Category: Medical Care

The San Jacinto County Sheriff’s Department, in Coldspring, Texas, filed a custodial death report with Ken Paxton, Attorney General of Texas, regarding the death of Tasha Lavergne. Ms. Lavergne was only 32 years old at the time of her death. We provide information in this post obtained from that report.

The report provides very little information about what occurred prior to Ms. Lavergne’s death. It is also difficult to determine when she was arrested and originally incarcerated in the San Jacinto County, Texas jail. The report indicates that the date and time of Ms. Lavergne’s original custody, or the incident, was July 6, 2021 at 5:45 p.m. However, the report does not make clear as to whether this was when Ms. Lavergne was originally incarcerated in the jail, or when the incident leading to her death occurred.

The summary portion of the report reads in its entirety:

“Offender was on suicide watch in Holding cell 270A for observation awaiting a Burke Center Mental Health evaluation. The offender wrapped the phone cord around her neck two times, but when someone would be in the area of the cell she would take it off and go lay down. The third time she wrapped it around her neck and leaned to put pressure on her neck. After she was found, she was laid down on the floor and CPR was started and EMS was notified. EMS was able to get a pulse on her after administering medications, and she was transported to Livingston CHI Emergency Hospital. A few days later, unsure of date due to not being in our custody, she was transferred to Lufkin CHI were she succumbed to her injuries on 07/13/2021.”

Normally, when we draft posts for this website about custodial deaths and other incidents occurring in Texas jails, we include a disclaimer indicating that we are merely providing information for the public and make no allegation of any wrongdoing against anyone related to the death. However, without alleging any wrongdoing against any individual person related to Ms. Lavergne’s death, there is absolutely no excuse for what occurred. As shown above, the summary indicates that Ms. Lavergne was on suicide watch. Thus, one or more people working at the jail obviously knew that Ms. Lavergne was suicidal. Knowing that she was suicidal, no jailer should have locked Ms. Lavergne into a cell with a phone cord.

Our law firm is currently handling three suicide cases occurring in Texas jails in which the person who committed suicide used a phone cord as a ligature. The Texas Commission on Jail Standards warned all Texas sheriffs and jail administrators – years ago – that telephone cords were being used to commit suicide. There is absolutely no excuse for the San Jacinto County jail placing inmates who are suicidal into jail cells with phone cords. Inmates commonly commit suicide using ligatures, and they will use whatever is available in the cell – sheets, blankets, clothing, and phone cords.

Further, while the summary is unclear about observations, the only appropriate observation for a suicidal inmate is continuous observation. It takes as few as 3-7 minutes to commit suicide using a ligature, and/or to suffer irreparable brain damage if death does not occur. The summary makes it appear as if jailers would observe Ms. Lavergne wrap the phone cord around her neck, and then remove it. If so, this is a further serious problem with the San Jacinto County jail. It is our experience as a Texas civil rights law firm that the Texas Commission on Jail Standards will conduct an investigation of Ms. Lavergne’s death. Moreover, depending on capabilities of San Jacinto County, the Texas Rangers may conduct an investigation. Likewise, it is common in many Texas counties for the district attorney’s office to investigate a county jail suicide.

The 14^th Amendment to the United States Constitution provides rights to people such as Ms. Lavergne. Those rights include the right to be protected from herself, including her suicidal tendencies, and to receive reasonable medical and/or mental health care. If Ms. Lavergne was not appropriately protected from herself, which it appears she was not, certain surviving family members may have claims related to her death. Those claims are usually included in a complaint, which is the first document used to file a federal law suit.

Before the booking process into Ector County Jail in Odessa, Texas, was completed, 65-year-old Antonio Villa Mendoza committed suicide. Alone in a holding cell, he used his jail-issued uniform to strangle himself. Mr. Mendoza died on February 1, 2020.

In 2017, sweeping changes in a new Texas law were made for the purpose of reducing custodial suicides. A report made two years later found that the changes did nothing to reduce the number of suicides. According to experts on the matter of custodial suicide, the failure of the law was in not addressing a major factor in suicide prevention, that being close supervision of at-risk inmates.

A common issue in county Texas jails is understaffing. Due to a limited number of jailers, an emergency may arise that pulls a staff member away from the task of checking in on prisoners within the allotted time frames.

The highly-publicized custodial suicide of Sandra Bland in 2015 led to protests and debate. A law was enacted that included the following requirements:

• Treatment must be made available to mentally ill inmates.
• Jail deaths must be independently investigated.
• Police must receive de-escalation training.
• All county jails received funding to add cameras or electronic sensors to ensure timely and accurate cell checks.

Learn more in Part 1 and this ongoing series.

Current and former prisoners in county Texas jails could benefit from the posts on this website, and for that purpose, they are added. There is no intention on this site to insinuate that misdeeds have occurred on the part of any entity or person.

–Guest Contributor

Antonio Villa Mendoza died in Ector County Jail in Odessa, Texas, on February 1, 2020, at the age of 65. Mr. Mendoza was still in the booking process and alone in a cell when he reportedly strangled himself to death using the uniform the jail issued to him.

According to research on custodial suicide in the U.S., the first 24 to 48 hours in which a person has entered a jail for booking is the timeframe with the highest risk for suicide. Being alone in a cell is the setting in which most suicides occur. Mental illness is the most significant risk factor for committing suicide. Another significant risk factor is when the inmate is a young white male.

Suicide prevention strategies for county Texas jails are determined by the Texas Commission on Jail Standards (TCJS). The following is information regarding the suicide prevention plan each county jail must implement.

CHAPTER 273-HEALTH SERVICES; RULE §273.5 Mental Disabilities/Suicide Prevention Plan

• Jail staff must have training on procedures for recognizing, supervising, documenting, and handling prisoners who are potentially suicidal and/or mentally ill. The staff members responsible for intake screening must also have supplemental training since it is during intake screening that determinations about inmates are made.
• Inmates at risk for suicide must have adequate supervision and appropriate housing.
• Staff members must follow procedures for intervening before a suicide has occurred and during a suicide attempt in progress.

Learn more in this continuing series.

This website’s posts are intended as resources to assist current and former inmates in county jails in Texas. On this site, there is no intention to insinuate that wrongs have occurred on the part of persons or institutions.

–Guest Contributor

The custodial death report filed for 37-year-old David Quannah Brown by the Attorney General of Texas shows that he died on June 6, 2021, less than 7 hours after being booked into Potter County Jail in Amarillo, Texas. Mr. Brown was on suicide watch, and officers have stated they thought he was under the influence of an unknown narcotic.

The Texas Commission on Jail Standards (TCJS) establishes the minimum jail standards for county jails in Texas. The rules of jail operation include specifics regarding admission processes and supervision.

RULE §265.3 – Observation During Holding

Jailers are required to observe inmates placed in detoxification cells at intervals that do not exceed 30 minutes. In a report dated June 16, 2021, an inspector with TCJS indicates that a county jail was in non-compliance. The gist of the inspector’s notes follows:

• Although observations of prisoners in holding and detox cells is required every 30 minutes maximum, documentation of face-to-face observation of inmates shows that the mandatory 30-minute time frame was exceeded routinely by 1 to 32 minutes.

RULE §275.1 – Regular Observation by Jailers

The same Texas jail, at the same time, was also found non-compliant regarding supervision of inmates housed in the general population and in the area where inmates recognized as being potentially suicidal or mentally handicapped are housed.

• The 30-minute observations in the at-risk area were routinely exceeded by 1 to 32 minutes. The 60-minute observations were exceeded by 1 to 27 minutes routinely.

See Part 1 and Part 2 of this three-part series.

Posts on this website are intended as helpful resources for prisoners now or previously incarcerated in county jails in Texas. There is never an intention on this site to infer wrongs on the part of individuals or institutions.

–Guest Contributor

David Quannah Brown was combative when he entered Potter County Jail in Amarillo, Texas, late the night of June 5, 2021. He was believed to be under the influence of narcotics. Less than seven hours after his arrival, Mr. Brown was pronounced dead by emergency medical services.

The minimum jail standards for county lockups established by the Texas Commission on Jail Standards (TCJS) include guidelines for the provision of detox cells. More information follows.

RULE §261.333 – Detoxification Cells

For any jail facility in which the housing of intoxicated individuals is anticipated, one or more detoxification cells must be included. The cells are to be used for the detention of individuals going through the detoxification process. The following are among the specifications.

• Seating-Stationary benches abutting the walls of the detox cells must be provided. The height of the benches must be no higher than 8 inches from the finished floor. The benches must extend the length of the cell.
• Surfaces-The wall, floor, and ceiling materials must be easy to clean and durable.
• Supervision-The cell must be located and built in such a way as to facilitate the supervision of the cell area and to reduce noise significantly.
• Plumbing-Detox cells must have at least one vandal resistive flushing floor drain with outside controls or standard floor drains with a vandal resistive toilet and lavatory. Floors must be pitched properly to drains. Drinking water must be provided with the installation of lavatories or drinking fountains.

See Part 1 of this continuing series.

Assisting Texas prisoners incarcerated in county facilities is the purpose of posts on this website. There is no intention to suggest that persons or organizations have engaged in misdeeds.

–Guest Contributor

Thirty-seven-year-old David Quannah Brown was booked into Potter County Jail in Amarillo, Texas, on June 5, 2021. Mr. Brown died on June 6 less than 7 hours later. Officers said they believed he was under the influence of unknown narcotics, per a report from the Potter County Sheriff’s Department.

According to journalistic reports, county jails are now the primary place where opioid addicts detox. Between half and 75% of the U.S. jail population today has a dependence or substance abuse problem. The expense of administering daily doses of the drugs such as buprenorphine that help to keep opioid cravings under control is far beyond the budgets of most county jails.

In the past, jails were not treatment providers. But with the drastic changes that have occurred such as inmates dying from withdrawals, county sheriffs are seeking solutions. A detailed guide to jail-based medication-assisted treatment (MAT) offering best practices was released by the National Sheriffs’ Association in 2018. The guide asserts that multiple partnerships and support services are needed, in addition to the needed medications.

The guide stresses the importance of client screening so that withdrawal treatment can be provided. U.S. jails that have implemented medically managed withdrawal services seek to launch inmates on a path of long-term recovery.

Learn more in this ongoing series. In the next segment, learn some of the guidelines for detoxification cells established by the Texas Commission on Jail Standards (TCJS).

This website seeks to help inmates incarcerated in county Texas jails. There is never an intention to infer wrongdoing on the part of people or organizations.

–Guest Contributor

The Harrison County jail, in Marshall, Texas, failed a Texas Commission on Jail Standards (“TCJS”) inspection in June 2021. The inspection was apparently as a result of an inmate death in the Harrison County, Texas jail on March 1, 2021. The special inspection report does not mention the name of the inmate.

First, the TCJS inspector determined that the jail violated a requirement related to, in our Texas civil rights law firm’s opinion, perhaps the most important intake form for all Texas county jails. The TCJS inspector determined, after reviewing written documentation from the March 1, 2021 custodial death, that the Screening Form for Suicide and Medical/Mental/Developmental Impairments was not completed in its entirety. Moreover, one or more jailers apparently did not document the fact that the inmate either refused or was unable to complete the form. This is a serious violation, as the purpose of the form is to help jailers determine if a person needs to be continuously monitored and/or receive immediate medical or mental health care.

The TCJS inspector also determined that the Harrison County jail, with regard to the inmate who passed away, did not run the Continuity of Care Query (“CCQ”) immediately upon intake. As with the intake form mentioned above, the CCQ is important to determine whether an inmate previously had certain mental health treatment. This assists in determining whether an inmate might be suicidal.

Without regard to what happened to the inmate in Harrison County, pre-trial detainees in Texas county jails have a constitutional right to receive reasonable medical care and mental health care, and to be protected from themselves and others when in jail. If an inmate dies as a result of suicide or denial of medical care, and a constitutional violation occurs, then certain surviving family members might have claims as a result of the death.

The Titus County jail, in Mt. Pleasant, Texas, failed a Texas Commission on Jail Standards (“TCJS”) inspection on June 16, 2021. The Titus County jail is now listed as being non-compliant by the TCJS.

The TCJS found at least five violations. From our perspective, the violations were serious and could lead to serious injury or death. We see a number of jail death cases in which TCJS violations occur, and which lead to inmate death.

The TCJS inspector noted, when reviewing records, that observations of inmates in holding cells routinely exceeded the 30-minute interval by as little as one minute and by as much as 32 minutes. Titus County jail records also revealed multiple initial custody assessments being completed improperly. This resulted in inmate custody levels being incorrect.

The TCJS inspector also found, when reviewing records, that multiple custody reassessments were completed improperly. Further, staff who had not completed the required four hours of classification training were, nonetheless, performing classification duties. Finally, documentation reviewed by the TCJS inspector revealed face-to-face observations of inmates exceeded the minimum 60-minute interval by as little as one minute and by as much as 27 minutes. The inspector also found that 30-minute face-to-face observations, as indicated above, routinely exceeded the required minimum interval.

These are serious violations. Hopefully, the Titus County jail will bring itself into compliance quickly and thereby protect inmates and jailers.

The Smith County jail, in Tyler, Texas, failed a Texas Commission on Jail Standards (“TCJS”) inspection. The inspection occurred from June 21, 2021 – June 23, 2021. As a result, the Smith County jail is now listed as being non-compliant.

The TCJS inspector found at least six violations. The inspector determined that the smoke management system failed to operate while under emergency power. Further, when reviewing inmate files, the TCJS inspector found multiple property records to be blank and missing required signatures from the receiving officer and inmate.

Inmates also were not receiving a change of clothing at least once a week, and washable items were not exchanged for replacements at least once each week. The TCJS inspector found, when reviewing inmate files, multiple inmate rules acknowledgment forms were blank and missing inmate signatures. Finally, when reviewing inmate grievances, the TCJS inspector determined that grievances were not handled in accordance with the approved grievance plan. Hopefully, the Smith County jail will quickly bring itself within compliance.

The Robertson County jail, in Franklin, Texas, failed a Texas Commission on Jail Standards (“TCJS”) inspection on June 3, 2021. The Robertson County jail is now non-compliant pursuant to TCJS standards.

The inspector cited a jail standard requiring documented observations of inmates every 15 minutes, at a minimum, for those inmates placed into a restraint chair. The inspector determined that observations of two inmates placed in a restraint chair were not documented. These are serious violations, as inmate safety is at risk for those inmates who are not observed properly, including assessment of security of restraints and circulation of extremities. This could  lead to serious injury if not remedied.