Federal statistics show more prisoners die from suicide than homicides, overdoses and accidents combined. So when an inmate committed suicide in the Green Bay Correctional Institution this summer we decided to investigate the matter.
Francisco Flores-Rocha attacked three staff members at the Green Bay Correctional Institution back in July of 2016. Officers put him in the segregation unit, placing him on suicide watch and checking on him every 15 minutes of every day. But in the Brown County Sheriff Offices Incident Report regarding Flores-Rocha’s death, officers admit the system failed in preventing him from taking his life.
When Francisco Flores-Rocha was put in the segregation unit he told his psychologist he was going to kill himself and even went so far as to work on a will with his social worker.
A note signed by his psychologist posted on his cell door warned officers to check the mattress and his property every 15 minutes to make sure they're not altered. But the way the message was relayed to the ever changing correctional officers was not protocol.
A post it note was stuck on his cell door that read, “Please check mattress and property of Mr. Flores-Rocha each shift to ensure fully intact and not altered in anyway.”
One officer who didn’t notice the note during his shift described it as odd later to investigators stating; “the sign that was the least visible was the most crucial.”
Some officers on duty that night admit, they didn't see the post it note and said they wouldn't have had time to inspect the cell without the help of a larger team anyway.
“It’s not always possible to grab more staff to help due to staffing shortages,” said one Correctional Officer on the Segregation unit in the report.
“It isn’t possible to conduct a check of 10 inmates every 15 minutes and require an officer to open cell doors that often,” adds another officer.
During his four days in segregation records indicate Flores-Rocha's welfare was monitored and recorded every 15 minutes. But some officers questioned if that was really the case.
“It is odd that there are no missed checks that appear on the observation log as that is not always possible,” adds an officer.
“They [sic] supposed to check on you every 15 minutes. That does not normally happen. They check on you about every 20 to 30 minutes,” adds an inmate in the segregation unit who was interviewed by Brown County Sheriff Investigators.
After some of the concerns brought up by staff during the investigation, a series of changes were made at the prison. It started with the glass on cell doors in the segregation unit. Panels were said to be scratched by inmates and permanently foggy, and hard to see through for officers to do their welfare checks, were recently replaced.
Now officers are also trained to get acknowledgement from inmates when they conduct their frequent welfare checks and to also record those moments in detail.
Rather than just documenting with a pen and pad that a prisoner was on the bed or floor, now officers are expected to have some interaction with the inmate or notice apparent breathing and then to document that incident accordingly.
And possibly the biggest change is that now when an officer is working the segregation unit and is overwhelmed by the amount of inmates they are responsible for, additional staff are made available so that the watch can be conducted more thoroughly.
All of those changes just happened in the last couple of months as the maximum security prison attempts to keep a more watchful eye on those, who may want to harm themselves.
