A correctional officer fired for "negligent inattention" by the Department of Corrections because he allegedly read a novel while Israel Keyes committed a "ritualistic" suicide in a cell 25 feet away was a scapegoat for widespread lax practices and shouldn't have lost his job, a review by an arbitrator found.

Records of the arbitration between the correctional officers union and the state, obtained by the Alaska Dispatch News, reveal never-before-public details about Keyes' suicide, the missteps that led up to his death and the blame-placing that came after.

Loren Jacobsen was fired shortly after the confessed serial killer was found dead in a bloody maximum-security cell at the Anchorage Correctional Complex on the morning of Dec. 2, 2012.

At the time of his death, Keyes was in federal custody but housed at the Anchorage jail on charges of killing Samantha Koenig, an 18-year-old who was kidnapped from the coffee stand where she worked.

In jail, Keyes told FBI agents he'd killed the teenager and seven other people, including victims in Vermont, New York and Washington state.

At the time of his death, FBI agents were interviewing him in hopes of identifying his other victims, an investigation abruptly halted by the suicide.

After Jacobsen, 54, was fired, the Alaska Correctional Officers Association appealed the decision, saying he deserved his job back.

The union has been locked in a bitter dispute with DOC management over staffing and scheduling, among other issues, for years.

Jacobsen, his union said, had been on a sanctioned meal break at the time of Keyes' death and had followed procedures throughout the night before the body was discovered, so the DOC did not have just cause to terminate him. Jacobsen was a convenient fall guy for a department under intense scrutiny from the media and the FBI, the union claimed.

In February, the matter went to arbitration, a process by which each party in a labor dispute submits its version of events and a neutral third party makes a decision that is usually legally binding.

It is not clear whether other correctional officers were disciplined after Keyes' death.

A DOC spokeswoman said Tuesday she was too busy preparing for a planned legislative hearing about inmate deaths to immediately answer questions about Keyes' death.

High-profile, high-value inmate

In December 2012, Israel Keyes was undoubtedly the highest-profile -- and, from a law enforcement standpoint, highest-value -- detainee in the Alaska Department of Corrections' care.

Keyes had confessed months before his death to kidnapping, raping and strangling Samantha Koenig. In jailhouse interviews with the FBI, he admitted to killing a Vermont couple, Bill and Lorraine Currier, as well as at least five other people over a span of 11 years.

From the get-go, the 34-year-old handyman was a difficult prisoner.

In the spring of 2012, he lurched from his restraints and tried to run from a courtroom appearance before being tackled and "Tasered" by U.S. marshals. He had also been disciplined for making a "pick-type device" for opening handcuffs with a paper clip and dental floss, according to the arbitration report. For most of his incarceration he was classified as a "max-max" detainee, subject to the highest-security precautions. Two officers escorted him in full restraints every time he left his cell.

Authorities had good reason to watch him closely: FBI agents were in the process of pulling clues from him about his unknown victims, whom he said he'd selected at random.

There were signs Keyes had suicide on his mind.

In July, Keyes was found with a makeshift noose in his cell, Jacobsen said in an interview with the Alaska Dispatch News on Monday.

He was sent to the mental health unit of the jail, where he was placed in a "suicide cell" stripped of bed sheets or other implements that Keyes might use to kill himself.

But eventually, he was returned to the Bravo module, a maximum-security unit for long-term prisoners. DOC officials said he was no longer considered a suicide threat.

There, Keyes was housed in a cell that directly faced a metal guard table and included bunk beds, though he had no roommate. A scuffed, floor-to-ceiling Plexiglas window was partly obscured by a desk.

Overnight shift

Jacobsen, a five-year veteran correctional officer, was surprised that Keyes was back in the Bravo mod.

"In the past when we'd have high-profile people, they'd been in camera cells on the other side of the building," Jacobsen said.

The rumor among the guards was that Keyes had "made a deal with the feds that he'd tell them more of his story if he could move out of the suicide watch back to Bravo mod," Jacobsen said, though that version of events has never been substantiated.

On the night of Dec. 1, 2012, Jacobsen was assigned to work the overnight security shift in the Bravo unit. Jacobsen was the lone guard for 15 prisoners. He was supposed to do a "visual inspection" of each cell every half-hour, as well as a "formal count" every four hours.

Keyes was last seen arranging items in his cell and then getting into bed at 10:12 p.m., the arbitration report said. Around this time Jacobsen left to go on a scheduled meal break, and another guard relieved him.

Sometime after 10:12, Keyes hid under his blankets on his bunk bed, slashed his wrist with a razor he had mistakenly been given by another correctional officer and used a makeshift noose to strangle himself, according to the arbitrator's report. On a surveillance video of the entire unit from the vantage point of a camera far above the guard's desk, movement can be seen in Keyes' cell until a jerk at 10:24 p.m.

Then everything goes still.

When Jacobsen returned from a meal break, he resumed his duties. He made a total of 16 checks until his shift ended, walking close to darkened cells and peeping in but never going inside. He apparently did not see the blood that began pooling on the floor of Keyes' cell sometime after midnight.

In between checks, Jacobsen read a novel, had personal conversations with other guards through an internal phone system and at one point researched purchasing an airplane online, according to the DOC's statement to the arbitrator. The activities distracted him to the point where his security checks were "perfunctory," the DOC said.

Jacobsen later told his supervisors that the cell was dark and it appeared that Keyes was sleeping covered by his blanket, as he often did.

Because of a dim LED light in the cell, "everything looks sort of black and white," Jacobsen said.

When the lights came on, a day-shift correctional officer who had taken over after Jacobsen's shift ended found Keyes in his cell just before 6 a.m. He had been dead for hours: The body was "pale and in rigor," the arbitrator's report said.

"Simply inexcusable"

On Dec. 28, Jacobsen's bosses fired him.

"You sat at the desk throughout your shift reading a book, assessing the Internet and engaging in lengthy conversations with co-workers. During this time, the inmate managed to tie a noose around his neck and cut his wrist resulting in the blood in his bunk, on the walls and blood pooling on the floor. The inmate was dead and remained undetected until the next officer came on shift. The totality of this circumstance and your actions is simply inexcusable and warrants nothing less than a dismissal of employment," read his dismissal letter.

In the arbitration, the union countered that the state's investigation was flawed, the enforcement of standards uneven and that management decisions -- such as assigning Keyes to the dimly lit cell -- contributed to the prisoner's ability to commit suicide. Jacobsen, the union contended, was not even on the unit when Keyes actually killed himself:

"Inmate Keyes is dead because one or more people authorized and moved him out of a suicide cell and because someone then gave him a razor," the union's representative wrote.

The union claimed the distractions the DOC said caused Jacobsen to make "perfunctory" checks were standard behavior for guards, widely known and tolerated by supervisors.

"These activities are very common on both day and night shift, but especially on night shift when officers are attempting to remain attentive and awake," the report said.

Jacobsen, the union wrote, was simply a convenient person to blame for an embarrassing lapse.

"DOC management had a vested interest in composing an answer that did not reflect poorly on the state by finding fault outside of DOC's management control," the union told the arbitrator.

That's how it felt to Jacobsen, who has since left his career as a correctional officer to take a job in maintenance.

"(Management) had a preconceived idea of where they wanted to go and they just went there, whether videotape backed them up on it or not," he said.

The Alaska Police Standards Board moved to revoke his police certificate but later dropped the case, according to the union.

"Rather commonplace"

In his decision, arbitrator Timothy Williams found that a determined and cunning inmate with an elaborate plan to conceal his suicide was no match for a complacent workplace culture.

"Keyes," he wrote, "was chillingly methodical and clever in completing his suicide."

Jacobsen's work performance on the night Keyes died was by no means of high quality, Williams wrote, but it was also no firing offense by usual DOC standards.

"The (officer) did not sit at his desk reading a book while Inmate Keyes committed suicide," he wrote. "When (Jacobsen) left for his meal break Inmate Keyes was still up and very much alive and when he returned Inmate Keyes had completed his efforts at suicide."

Jacobsen did read a book, talk on the phone and peruse the Internet during his shift, the arbitrator found. But interviews with other guards and previous discipline cases showed that his conduct was "standard fare" that others hadn't been fired or even disciplined for. His performance was "not aberrant but rather commonplace."

In one case, the arbitrator wrote, an officer who failed to perform any checks for five hours and then falsified a logbook was not fired.

"There are numerous examples where a death of an inmate is not discovered until lights are turned on in the morning and COs on duty were neither disciplined or discharged," the arbitrator wrote.

But Williams found an "unacceptable gap" between correctional officer practice and policy on security checks and prisoner counts.

"It seems to this Arbitrator," he wrote, "that the State has more than a simple problem of discharging (Jacobsen) but rather has a larger problem with regard to the effectiveness of training and the manner in which COs are supervised."