal justice reform advocate and founder of Helping Ourselves to Transform, a social justice nonprofit, has been lobbying Maryland lawmakers for legislation that would mandate the same type of independent investigations that follow police shootings for jail deaths as well.

“A lot of them understand it and see the need for it,” said Johnson.

In the current legislative session, momentum is building behind a bill that would create new oversight for state prisons in the form of an ombudsman’s office. But it’s unclear to what extent, if any, the ombudsman’s office would deal with local jails.

Johnson has been advocating for a separate bill in the Maryland General Assembly, along with Keel, lead author of the UCLA study, that would create a “deaths in custody oversight board” within the Governor’s Office of Crime Prevention, Youth and Victim Services. That legislation would mandate new reporting requirements for in-custody deaths in both jails and prisons. It would also require the board to conduct an “independent review” of any suicides or deaths deemed to stem from a mental health crisis in those facilities.

In his research, Keel found that the majority of those who died in Maryland detention facilities were largely under the age of 45, male and had not yet been convicted of a crime.

That latter part, he said, was especially important to remember: “We live in a society that can put you in jail before it actually confirms you committed a crime, and then you can lose your life in that jail.

“It’s a new type of capital punishment.”

Baltimore Banner audience engagement editor Krishna Sharma and data reporter Greg Morton contributed to this report.

Ben Conarck

benjamin.conarck@thebaltimorebanner.com

Ben Conarck is a criminal justice reporter for The Baltimore Banner. Previously, he covered healthcare and investigations for the Miami Herald and criminal justice for the Florida Times-Union.

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