The nurse who was supposed to be watching Tommy Wayne Pardew on a video monitor was on her third day of employment, still in orientation.

Less than a week earlier, in April of 2019, Pardew had been booked into the Harford County Detention Center for violating his probation on a drinking-and-driving charge. He was immediately placed on suicide watch after a mental health screening.

He would die there.

Many of the details surrounding Pardew’s mental health struggles, including what he told the nurse that led him to be placed on suicide watch, were redacted in the Harford County Sheriff’s Office’s report on his death.

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The details left in, however, are damning.

The last log entry for Pardew’s 15-minute wellness checks, for instance, was recorded at 12:40 p.m. on May 1, 2019. It said Pardew was lying in his bunk. In reality, he had been hanging from the bars of his cell for about 20 minutes.

The death of Pardew, one of a string of suicides at the detention center over a four-year span, demonstrates in stark terms how the Harford County Detention Center has failed to treat people suffering from mental health crises, and how flawed its suicide prevention practices have been, according to experts interviewed by The Baltimore Banner.

A Banner investigation revealed disturbing patterns between five suicides, four of which took place in the R-dorm, which was for years used for intake and quarantine but has been temporarily shuttered for renovations.

But the case of Pardew stood out — a staggering example of how the Detention Center failed to prevent the suicide of someone who was known to be at risk and who should have been under strict observation.

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In an interview, Harford County Sheriff Jeffrey Gahler defended the jail and said he has never had to discipline any of his deputies over any of the deaths by suicide.

“We’ve never had an issue during my tenure with finding that one of our employees did not operate within our policies, or that there was any wrongdoing associated with it” said Gahler, who took office in 2014.

Gahler, who declined to discuss specific cases, indicated that there was “concern” about a “time check” in one of the five suicides on behalf of a medical staff member, who is not a sheriff’s office employee, and therefore he wasn’t aware of any consequences that might have resulted.

“How they dealt with it,” he said, “I don’t know.”

When asked about the death of Pardew specifically, Gahler said he could not speak to the case because he did not remember the specifics of it, despite being given findings on the case days earlier. Gahler contended that “none of the issues with the checks or the timings” of any of the five suicide deaths “had anything to do with Sheriff’s Office personnel.”

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Though the sheriff has maintained that his staff have done the best they could with the resources they have, he and his warden have also conceded that their jail has struggled to meet the growing needs of people with serious mental health challenges.

The Harford County Sheriff’s Office emphasized that it has replaced its former health care provider, PrimeCare Medical, with WellPath Care, a different private vendor. But experts said that The Banner’s findings on the suicide death at the jail indicate wide-ranging, systemic issues that would not be solved by simply switching medical care providers.

Michele Deitch, a senior lecturer at the University of Texas who specializes in correctional oversight and deaths in custody, said that changing a medical provider would likely leave in place much of the jail’s screening process. It would not affect other contributing factors such as the layout of the facility and housing decisions, she added.

“Suicide prevention is not a function of just one part of an agency,” Deitch said. “It requires systemic changes.”

On suicide watch, Pardew practiced hanging himself

Documents obtained through a public-records request by The Banner illustrate an unsettling account of Pardew’s final days on suicide watch.

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When a Harford County Sheriff’s Office detective came to investigate Pardew’s death, he found the restricted housing unit in disarray.

The area around Pardew’s cell was littered with scraps of food. The walls were smeared with feces. And there was paper covering his cell window from the inside.

The main door to Pardew’s cell was made of bars, which allowed him to fling food and bodily waste at correctional staff, according to the incident report on his death. Jail deputies closed the solid door to block off the area in front of his cell, the report said.

Pardew had proven to be difficult to manage, according to the report, which said he had been yelling racial slurs at one of the senior deputies in charge of the restricted-housing unit, leading the other senior deputy to tell her not to enter Pardew’s cell area.

On the day of his death, May 1, 2019, Pardew was on “Level 2″ of a three-tiered suicide watch system that has since been discontinued.

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A sheriff’s office report for a different suicide death, that of Randy Gisiner, defined his “Level 2″ plan as 15-minute watches and “no sharps, belts, shoelaces, no writing materials, a mattress, suicide blanket and a pillow, no sheet, no pillow case.”

It continues: “May have underwear, jumpsuit or uniform, shower shoes, regular food with spork, no commissary.”

The report on Pardew’s death states only that he was allowed to have “everything but his property” in his cell, with 15-minute observation periods.

Just before noon, Pardew got out of bed and removed a pair of pants from underneath his mattress, then tied them into a knot, according to video footage reviewed by detectives.

Pardew then tied the pants around his neck and walked over to the bars of his cell, where he “appeared to be practicing how to hang himself,” the detective noted. He left the pants up on the cell bars, then lay back down in his bunk, covering his face with his shirt.

About 15 minutes later, Pardew appears on the footage to be talking with a corrections deputy at the cell door, then gets up, puts his slippers on, and removes the pants from the bars, throwing them on his bunk, the detective noted in his report.

One minute later, the deputy and another staff member are captured leaving the cell area from a camera trained outside Pardew’s cell. At the same time, Pardew could be seen picking the pants up from the bunk and once again tying them to his neck, and then the cell bars.

At 12:18 p.m. Pardew stepped off his bunk, hanging suspended for a minute, moving his arms, and then going limp.

More than 30 minutes went by before correctional staff discovered his body at 12:52 p.m., when the medical staff’s pharmacist entered Pardew’s cell to administer medication.

An interview with one of the senior deputies revealed that the last conversation between Pardew and staff happened around 12:18 p.m. when deputies were attempting to question Pardew, “at which point he began cussing and did not answer her.”

“[Senior Deputy] Brown was crying and visibly upset by this incident,” the detective wrote in his report.

It’s unclear whether the report is referring to Brown’s confrontation with Pardew, or his death.

The detective also interviewed the newly hired registered nurse who was supposed to be, along with other medical staff, monitoring Pardew and logging entries on his wellbeing every 15 minutes. The nurse “advised that she did not know any names of any of the other personnel who were watching him,” the detective noted.

The nurse told the detective that she had last logged an entry for Pardew at 12:40 p.m., recording him lying on his bunk, even though he had been hanging for more than 20 minutes.

In a second interview, the nurse told detectives that “she must have documented the wrong inmate on Pardew’s log” and that she was watching “4 or 6 inmates” at once.

One of the senior deputies in charge of the restricted-housing unit told the detective that he was not in the area because he had gotten “side tracked while he was in D-Block with another inmate.” He said he did not initially hear the call for available officers after the pharmacist found Pardew hanging because he had his “radio turned down low.”

The senior deputy told the detective he heard two other staff members yelling that Pardew “hung it up, which he knew meant an inmate hanged themselves.”

“He advised that it took approximately 10-15 seconds for him to retrieve the tool and unlock the cell,” the detective noted. “He advised that no one brought scissors, so he held Pardew up by the waist, while Deputy Mace untied the knot.”

Marc Bullaro, a former assistant deputy warden at Rikers Island who examined The Banner’s reporting on jail suicides in Harford County, said “it shocked me a little” that the deputy did not have a pair of scissors on him. It’s standard practice that having a rescue pair of scissors should be “part of your duty belt and should be on you at all times,” Bullaro added.

In response, the Harford County Sheriff’s Office said that “all deputies are now equipped with scissors.”

“This is not a result of this incident, but a continuing effort to advance our methods, update best practices, and continue to evolve as an institution,” the sheriff’s office said.

Bullaro said that there are certainly instances where a determined detainee might find ways to kill themselves even while under strict observation.

But he, and several other suicide prevention experts, said those who are at known risk for self-harm should be placed on one-on-one observation. That means that an officer is placed in front of the cell and keeps constant tabs on the person suspected of having suicidal intent, relieved by another staff member even if they get up to use the restroom or take lunch.

The Harford County Sheriff’s Office said it uses one-on-one observation, which it calls “constant watches,” if “somebody is actively suicidal.” It said “that would be handled by our medical staff, they are responsible for providing that one-on-one, constant watch.”

An ‘urgent need to boost safety’

The Harford County Sheriff’s Office said that its recent $5.9 million contract with Wellpath allocated more resources toward mental health treatment, but it remains a vexing challenge.

Those booked into the jail frequently suffer from mental health issues and substance abuse, Warden Daniel Galbraith said, and they are often distrustful of the jail staff who attempt to treat them.

In written responses to The Banner’s questions, the sheriff’s office answered that “detention centers are microcosms of our communities” and that the “suicide rates in our facility are well below the rate of Maryland or Harford County.”

Harford County, the sheriff’s office added, has the highest suicide rate in the state. When comparing the suicide rate in the jail, however, a Banner analysis found it higher than the statewide or county rate.

The agency said it switched medical providers to Wellpath in 2022, which has different suicide prevention policies than the previous provider, PrimeCare Medical. That change “had nothing to do with past suicides,” the sheriff’s office said, and was made because the contract was due to go out to bid and the sheriff wanted to ensure the detention center had the best medical care at “an appropriate price.”

Cristie Hopkins, a spokesperson for the sheriff’s office, said that Wellpath was not willing to share its suicide prevention policies with The Banner, but provided an email listing “service highlights” from its contract with the new medical provider that included some details about its new screening process.

“What I think is important for you to know is that system, which seems to be highly criticized, is not at all the system that Wellpath uses, and I would have loved to have been able to illustrate that for you,” Hopkins said.

Though the Harford County Sheriff’s Office rejected the suggestion that any of the suicides in its facility could have been prevented, experts interviewed took a different view.

After reviewing The Banner’s findings, Holly Wilcox, a Johns Hopkins University professor who specializes in suicide prevention, said the reporting indicated neglect and a lack of transparency at the jail.

That was especially true for Pardew’s case, Wilcox said. She raised questions about the jail’s mental health screening policies and protocols in regards to suicide prevention.

“From the data I have seen, there is an urgent need to boost safety and security,” Wilcox said.

Gahler, the sheriff, said the jail has allocated new resources to mental health treatment under its current medical provider and has renovated certain parts of the jail, including the addition of more “rubber rooms,” designed to prevent detainees from using the physical space around them to injure themselves.

Deitch, the University of Texas lecturer, said it was important to note that those rooms are actually outfitted with hard walls that have some give to them, not “some big, comfy room that you can bounce off the walls.”

Such settings may or may not be appropriate for people determined to be at a high risk of self-harm, she said, but she emphasized that “putting in more rubber rooms is not the answer” to the jail’s suicide prevention issues.

“Providing treatment is the answer,” Deitch said. “The solution is, first of all, not putting people in the jail who are at that level of risk, and getting them the mental health treatment that they need.”

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

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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