Staff at a juvenile detention center where a teenager died by suicide in 2016 did not follow policies and protocols upon finding the boy unresponsive in his cell, records show.
Detention center employees — including the shift supervisor on duty at the time — told investigators they were not trained to properly respond to the incident.
An Oklahoma Department of Human Services Office of Client Advocacy report, recently filed in a lawsuit brought by Billy Woods’ estate, states employees in several instances did not abide by the facility’s written policies and protocols for suicide prevention.
Following Woods’ death, the state’s Office of Juvenile Affairs revoked the detention center’s license to operate. MCCOYS had contracted with Muskogee County, which contracts with the Office of Juvenile Affairs.
On Dec. 16, 2016, Woods, 16, hanged himself in a regional juvenile detention center operated by the Muskogee County Council on Youth Services (MCCOYS).
The Frontier reported in 2017 that DHS had found instances of abuse and lack of supervision involving four employees in the facility. However, under state law, Office of Client Advocacy investigative reports are considered confidential. The report became public after it was filed in the lawsuit last week.
The DHS report outlines four instances of neglect, one of abuse and four cases of caregiver misconduct in connection to Woods’ death.
On the night employees found Woods unresponsive in his cell, they waited 20 minutes to call 911, DHS found. However, facility protocol required staff to immediately call emergency services.
Employees could not explain the delay to investigators, according to the report.
Jerrod Lang, who was shift supervisor at the time, found Woods. Despite a policy that required staff to check on residents every 15 minutes, no one had checked on Woods for more than two hours, the report states.
Additionally, Lang admitted he falsified documents by preemptively filling Woods’ paperwork out ahead of time, indicating Woods had been checked on every 15 minutes that night, although video shows that did not happen.
After staff found Woods’ unresponsive, no one tried to check Woods’ vital signs, render aid or remove a bed sheet around his neck, the DHS investigation found. Lang reportedly told another employee not to conduct CPR on the teen, the report states.
When investigators asked how Lang knew Woods was dead, Lang said it was “obvious” based on the teen’s appearance.
“Lang said he also called Woods’s name, and when Woods did not respond, Lang knew he was dead. … Lang said he ‘panicked and got out of there,’” the report states.
Lang also told investigators he nudged Woods with his foot.
“Lang said after they left the room, he went outside and ‘smoked a bunch of cigarettes,’” the report says. “Lang said staff came outside a few times to check on him, but he could not deal with the situation.”
Lang told investigators he was trained in CPR, but could not recall what to do if he discovered an unconscious victim, according to the report.
Several employees said they did not know how to respond to the incident.
One employee said he didn’t receive training on the facility’s policies and procedures. Another employee told investigators “when they were dealing with the emergency situation, no one knew what to do.”
Lang told investigators he had worked at the detention center for about eight months, had received no formal training and had no prior experience working in a similar facility, the report states. Meanwhile, the facility’s policies required shift supervisors to have worked there for at least one year.
Lang said he read “most” of the policies and procedures, but did not understand some of them, according to the report. He told investigators there had been “disagreements about staff being trained wrong.”
Lang could not be reached for comment, but in a deposition taken in January, he said the incident left him “traumatized” and “devastated.” In court filings, he denied any wrongdoing.
In interviews with investigators, some facility residents said Lang made fun of the way Woods talked and his middle name — Duane — which Woods preferred to be called, according to the report.
“Reportedly, Lang’s actions contributed to Woods not wanting to be out of his room and with the rest of the residents,” the report states.
One resident, whose name was redacted from the report because he was a minor, told investigators a facility employee called him “retard” and “retarded.”
Concerns around suicide assessments
The DHS investigation found although shift supervisors were tasked with conducting juveniles’ suicide assessments upon intake, they did not have formal training to recognize the signs and symptoms of suicidal ideations or behaviors.
Additionally, the facility had no mental health professionals to conduct the assessments, according to the report.
If a resident was found to be at risk, employees only learned of the risk if it was discussed among staff during shift changes.
At intake, Woods told an employee he had attempted suicide in the past, but was not at risk at the time, according to the report. The teen was not placed on suicide watch, which requires residents to be checked on every five minutes.
Lang told investigators he meant to tell his supervisor about Woods’ past, but forgot.
The DHS report noted that Woods signed all of his paperwork except for the suicide assessment.