Cleveland County detention officers failed to perform required safety checks on detainees in critical care the same month two women died waiting for mental health evaluations in the jail, a health inspector found.
Jailers failed to follow a policy that requires them to observe detainees who are violent, suicidal or struggling with mental health problems at least every 15 minutes.
A state health department inspector reviewed logs for at least four people detained in December and January. Jailers missed scheduled checks on all of the unnamed detainees.
Logs from Dec. 5 and 6 reveal that detainees were left alone and unsupervised for up to 45 minutes at a time. Norman mother Shannon Hanchett was under critical watch on those days, according to a Health Department incident report.
Hanchett, 38, died in a medical cell on Dec. 8, hours before she was scheduled to receive a court-ordered mental health evaluation from Griffin Memorial Hospital. Her death raised questions from the community about the jail’s care of those who are locked inside. The Office of the Chief Medical Examiner has yet to rule on Hanchett’s cause of death.
Those 15-minute checks are the minimum standard for detainees in distress, said Richard Forbus, a former jail commander and spokesman for the National Commission on Correctional Health Care. They can’t be housed with other detainees because that could lead to a fight, he said. Isolating them can exacerbate mental health issues, he said, which is why it is important to check on them so frequently.
Forbus said 45 minutes may not seem like a long time, but it can be dangerous or even deadly for people in crisis.
A month after the inspection, Joe Allen Sims Jr. died by suicide, alone in a cell where he was under critical watch, according to a health department incident report. Video footage shows Sims hanged himself 16 minutes after an officer had last checked on him, according to the report. Officers found his body 77 minutes later.
The day Sims died was former Norman Police Lt. Cary Bryant’s second day running the jail. Bryant previously trained law enforcement officers statewide to respond to people experiencing mental health crises. He was hired at the jail Jan. 30 to evaluate mental health and substance abuse treatment and policies. Two weeks later, Sheriff Chris Amason hired Bryant to run the jail.
Amason was unavailable for an interview.
Bryant refused to talk about the inspection saying he wouldn’t address anything that happened before he took over. Bryant replaced Deputy Chief Scott Sedbrook who along with support services head Major Dennis Hansen resigned in January, weeks after the deaths of Hanchett and Noble grandmother Kathryn Milano.
Milano was in a medical cell waiting for a mental health assessment when jail staff found her unconscious with blood dripping from her nose on Dec. 20. She was taken to Norman Regional Hospital where she was removed from life support and died the following day. The medical examiner has not yet released her cause of death.
The State Health Department oversees living conditions in Oklahoma’s 93 jails. If a jail fails to correct violations, the commissioner of health can file a complaint with the county prosecutor or state attorney general who could file charges. Since 2019, the only complaint filed was against Oklahoma County.
The January inspection included investigations into the deaths of Hanchett and Milano, three serious detainee injuries, one attempted suicide and one complaint, according to the inspection report.
The inspection also found a faulty smoke detector and missed safety checks for detainees who were not under critical supervision. The Health Department mandates hourly checks during which jailers are required to view every detainee and all areas of each cell. Some of those checks were missed after Hanchett was released from critical care and fewer than 48 hours before she died.
An inspector cited similar violations at the jail in May of 2022. Detention officers missed dozens of 15-minute checks required for three detainees under suicide watch, according to the report.
In one case, the report shows jailers missed 50 of 73 safety checks needed over 18 hours for a detainee deemed a suicide risk.
A 2021 inspection of the jail found no violations.
Safety checks were the second most cited violation by inspectors in 2021, according to a health department analysis. Fire safety violations were the most cited.
The inspection reports include a plan of correction for each of the violations.
Each plan directs jail leadership to interview staff about why the violation occurred, review policies to determine if they need to be updated and adopt further corrective actions as needed. The requirements are vague and nearly identical for varying violations.
Health inspectors have no authority over disciplinary action. It is up to jail administrators to investigate the cause of the violations and determine disciplinary action.
An inspector is required to perform a follow-up inspection to ensure the jail has fixed deficiencies, according to the department’s website. There is no set time for the return visit. It is based on the severity of deficiencies and how busy inspectors are, the website states. The department has two inspectors covering the entire state. January’s report is the most recent inspection of Cleveland County’s jail available online.
An Oklahoma Watch review of past inspections found that violation follow-ups most often occur during the following year’s inspection.
Whitney Bryen is an investigative reporter at Oklahoma Watch covering vulnerable populations. Her recent investigations focus on mental health and substance abuse, domestic violence, nonprofits and nursing homes. Contact her at (405) 201-6057 or firstname.lastname@example.org. Follow her on Twitter @SoonerReporter.