Police: Teen unsupervised before suicide

Molly Ball

Monday, June 13, 2005 | 10:50 a.m.

Despite being on suicide watch in juvenile detention, Brittany Kish had not been checked on for at least 35 minutes when the 16-year-old was found dead in her cell in April, according to a police detective's report on the suicide.

The report reveals troubling details about the incident, which was the first suicide of a youth in detention in Clark County in 26 years.

Other detention inmates noticed something amiss and alerted a detention center worker an hour before Brittany was found dead, but the worker didn't check in on her, the report states.

Brittany then went unsupervised for 35 minutes because the only available staffer was busy with other duties, according to the report written by Metro Detective Todd Hendrix.

Youths placed on suicide watch are supposed to be checked at least every five minutes, according to the department's procedures, Juvenile Justice Director Kirby Burgess said.

Based on its own investigation, the county believes the police report to be accurate, said Stephanie Barker, chief deputy district attorney in charge of litigation.

"The factual findings of our internal investigation essentially mirror the factual findings of the Metro report," she said.

As a result, discipline has been recommended for some employees, she said, declining to say who or how many because it is an ongoing personnel matter.

The detention center's protocols have also been reviewed and found to be basically sound, although sheets have been taken away from suicidal youths. Rather, Barker said it was human error that allowed the suicide to take place.

"The policies and procedures are adequate when followed," she said. "Had they been followed on that day, this incident should not have happened."

Brittany, who had previously been sexually abused while undergoing state-mandated treatment at a private facility, strangled herself on April 11 with bedsheets knotted around a sink and looped through a door opening. She was found dead less than three hours after being taken to the facility.

Brittany had bipolar disorder and was frequently in trouble, according to her mother, Lynette Kish, who said the girl had tried to kill herself by slitting her wrists a few weeks before her death.

Brittany had been in the juvenile justice system many times, for offenses ranging from shoplifting to assaulting her parents, committed when the normally vivacious girl's devastating illness took control of her, her mother has said. The report on Brittany's death notes that many of the workers at the detention center that day knew the girl from her previous stays there.

Brittany arrived at the detention center at 12:30 that day, taken into custody by a parole officer because she had run away from home. The parole officer told the nurse on duty that she had suicidal tendencies, according to the report.

The nurse then interviewed Brittany, who told the nurse about the recent suicide attempt. The nurse, who knew Brittany from her previous visits to detention, classified her as "S3."

S3 is the designation for suicide watch, one of three basic classifications for detained youth, Burgess said. S1 is the code for youths who may be violent or disruptive, and S2 is for youths without special concerns.

A classification of S3 means the youth must be checked at least every five minutes, and a referral must be made to psychiatric staff, Burgess said. On April 11, six of the 43 girls in detention were classified as S3.

A detention center officer, Catriva Anderson, escorted Brittany to a cell shortly after 2 p.m., the police report states. Anderson's shift ended at 2:30, and she briefed another officer, Michelle Maluafiti, for the next shift.

"Anderson said she was certain she discussed Kish's classification as 'S3' with Maluafiti, but if not, that information was included on the 'Bedsheet' (list), and on the cards posted at the doors to the girls' rooms," the detective's report states.

Meanwhile, around 2:20, another worker, a part-time employee named Tyrone Tucker, was leading a group of six or seven girls back to their cells. As they passed Brittany's cell, one of the inmates commented on something going on in "the new girl's" room.

According to Tucker's recollection, the girl said "something akin to 'she's doing something with her sheets,' or words to that effect."

Accounts differ about what the girl said, but the girls in the group told the detective they all saw sheets coming through the door.

An inmate in the group who knew Brittany from a counseling program recalled seeing sheets being pushed through an opening in the door and falling to the floor. The girl recalled hearing someone say, "Is that girl trying to kill herself?"

The inmate who made the remark told the detective she commented on the sheets but didn't mention suicide. The girl wrote in a statement, "We all said ... she had a sheet hanging from her door, he told us to go to our rooms, I don't think he aknolage (sic) what (we) were saying."

Another inmate in the group returned to her cell across the hall from Brittany's, where she could see the sheet being pushed through the door opening. The girl "knocked on her window in an attempt to get the attention of the staff. (She) suspected the girl in the room was trying to commit suicide." The girl told the detective she'd previously been in custody in San Francisco and seen someone commit suicide by hanging herself with bedsheets.

Tucker, the detention center worker, said he heard no comments about suicide, only something about a sheet. After all the girls were in their cells, Tucker said, he went back to Brittany's cell and checked the doors. They were locked, and he didn't see any sheets, he said.

Tucker told the detective he didn't look inside the cell because he didn't want to be accused of peeping. He said he was afraid of "being accused of inappropriately looking at the girls going to the bathroom or something like that."

Tucker said he didn't know Brittany was on suicide watch, even though he said he knew what S3 meant and was aware the information was posted on inmates' doors.

Maluafiti, the officer in charge of the hall, said she checked on Brittany around 2:40 but "saw nothing out of the ordinary." She then took a group of 10 girls to a classroom in the detention center, where she stayed with them until 3:15.

There were about eight girls still in their cells on the hallway, but no one was watching them during those 35 minutes, Maluafiti told the detective. Her supervisor said there was no one else available to assign to monitor the hallway during that time.

Burgess said there was no question that was unacceptable. "Absolutely, anytime you have S3 kids, that hallway and particularly those kids should be checked according to procedures, every five minutes," he said.

He said he has, with county approval, authorized detention administrators to pay additional overtime if needed to make sure hallways are staffed.

"The message has been given, clear and succinctly: Call in the people you need," he said.

At 3:15 p.m., Maluafiti passed Brittany's cell and noticed "a sheet draped through the upper slot of the interior door," which she "immediately recognized ... as a concern." When she called into the room and got no answer, she called for help.

Nurses performed CPR and paramedics, when they arrived, tried to revive Brittany. But it was too late.

Burgess said bedding policies have been overhauled in response to the incident. Previously, sheets and blankets were distributed to all inmates and kept in their cells.

Under the new policy, all sheets and blankets are collected during the day. At night, bedding is distributed, but youths designated S3 do not receive sheets. They are given sock-shaped "suicide blankets" and sleeping bags to keep warm.

Burgess said the detention staff would also get improved training on suicide warning signs. But fundamentally, he said, it wasn't the policies that were to blame.

"This case has to do with the human factor," he said.

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