An independent review determined the Montgomery County jail where inmates Tyler Tessier and Thierry Nkusu each committed suicide in 2018 is hampered by outdated metal bunks, which make it easy for a person to hang themselves, and a configuration that reduces a guard’s ability to monitor inmates.

An independent review determined the Montgomery County, Maryland, jail where inmates Tyler Tessier and Thierry Nkusu each committed suicide in 2018 is hampered by outdated metal bunks, which make it easy for a person to hang themselves, and a configuration that reduces a guard’s ability to monitor inmates.

Tessier killed himself at the Montgomery County Correctional Facility on Sept. 6, 2018, hours before the start of his murder trial for the 2017 death of his pregnant girlfriend, Laura Wallen. Nkusu killed himself on July 4, 2018, days after being sentenced to life in prison for the stabbing death of his pregnant fiancee.

Shortly after Tessier’s suicide, then-director of Montgomery County’s Department of Correction and Rehabilitation Robert Green requested an operational assessment by the National Institute of Corrections — a federal agency that assists local and state corrections departments.

Following a Maryland Public Information Act request, the agency provided WTOP with a heavily redacted version of the 16-page report — Mental Health Evaluation and Management Review — with NIC’s “Suggestions” and “Closing Thoughts” sections completely blacked-out.

The county’s corrections department initially denied WTOP’s public information request, citing an exception for security procedures, as well as executive privilege. County Executive Marc Elrich authorized the release of material protected by executive privilege.

In its introduction, NIC said Montgomery County’s three corrections facilities — Montgomery County Correctional Facility, which opened in 2001, in Clarksburg, and the county’s detention center and pre-release center, both in Rockville — had compliance scores of 100% in recent statewide and federal audits.

However, the federal report was critical of the architecture and configuration of housing cells in the Clarksburg jail. The National Institute of Corrections said more-contemporary jails are being built with open dormitories and smaller multiple-occupancy housing units “to encourage interaction with staff and other inmates rather than keeping inmates locked in their cell for extended periods of time.”

While treatment units have been implemented, the outdated cells and housing units remain in place.

“The cells (at the county correctional facility and detention center) are configured with metal bunks welded to an embed in the wall. Most cells are double occupancy. Between metal shelves and desks, there are numerous ligatures (i.e., tie-off points) that can be used to further a suicide attempt,” according to the report.

As WTOP reported in February, in its death investigation, Montgomery County police determined Tessier had stacked five suicide letters on top of his bunk bed and tied bed sheets to the top of his bunk.

“Renovation of the existing facility is being explored to remove any ligatures,” according to the report. “Such a renovation may require retrofitting each cell.”

According to the report, altering the current housing areas to meet current guidelines “may be cost prohibitive.”

In addition, the report found the building’s floor plan makes it more difficult to monitor prisoners.

“Merely changing the cell furnishings does not address the lack of visibility by officers into cells holding inmates with severe behavioral health issues, including those who are highly suicidal,” said the report.

The jail’s Crisis Intervention Unit, where potentially suicidal inmates are housed, is two-tiered, which adds an additional challenge in monitoring prisoners.

“Like other cells in the facilities, visibility into the cells is limited and staff rounds are the primary means for monitoring inmates,” the agency said in its report.

Montgomery County is considering, but has not finalized plans for a new criminal justice complex.

“Should this project move forward, there is a tremendous opportunity to construct the new behavioral health housing to minimize ligatures and using formed plastic furnishings,” the report said.

In the wake of Tessier’s and Nkusu’s suicides, National Institute of Corrections noted that the corrections department has made some changes.

“One immediate response to the recent suicides was the removal of sheets from the entire facility until such time as an alternative can be identified and purchased,” according to the report. “The inmate reaction has been negative, but not to the point of significant behavioral consequences.”

After its visit and assessment of the Clarksburg facility, the National Institute of Corrections said the county uses a multitiered system to determine whether inmates have mental health, substance abuse, or other health issues that would require special care.

Incoming inmates are asked at least three times if they are thinking of harming themselves. Police and prosecutors have said there was no indication Tessier or Nkusu planned to kill themselves.

The federal agency recommended the county facilities should seek suicide precautions that are not punitive.

“Often suicide precautions result in housing transfers with the removal of all inmate property and the donning of a suicide smock with the goal of minimizing the opportunity to attempt suicide,” the National Institute of Corrections found. “While well intentioned, these measures, particularly if known to inmates, have the potential to have the opposite effect.”

After speaking with inmates in the Montgomery County facilities, several said they would be reluctant to discuss thoughts of hurting themselves with staff, for fear of seemingly punitive suicide precautions.

The National Institute of Corrections report makes no mention of Tessier or Nkusu by name, and while both left suicide notes, police have never made the contents public.

Citing recent studies, the National Institute of Corrections wrote: “Jail suicides are three times higher than in prisons, and nine times higher than in the general U.S. population.”

The two 2018 suicides in Clarksburg followed six years of no suicides, and previously no more than one annually.

“While suicide profiles can change, pretrial inmates are generally male, young (20-25 years), unmarried, and first-time offenders who have been arrested for minor, usually substance related, offenses,” according to the report. “A second period of suicide risk is near the time of a court appearance, especially when a guilty verdict and harsh sentencing may be anticipated.”

In pretrial motions before Tessier’s trial, a circuit court judge ruled prosecutors would not be able to play videotape or quote from an interview in which Tessier told detectives he buried Wallen when she collapsed after running into a wooden pole and shot her once in the head because he was afraid he’d buried her alive.

Still, Montgomery County prosecutors had gathered strong evidence and testimony against Tessier, and could have found other ways to enable jurors to hear Tessier’s admissions.